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  • Review Article
  • Published:

Peroral endoscopic myotomy: an evolving treatment for achalasia

Nature Reviews Gastroenterology & Hepatology volume 12, pages 410–426 (2015)Cite this article

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This article has been updated

Key Points

  • Peroral endoscopic myotomy (POEM) is a novel endoscopic procedure initially developed for achalasia, combining the performance of surgical myotomy with safety profile of an endoscopic procedure

  • POEM offers advantages over the current treatment standards, namely pneumatic dilation and surgical myotomy, such as easy control over the length and position of the myotomy

  • POEM can also be successfully applied to patients with advanced sigmoid achalasia, failed surgical myotomy, multiple previous treatments and even other spastic oesophageal motility disorders

  • The most common adverse events are insufflation-related complications and mucosal injury, both of which are generally well managed and without clinical morbidity

  • International collaboration is required to determine optimal position, length and selectivity (full thickness versus selective myotomy) of standard myotomy, standardize adverse event reporting and develop a formal training curriculum

Abstract

Peroral endoscopic myotomy (POEM) was first performed in Japan in 2008 for uncomplicated achalasia. With excellent results, it was adopted by highly skilled endoscopists around the world and the indications for POEM were expanded to include advanced sigmoid achalasia, failed surgical myotomy, patients with previous endoscopic treatments and even other spastic oesophageal motility disorders. With increased uptake and performance of POEM, variations in technique and improved management of adverse events have been developed. Now, 6 years since the first case and with >3,000 procedures performed worldwide, long-term data has shown the efficacy of POEM to be long-lasting. A growing body of literature also exists pertaining to the learning curve, application of novel technologies, extended indications and physiologic changes with POEM. Ultimately, this once experimental procedure is evolving towards becoming the preferred treatment for achalasia and other spastic oesophageal motility disorders.

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Figure 1: Important luminal landmarks in POEM.
Figure 2: Anatomy surrounding the gastro-oesophageal junction to consider during POEM.
Figure 3: Landmarks and signs indicative of location in the submucosal tunnel.
Figure 4: POEM procedure.
Figure 5: Endoscopic, radiological, manometric and distensibility changes before and after POEM.
Figure 6: Representative images for severe sigmoid achalasia (type 2).
Figure 7: Representative images of high-resolution manometry of Jackhammer oesophagus.

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Change history

  • 16 June 2015

    In the version of this article originally published online, incomplete data for the Charton et al. and Sharata et al. studies were reported in Supplementary Table 1. These errors have now been corrected.

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  1. Digestive Diseases Centre, Showa University Koto-Toyosu Hospital, Toyosu 5-1-38, Koto-Ku, 135-8577, Tokyo, Japan

    Robert Bechara, Haruo Ikeda & Haruhiro Inoue

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All authors contributed to reviewing and editing the manuscript before submission. R.B. and H. Ikeda contributed equally to researching data for the article. R.B. and H. Inoue contributed equally to writing the article. H. Inoue substantially contributed to the discussion of content.

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POEM procedure (MP4 458638 kb)

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POEM studies including ≥10 patients (PDF 170 kb)

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Bechara, R., Ikeda, H. & Inoue, H. Peroral endoscopic myotomy: an evolving treatment for achalasia. Nat Rev Gastroenterol Hepatol 12, 410–426 (2015). https://doi.org/10.1038/nrgastro.2015.87

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