Per Oral Endoscopic Myotomy (POEM)
Per oral endoscopic myotomy (POEM) is a minimally invasive procedure used by surgeons at Massachusetts General Hospital to treat eligible patients experiencing symptoms of achalasia.
Per oral endoscopic myotomy, commonly known as POEM, is a minimally invasive procedure used by surgeons at Massachusetts General Hospital to treat appropriately selected patients experiencing symptoms of achalasia.
Achalasia is a rare digestive disorder that occurs when the muscle at the bottom of the esophagus that normally functions as a valve fails to relax, preventing food from entering the stomach. Patients with achalasia feel like they can’t swallow.
Specialists in the Gastroesophageal Surgery Program work closely with the Swallowing and Heartburn Center at the Mass General Digestive Healthcare Center, as well as patients and referring physicians, to determine the treatment plan that is best for each patient. Not all patients with achalasia are candidates for the POEM procedure (see below for eligibility).
How Does POEM Work?
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.
During the procedure, the surgeon inserts an endoscope into the patient's mouth. The endoscope uses a small camera, which allows the surgeon to see the lining of the esophagus.
Using a specially designed endoscopic tool, the surgeon makes a small slit in the inner lining of the esophagus to tunnel down to the sphincter muscle, which is a ring of muscle that allows access to the stomach. The surgeon then divides the muscle fibers that block the passage of food. Once the surgeon confirms that the blockage caused by the malfunctioning sphincter muscle has been relieved, the endoscope is removed and the slit is repaired.
Patients are placed under general anesthesia during the procedure, which is typically completed in two-three hours. Every case is different, so there is some variability in the time it takes to perform the procedure.
What Preparation is Required Before POEM?
Before considering the POEM procedure, patients must undergo a careful evaluation that includes an upper gastrointestinal endoscopy and esophageal motility testing to monitor the movement of food through the digestive system and to check for digestive disorders.
If tests confirm that a POEM procedure is appropriate, patients will need to follow specific preparation instructions that include:
- A liquid diet for two days prior to the procedure
- No eating or drinking for 12 hours prior to the procedure (to ensure that the patient’s esophagus is clear of food products)
Patients are often instructed to take liquid medication to reduce microorganisms that have grown in the esophagus due to achalasia.
What is the Recovery Time and Follow-Up?
Following the procedure, the patient is asked to drink a barium liquid the next morning that will show on an X-ray and confirm that there is no leakage at the surgical site. When that has been confirmed, the patient can begin drinking liquids. One week later, the patient can return to solid foods.
Because there are no pain fibers in the esophagus, the patient experiences little to no pain, which may lead to a faster recovery period. Most patients receive complete relief from swallowing difficulties and may return to regular activity in about a week. Patients are asked to check in by phone with their surgeon at this point and return for an office visit two weeks later.
Who is Eligible for POEM?
Not all patients are candidates for the procedure. A full evaluation is needed to determine if a patient is eligible. Ideal candidates include patients who have been diagnosed with achalasia and have not been previously treated with Botox®.
Patients who have experienced any of the following may not be eligible for the procedure:
- Inability to tolerate general anesthesia
- Portal hypertension (increase in blood pressure within a system of veins called the portal venous system)
- Esophageal varices (abnormal, enlarged veins in the lower part of the esophagus)
- Previous esophageal surgery
- Need for blood thinners
How Safe is the Procedure?
The first POEM procedure was performed in 2008 in Japan. Since then, more than 3,000 patients world-wide have benefitted from the procedure.
All surgical procedures have risks, such as the risks associated with anesthesia, risk of bleeding and risk of infection. These risks are small. The most common short-term side effects of POEM are:
- Sore throat
- Mild chest discomfort
- Heartburn and gastroesophageal reflux
Why Mass General?
Mass General is consistently ranked among the best hospitals in the country by U.S. News & World Report. Our surgeons, among the most experienced in the region, are accustomed to seeing both local and international patients with multiple medical conditions. The Swallowing and Heartburn Center at the Mass General Digestive Healthcare Center brings together a team of gastroesophageal specialists who provide expert diagnosis and leading-edge surgical options for throat, esophageal and stomach disorders.
The POEM procedure was developed by a physician in Japan, but began as Natural Orifice Translumenal Endoscopic Surgery (NOTES) research conducted by the Center for Integration of Medicine and Innovative Technology at Mass General. Since 2006, the NOTES program has worked to develop minimally invasive surgical procedures using the body’s natural orifices as entrance points for surgery.
The MGH offers its first per-oral endoscopic myotomy (POEM) procedure, a new surgical treatment for achalasia.