Peroral Endoscopic Myotomy (POEM)

Jurisdiction: JJ Part B. States: Alabama, Georgia, Tennessee. Type: Active LCD

Achalasia is a disorder of the esophagus that makes it difficult for food and liquid to pass into the stomach. Achalasia results from the degeneration of ganglion cells in the myenteric plexus in the wall of the esophagus. This degeneration leads to failure of relaxation of the lower esophageal sphincter (LES) together with loss of peristalsis in the distal esophagus. The most common symptoms in patients with achalasia are dysphagia for solids and liquids as well as regurgitation of undigested foods or saliva. Additional symptoms include chest pain, heartburn, and difficulty belching. Complications of achalasia may include progressive dilation of the esophagus (megaesophagus) possibly leading to esophagectomy. Patients with achalasia are also at increased risk of developing esophageal cancer. Achalasia can be treated with pneumatic dilatation (PD), botulinum toxin injection, and surgical myotomy. Laparoscopic Heller Myotomy (LHM) is the most common surgical myotomy procedure for treatment of achalasia. Peroral Endoscopic Myotomy (POEM) is the endoscopic complement of surgical myotomy and is a newer, less invasive procedure for the management of achalasia. POEM is an endoscopic procedure, which creates a tunnel in the submucosal layer of the esophagus and proximal stomach. Through this submucosal tunnel, an esophageal and gastric myotomy are made using a flexible endoscope. 1 The POEM procedure is performed in 4 steps: 1) mucosal incision/entry into the submucosa, 2) creation of a submucosal tunnel, 3) myotomy, and 4) closure of the mucosal incision. 6,7,8,12,21,23,24,31 POEM is a form of natural orifice transluminal endoscopic surgery (NOTES). The procedure is performed perorally, without any incisions in the chest or abdomen. The advantage of this approach is to reduce procedure-related pain and return patients to regular activities sooner than surgeries requiring external incisions. POEM may be considered medically necessary for treatment of symptomatic, monometrically proven primary idiopathic achalasia, types I, II, or III. Prior to performing a POEM procedure, it is crucial to confirm that patients have the correct diagnosis of achalasia and the following documentation must be included in the clinician’s preoperative evaluation: History and physical exam – in cluding a standardized, validated symptom assessment form completed by all patients (i.e., Eckardt score ≥3); High-resolution esophageal manometry (HRM) – achalasia is subclassified according to the Chicago Classification of esophageal motility disorders, which is based upon the result of a high-resolution esophageal manometry test; Contrast esophagram – findings on contrast esophagram that are suggestive of achalasia include a narrowed esophagogastric junction (EGJ) with a "bird-beak" appearance and esophageal aperistalsis. Late or end-stage achalasia may give the appearance that the esophagus is significantly dilated, angulated, and tortuous, giving it a sigmoid shape 35 ; E sophagogastroduodenoscopy (EGD) – EGD sometimes reveals a dilated esophagus that contains residual material with normal appearing esophageal mucosa. Contraindications — if 1 of the following conditions is present, the patient should not undergo POEM: Severe erosive esophagitis Significant coagulation disorders Liver cirrhosis with portal hypertension Severe pulmonary disease Esophageal malignancy Prior therapy that may compromise the integrity of the esophageal mucosa or lead to submucosal fibrosis, including recent esophageal surgery, radiation, endoscopic mucosal resection, or radiofrequency ablation Previous therapies for achalasia, such as PD, botulinum toxin injection, or LHM, are not contraindications to POEM. Prior to treatment with POEM, patients should be educated on the risk of gastroesophageal reflux disease (GERD). Also, follow-up acid suppression treatment should be considered after POEM. Patients should be counseled that treatments exist with a lower incidence of post-procedure GERD, such as LHM and PD. POEM is considered a safe but complex procedure. POEM will be considered medically reasonable and necessary only if it is performed by adequately trained, experienced physicians in high-volume centers. These centers must have the available staff to address any potential adverse events from POEM immediately, including but not limited to gastrointestinal or cardio-thoracic complications.