POEM for Treatment of Achalasia: Our Early Experience and Technical Details of the Procedure

Abstract

Achalasia cardia is a rare disease characterized by incomplete relaxation of the lower esophageal sphincter (LES) and nonperistaltic esophagus leading to symptoms of dysphagia and chest pain. The traditional treatment options include endoscopic balloon dilation, Heller’s myotomy and botulinum toxin injection. Per Oral Endoscopic Myotomy (POEM) is a new treatment option for achalasia cardia based on concept of natural orifice transluminal endoscopic surgery (NOTES). There are important ethical considerations regarding training in POEM, which is a novel procedure falling between NOTES and advanced endoscopic intervention. Experienced endoscopist with good endoscope manipulation skills can perform this technically demanding procedure. Twenty-four POEM procedures are performed by single operator who had experience in advanced laparoscopy and therapeutic endoscopy including endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in tertiary care endoscopy center. Except one patient who had mucosal injury during submucosal tunnel creation which was clipped and procedure was completed, all other procedures were uncomplicated. At 6-month follow-up, 100% of patients had relief of symptoms (Eckardt scores; Pre POEM 9.70 vs post-POEM 0.66) and 60% reduction in IRP on esophageal manometry. One third of patient experienced symptomatic gastroesophageal reflux disease (GERD) which is easily managed by medication. POEM is a safe and effective treatment for the management of achalasia cardia. In recent future, it will be the preferred option in achalasia cardia treatment as the long-term data will be available and more number of endoscopist will master this technically demanding procedure.