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Per-Oral Endoscopic Myotomy (POEM) for Treatment of Achalasia

Patients with rare esophageal disorder find relief with minimally invasive endoscopic procedure

UH Digestive Health Institute - Summer 2018

Jeffrey Marks


Program Director, General Surgery and Director of Surgical Endoscopy, UH Cleveland Medical Center; Professor of Surgery, Case Western Reserve University School of Medicine

To taste a favorite food is one of life's great pleasures. To stay nourished, we need to swallow and digest those morsels. People with achalasia lose this ability, which dramatically impacts their quality of life and health.

A relatively new procedure, pioneered in part by University Hospitals Cleveland Medical Center, provides a minimally invasive treatment option for people with achalasia and others suffering from certain esophageal disorders.

In patients with achalasia, the esophagus does not push food or liquid into the stomach. In addition, the lower esophageal sphincter (LES), a band of muscle that encircles the lower portion of the esophagus, does not relax normally with swallowing. This prevents food and liquid from passing into the stomach.

People with achalasia often have difficulty swallowing or will regurgitate what they eat. They may feel like food stays stuck their chest. Because food can't get to the stomach, many experience unintentional weight loss and malnutrition.

Until recently, the endoscopic treatment for achalasia was either Botox injections or endoscopic pneumatic dilation (PD). Both show a high initial success rate; however, positive response declines over time. The surgical standard of care is a laparoscopic Heller, where a surgeon cuts the muscle fibers to weaken the LES.

In a study published in Journal of Thoracic Disease co-authored by Jeffrey Marks, MD, Program Director, General Surgery and Director of Surgical Endoscopy at UH Cleveland Medical Center, out of 73 patients treated with LHM, 89 percent experienced a good or excellent response rate at six months. At six years, that number declined to 57 percent. (1)

Now, achalasia sufferers can opt for per-oral endoscopic myotomy (POEM), a minimally invasive endoscopic procedure that offers results comparable to surgery, but with potentially shorter procedure and recovery times and fewer serious complications. Because the first POEM procedure was performed in 2010, little long-term outcome data are currently available.

As a health system committed to advanced endoscopy, UH Cleveland Medical Center was one of the first hospitals to use POEM as well as to provide direct education in the procedure. To date, UH Cleveland Medical Center has trained more than 150 surgeons and gastroenterologists to perform POEM, Dr. Marks says.

“We're one of the top five hospitals in the country to perform this procedure,” he says. “We've also trained surgeons and gastroenterologists from around the world so that they can provide quality care.”

To perform POEM, a surgeon uses an endoscope to travel through the mouth and down the esophagus. Like surgical myotomy, the surgeon then cuts muscle fibers to relax the LES. This allows food to enter the stomach.

Because POEM uses an endoscope, surgeons don't need to make an incision in the abdomen or chest. This means a shorter hospital stay for some patients — two days versus three for surgical myotomy, according to the Journal of Thoracic Disease study (1).

Although surgeons mainly use POEM for achalasia patients, they can also use it to treat other esophageal disorders. Dr. Marks says POEM serves as a minimally invasive treatment for esophageal tumors. The procedure also benefits patients who aren't ideal surgical candidates, possibly due to prior esophageal or stomach operations or morbid obesity.

A similar procedure, gastric per-oral endoscopic pyloromyotomy (G-POEM), offers patients with gastroparesis, a stomach nerve disorder, an alternative to medication. Early data presented at Digestive Disease Week 2016 demonstrated promising short-term outcomes. Of 30 patients who underwent G-POEM for gastroparesis, 86 percent achieved clinical improvement at a five-and-a-half-month follow-up visit.

UH Cleveland Medical Center has been performing POEM since 2010 — two years after Dr. Hirano Inoue pioneered the procedure. The hospital has also trained surgeons nationwide since 2012.

POEM is a challenging procedure that requires technical precision, Dr. Marks notes. To date, UH Cleveland Medical Center has completed 210 POEM procedures.

“If a patient is interested in POEM, they should go to a center that's highly skilled,” he says. “UH is a regional and national leader in performing this procedure, and we understand the physiology of the disease.”


For more information on POEM, contact a surgeon at UH Cleveland Medical Center by calling (216) 844-3209.


1. The future of achalasia therapy: expanding the minimally invasive armamentarium and risk of secondary gastroesophageal reflux. Journal of Thoracic Disease.