Ping-hong ZHOU, MD

Endoscopy Center, Zhongshan Hospital

Fudan University, Shanghai, China

How I Do It?

Per-oral Endoscopic Myotomy (POEM)

Prof. Pinghong ZHOU

Zhongshan Hospital, Fudan University, Shanghai, China

Per-oral Endoscopic Myotomy (POEM)

Disclosure of Interest: Nothing to Disclose

The 2nd World Congress on

CONTROVERSIES IN GASTROENTEROLOGY

Treatment

No curative option!

Objective

Reduction of the gradient across the LES for

relieving symptoms

improving esophageal emptying

preventing development of megaesophagus

Pharmacological treatment Disruption of the LES

Endoscopic botox injection

Calcium channel blockers Surgical

myotomy

Pneumatic

dilation

Endoscopic

myotomy

History of POEM

NOTES has inspired endoscopists to creat less invisive treatment even for achalasia.

Pasricha et al. performed submucosal endoscopic esophageal

myotomy on 4 pigs and found it feasible, safe and effective.

It provided experimental evidence for peroral endoscopic

myotomy later on.

Pasricha et al. Endoscopy, 2007

Inoue,et al. Endoscopy 2010; 42: 265–271

Inoue et al. reported a novel endoscopic

surgery: peroral endoscopic myotomy

(POEM) for treating esophageal achalasia

Significant improvement in dysphagia

score (preop 10 ↓to 1.3 postop (P<0.001)

Improvement in LES pressure (mean

preop 52.4mmHg ↓19.9mmHg postop

(P<0.001)

It is a milestone event of tunnel

endoscopic surgery

July 2010, Hongkong

• First case (16-Aug-2010)

• Operative time: 85 minutes

POEM - Clinical setting

Gastroscope with jet system

Hook, TT Knife (Olympus, Japan)

Hybrid Knife (T-type, ERBE, Germany)

Distal attachment: transparent cap

Diathermy: VIO 300D (ERBE, Germany)

Forced Coag, Effect 2,45W, 3-2-4

CO2 insufflation

Instruments

Preparation of esophageaus

POEM - Clinical setting

All performed under GA

Tips for POEM procedure

When coagulating the blood vessel, the coagulation forceps are suggested

to be close to the muscular side to avoid mucosal injury

Tips for POEM procedure

The fibrosis at the EGJ is common for pre-treatment patients

Sufficient submucosal cushion is important to prevent mucosal rupture

Judgement of EGJ

1）Length of insertion; 2）Resistance of gastroscopy;

3）Typical vessels； 4）Color change in cardia mucosa

Bleeding during myotomy

Presidental plenary session, DDW, 2012, San Diego

Water-jet assisted POEM in comparison to conventional

myotomy technique for treatment of esophageal achalasia

www.asge.org/ddw

Water-jet assisted POEM lead to significantly shorter

operation time, lower bleeding rate and a lower frequency

of usage of coagulation forceps

The water-jet assisted procedure simplifies the POEM

procedure and makes it safer

“push and pull” technique

Full-thickness myotomy

A circular muscle myotomy preserving the longitudinal outer

esophageal muscular layer is often recommended during POEM

But the longitudinal muscle fibers of the esophagus are extremely thin

and fragile

Full-thickness myotomy

Zhou PH et al. J Am Coll Surg, 2013

Reduced the procedure time

Did not increase the procedure-

related adverse events

Did not increase clinical reflux

complications

UEG Week 2012, Amsterdam

Familiari Zhou V. Rentile Maselli Charton

Patients 22 46* 69 8 21

Success 91% 93% 96% 100% 95%

Major complications 0 0 0 0 0

GERD occurrence 0 1 18% 0 31%

*

Paediatric N = 21

Prior LM N = 12

Sigmoid type N = 13

Results presented at the UEGW 2012

Reasons for operation failure

Incomplete myotom

Healing of myotomy edges by fibrosis

Hypertensive fundoplication

Esophageal diverticula

Gastro-esophageal reflux disease

POEM for failed HM

Controversy exists regarding the therapy of failed HM

Peroral endoscopic myotomy (POEM)

Pneumatic dilation was associated with unpredictable

outcomes and significant complications

Laparoscopic remyotomy was still an invasive procedure

with an increased risk of failure and complications

POEM may offer another option for failed HM

Subsequent POEM may be more challenging

because of scars and tissue adhesions

No systematic data HM have yet been published

Management of failed HM

The patient once had thoracoscopic HM 10 years ago, but the symptom was

recurrent due to imcomplete myotomy around the cardia

POEM was performed at the opposite side of the esophagus

POEM seems to a promising new treatment for

failed HM resulting in short-term symptom relief

in > 90% of cases

Previous HM may make subsequent endoscopic

remyotomy more challenging, but does not

influence subsquent POEM procedure

POEM for sigmoid type

The S type was considered to be the advanced stage of

achalasia

The esophageal lumen was dilated, tortuous and stored

with lot of effusion

Strategy for S type

Treatment of S type is still controversial

POEM may offer another option for S type

Interventional treatments (balloon dilation, botox et al.) are ineffective

Esophagectomy has historically been considered as standard treatment

Some recommend a myotomy as the first step

several studies have examined successful treatment of achalasia with

laparoscopic Heller myotomy

A new way of myotomy

Less invasive

Effective in primary cases

It is very difficult and time-consuming to make the tunnel for sigmoid type achalasia

S type POEM difficulties

Easy to be lost in the tunnel

Tortuous lumen

fibrosis in SM layer

thickened and disordered muscle fiber

During follow-up, the esophageal lumen is still dilated,

but no more effusion

Clips sometimes remains and cardia is loose

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Gentleman, 98 years old

Severe fibrosis in sm layer

Child, 3 years old

Child, 2 years old

POEM was performed in another hospital 4 monthes ago, but dysphagia

was not relieved due to imcomplete myotomy around the cardia

Thorough myotomy was achieved by Hybrid Knife

Re-myotomy after POEM

Gas-related complications

Pneumothorax

Small-caliber thoracic tube

Pneumoperitoneum

Puncture with 20G needle

Subcutaneous emphysema

mediastinal emphysema

Delayed bleeding

Zhou PH et al. GIE, 2013

Early manifestations Hematoma on CT scan

Progressive retrosternal pain

Vomited fresh blood

Hemostasis Emergency endosopy

Sengstaken–Blakemore tube

Orlando, 2013 DDW

Delayed bleeding in the submucosal tunnel

Vomiting of fresh blood and progressive retrosternal pain were the major early

manifestations

Emergency endoscopic diagnosis and hemostasis should be taken as early as possible

A Sengstaken–Blakemore tube is particularly effective for hemostasis by compression

Esophageal leakage

Clinical signs

Chest CT scan

Endoscopy

chest pain continuous high fever dyspnea

pleural effusion

mediastinal emphysema pneumonia and segmental atelectasis of the lungs

esophageal leakage

GI tract leakage

Metallic clips falling off from entry of the tunnel and endoscopic observation

revealing orificium fistulae which were successfully clipped with metallic clips

A satisfactorily healing was seen at 2-3 weeks follow-up endoscopy

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Sealant Pocrine Fibrin Kit (fibrinogen+thrombin)

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44

String suture with endoloop and meatllic clips

45

Day 3 after Procedure

• Body Temperature: 39.1 ℃

• Gastroscopy: leakage of mucosa in EGJ

purulent secreta in tunnel

• Washing the tunnel with NS

• Position: semireclining

• NGT drainage

• Antibiotics and PPI

Retroperitoneal Infection

• Body Temperature: 38.5 ℃

• Complain of pain at right lower back

• CT Scan

• Drainage of the retroperitoneal abscess

Day 10 after Procedure

Discharged: Day 29

promises to be

• as effective as laparoscopic myotomy (LM) or

pneumatic dilation (PD)

• less invasive than LM (no injury of surrounding tissue)

• at least as safe as PD

• more durable than PD

could be effective in failures or predictable negative outcome

of LM or PD

Current Status

Summary

When, whom, how long and which direction for POEM ?

POEM allows myotomy in any direction and any length

POEM for achalasia type I-III

POEM for tortuous achalasia

POEM for children

POEM for failure after surgery

Re-myotomy for failure after POEM

POEM for EVERYBODY !

is still investigational

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