POEM - Per-oral Endoscopic Myotomy

A POEM is a treatment for motility disorders of the esophagus. The procedure is often used to treat “achalasia.”

A POEM is a minimally invasive endoscopic procedure. No incisions are made in the skin. A POEM is performed entirely through the esophagus, giving the doctor access to the entire length of the esophageal muscle.

A POEM can therefore be used to treat motility problems along the entire length of the esophagus.

Diet

• 5 days before the procedure: semi-solid diet.
• 2 days before the procedure: liquid diet.

Starting at midnight before the procedure: do not take anything by mouth.

Talk to your doctor to see if you should stop taking blood thinners.

The doctor makes an incision in the inner wall of the esophagus to create a tunnel. The endoscope is used to create this tunnel up to the level where the esophagus meets the stomach. This tunnel is located between the mucous membrane and the muscle layers. The doctor can then precisely cut through the esophageal muscle at any level. There are two types of muscles in the esophagus. With a POEM, these can be incised selectively and individually. At the end of the procedure, the doctor closes off access to the tunnel with endoscopic clips.

The incision in the esophageal muscle may cause discomfort. For this reason, all patients receive an IV with a pain reliever after the procedure. You can control the administration yourself: if you want additional pain relief, simply press a button. This is an effective way to make you as comfortable as possible after the procedure. You must fast until the morning after the POEM procedure. We do this to protect the delicate tunnel we created during the procedure. You may dampen a small sponge with water to moisten your mouth, but be sure not to swallow the water. The doctor will prescribe antibiotics to protect the tunnel. You must take them for five days after the procedure. Please let us know in advance if you are allergic to antibiotics. The day after the procedure, we’ll schedule a swallow test using a liquid that shows up on X-rays. This allows us to check whether the tunnel the doctor created is completely closed. If that is the case, you may drink clear liquids for the next two hours. If that goes well, you’ll follow a one-day liquid diet. On the second day after the procedure, we’ll start you on a soft diet. You’ll need to follow this diet for 14 days after the procedure. If all goes well, you may resume a normal diet after 14 days.

Recovery after a POEM can take up to a month. Most people can return to work after two weeks. We recommend that you avoid strenuous exercise and heavy lifting for two weeks after the procedure. If you continue to experience pain or start bleeding, notify the Endoscopy Unit as soon as possible. Acid reflux can also be a problem after the procedure (occurs in up to one in three people). In that case, the doctor will prescribe high-dose acid-suppressing medications (e.g., pantoprazole). You must take these twice a day for four weeks. After that, the dose is reduced to 40 mg once a day. In only 2 to 3 percent of people with acid reflux after a POEM does the medication not work. An endoscopic procedure is being developed to treat reflux in this situation. Discuss this with your doctor.

As with any interventional procedure, a POEM also carries risks. These are the most common ones:

• Permanent perforation of the esophagus that cannot be closed. This may require repeat endoscopy and revision of the metal clips (1%) or placement of a stent.
• Bleeding in the tunnel that cannot be assessed endoscopically or that requires a repeat endoscopy (<1%).
• Gas buildup in the abdomen (10%). This is quite common during the procedure. We can resolve this by inserting a small needle into the abdomen. You will have a bandage on your abdomen after the procedure.
• Accumulation of gas used during the procedure in the neck (10%). This improves quickly after the procedure and is not dangerous.
• Damage to the pleura (<1%).
• It is very rare for the problem not to be completely resolved after a POEM (the percentage varies depending on the type of movement disorder, previous treatment, etc.). Discuss this with your doctor before the test.
• Symptoms of acid reflux