Peroral Endoscopic Myotomy (POEM) for Treatment of Achalasia

History

A female patient in her 30s experienced dysphagia for six years. She had an esophagogastroduodenoscopy (EGD) and esophagram performed at an outside hospital in 2020 and 2021, respectively, the results of which were consistent with achalasia, an esophageal disorder that makes it difficult to swallow food and beverages.

The patient said she had food stuck in her esophagus after every meal, which would eventually pass. She had daily regurgitation of food and water and, at night, she would wake up with chest pressure, coughing, and regurgitation of water and food with choking. In the last 1.5 years before coming to Rush, the patient reported worsening symptoms. In addition, the patient was not experiencing any weight loss issues.

Presentation and Examination

In 2023, Dr. Abraham performed a repeat EGD on this patient, which showed a fluid-filled, dilated esophagus with fluid and saliva, as well as dilation, in the middle and lower third of the esophagus. Her distal esophagus was notably narrowed. This examination was concerning for achalasia.

A repeat esophagram at Rush also showed a markedly dilated esophagus with features compatible with achalasia or an obstructive esophagogastric junction (EGJ): Delayed passage of the contrast material through the esophagus was noted on the five-minute, post-procedure X-ray. She had an Eckardt score of 7.

Given her diagnosis, Dr. Abraham referred this patient to Irving Waxman, MD, to undergo peroral endoscopic myotomy (POEM), a minimally invasive, endoscopic procedure used to treat achalasia.

Treatment

POEM is a nonsurgical endoscopic procedure that uses myotomy to cut the muscle and relieve the muscular obstruction of food and liquid to pass into the esophagus, which is the cause of achalasia. The use of POEM prevents the esophageal muscles from tightening and interfering with activities like swallowing food and water.

Dr. Waxman began the procedure by performing a mucosectomy, followed by a myotomy. He lifted the mucosa at the site of the initial mucosectomy. The initial mucosal incision was made longitudinally starting at 34 cm from the incisors using a HybridKnife T-Type.

The endoscope with the clear cap was used to enter into the submucosal tunnel, which was further created by continued dissection and extended to 42 cm from the incisors and into the cardia by 2 cm.

The myotomy was started 41 cm from the incisors using a HybridKnife T-Type to perform circular and full thickness myotomies. The myotomy was extended to 36 cm from the incisors and extended into the cardia by 2 cm.

The patient had minimal intraoperative bleeding, and the myotomy was closed with endoscopic clips. Dr. Waxman examined the patient’s esophagus and gastroesophageal junction with white light from a forward view and retroflexed position. There was no visual evidence of Barrett’s esophagus, and the stomach and duodenum were normal.

Outcome

Post-procedure, the patient had no leak. She is now on a general diet and has been tolerating solid foods well. She reports no symptoms of dysphagia, regurgitation and odynophagia and has no weight loss. She says that no food is getting stuck in her esophagus. Her Eckardt score is now 0. Additionally, some of her other medical issues, such as her asthma, have improved or resolved since undergoing POEM.

Analysis

Outside of POEM, other available options to treat achalasia include Heller myotomy or pneumatic balloon dilation. Heller myotomy can help relieve symptoms about 75% of the time. The pneumatic balloon dilation carries a 3% risk of perforation and about a 7% to 10% chance of recurrence within seven to 10 years post-procedure, but will not typically provide as long-lasting relief as surgical myotomy.

POEM is a safe, minimally invasive procedure that carries low risk for developing comorbidities such as risk of perforation from cutting the lower esophageal muscle (5%), risk of perforation that would require surgery (2%) or bleeding intraoperatively or postoperatively (2%). Sometimes, POEM can create more GERD-acid reflux post-procedure, which can be remedied by the use of an oral antacid medication.

Overall, we believe POEM is a great choice for treatment of achalasia given the similar outcomes compared with Heller myotomy and the overall faster recovery and reduced pain associated with an endoscopic procedure.