POEM

D Nageshwar Reddy MD, DM, DSc, FAMS, FRCP, FASGE, FACG, MWGO

Asian Institute of Gastroenterology

Hyderabad, India.

Chicago Classification

Res

pons

e

Achalasia Cardia

Balloon Dilatation POEM Heller lap Myotomy

Treatment

Type III Achalasia

Failed Heller’s Myotomy

Failed Pneumatic dilatation

POEM

POEM

Technique of mucosal incision: Mohan Ramchandani, D N Reddy. Clinical Gastroenterol and hepatol 2013

Technique of mucosal incision

Mohan Ramchandani, D N Reddy. Clinical Gastroenterol and hepatol 2013

POEM Technique STEP-2Submucosal dissection

POEM Technique STEP-3Myotomy

POEM Technique STEP-4Closure of mucosal incision

Timed Barium (1 Minute)

Pre Dilatation Post Dilatation

POEM : AIG data 282 patients

M

F

FPD

Type III

FHM

SO

T I&II

6 months

24

10

LES pressure Eckhardt Score

Pre Post Pre Post

Reddy DN. Ramchandani M. Digestive Endoscopy 2015

Successful POEM in Situs Inversus TotalisDomenico Galasso, Mohan Ramchandani, Rakesh Kalpala, Sundeep Lakhtakia, Rajesh

Gupta, Santosh Darisetty, D.Nageshwar Reddy

Endoscopy 2014

Reddy D N 282 7/1 23/9 90% 10 -

World J Gastrointest Endosc 2015

The surgical argument

Why not POEM

•Invasive ?

•Not effective

•Side effects

•Cost

Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia cardia: A systematic review and metaanalysis

Talukdar R, Inoue H, Reddy DN. Surgical Endoscopy 2014

Eckhart’s score

Post-operative pain

How POEM is different from LHM?

Can be done in Endoscopy room

Equipment required•Standard upper GI scope

•Transparent tapered cap

•CO2 insufflator

•Triangular tip knife

•Electrical generator ERBE 300D

•Sub mucosal solution – NS+ 0.3%

indigo carmine

•Injection needles, hemoclips

Full control on extent of myotomy

• Only the circular muscle layer of the esophagus

is divided

• Length of myotomy can be extended in

esophagus

Preservation of Phreno-Oesophageal membrane

• The hiatus is not mobilized

• Vagus nerve is not mobilized

• An antireflux procedure is not performed

GERD after POEM

Subjective data (GERD symptom score)• No GERD symptoms 68%• Minimal (few times/month) 16%• Moderate (few times/week) 13%• Severe (daily) 3%

Stavropoulos et al , Ther Adv Gastroenterol 2013

GERD not as low as initially reported but similar to rate reported in high quality studies post LHM+Dorfundoplication

Rawlins, Surg Endo 2012; Khajanchee Arch Surg 2005

Annals of Surgery Volume 259, Number 6, June 2014

Operative Details

Hellern = 64

POEMn = 37

P

Operative time, min Median Range

160100-280

12060-215

0.003

Full-thickness injury, n Esophagus Stomach

83

40

0.10.8

Return to the OR, n Bleeding Length of stay,mean day (SD)

12.5(1.9)

11.1(0.6) <0.0001

OR indicates operating room.

POEM After Failed Heller’s Myotomy

Normal Submucosal dissection Submucosal Fibrosis in prior LHM

Endoscopy 2013

POEM

• Must await accumulation of evidence from well

designed clinical trials

– Comparative studies

– Long term follow up

Achalasia Cardia indications

Balloon dilation POEM Heller lap Myotomy

Type I,II Type III Type III

Elderly Younger Younger

< esophageal luminal Failed BD / HM Sigmoid esophagus

70% 20% 10%

‘‘There are three steps in the revelation on any truth:

In the first, it is ridiculed;

in the second, resisted;

in the third, it is considered selfevident.’’

Arthur Schopenhauer

The ability to think differently today from

yesterday distinguishes the wise man

from the stubborn.

John Steinbeck