Treating Achalasia With Per Oral Endoscopic Myotomy (POEM)


Per oral endoscopic myotomy, or POEM, is performed at Massachusetts General Hospital for patients with achalasia. Achalasia is a disorder of the esophagus that makes swallowing difficult. The POEM procedure is performed within the inner lining of the esophagus near the lower esophageal sphincter, which is a ring of muscle that allows access to the stomach. Treatment for the condition involves dividing the malfunctioning muscle fibers that disrupt digestion, which helps to relieve the swallowing difficulty for many patients. Before the procedure, the patient is prepared and is placed under general anesthesia. The POEM procedure starts by inserting an endoscope into the patient’s mouth. The endoscope uses a small camera, which allows the surgeon to see the lining of the esophagus. Fluid is injected beneath the inner lining of the esophagus called the mucosa This allows the surgeon to perform a delicate incision that only goes through that mucosal layer. Using a specially designed endoscopic tool, the surgeon makes a two-centimeter incision in the mucosal lining. The incision serves as the entry point to create the submucosal tunnel between the lining and the muscular wall of the esophagus. As the endoscope is inserted through the opening, loose, filmy tissue is divided with brief bursts of energy called cauterization. The surgeon creates a tunnel that extends into the wall of the stomach three centimeters beyond the sphincter muscle. The tunnel narrows when the endoscope reaches the level of the lower esophageal sphincter At that location, the muscle fibers of the sphincter area are clearly visible. The separation of the mucosal lining and muscle wall continues past the sphincter area. Once the tunnel is completed, the endoscope is withdrawn and reinserted through the natural opening of the esophagus to check the length and integrity of the tunnel. The surgeon uses a camera view from the stomach to confirm that the tunnel extends below the esophageal sphincter. The endoscope is reinserted into the tunnel to the lower esophageal sphincter. Here the surgeon begins to divide the muscle fibers that obstruct the normal digestion process This is called a myotomy. The myotomy is performed through cauterization. The cauterization continues to the end of the tunnel the doctor created. After viewing the entire tunnel area to confirm that it is open and intact, the entry to the tunnel is closed with small metal clips These clips fall off after healing, and are easily passed through the gastrointestinal tract. Following the procedure, the patient is awakened and begins oral intake of liquids the next morning. Most patients receive complete relief from swallowing difficulties and may return to regular activity in about a week. For more information on the POEM procedure, visit massgeneral.org/POEM

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