PerOral Endoscopic Myotomy for Motility Disorders and GISTs

Steven R. DeMeesterThoracic and Foregut Surgery

The Oregon Clinic

POEM• First human procedure in 2008 with Dr. Haruhiro

Inoue in Japan (who had previously introduced endoscopic mucosal resection)

• Concept based on animal work by Dr. Pasrichafrom one year earlier at Hopkins

• First publication of results in 17 patients by Dr. Inoue in 2010

POEM

• By 2011 first reports coming from USA and shortly after Europe and China

• To date an estimated 10,000 or more procedures have been performed, and indications have expanded to include failed prior therapies for achalasia, other motility abnormalities in the esophagus, cricopharyngeous and pylorus, and for intramural tumors of the esophagus and stomach

JACS

Concept of POEM

• Inject to lift submucosa• Create mucosotomy• Develop submucosal tunnel• Extend tunnel 2-3 cm distal to GEJ• Perform myotomy• Close mucosotomy

Concept of POEM

Confirm Tunnel is 2-3 cm Distal to the GEJ

Perform Myotomy

Close Mucosotomy

Outcome with POEM• 500 consecutive patients, achalasia types I,

II and III• Included redo procedures and sigmoid

esophagus• Median operative time 90 minutes• Complications in 3.2%, no conversions• Overall success rate at 1-2 years after

POEM was 91%, 89% at 3 years• Heartburn symptoms in 21% with

endoscopic esophagitis in 56%Inoue H, et al. J Am Coll Surg, 2015

500 Consecutive POEM Procedures: Outcome

Inoue H, et al. J Am Coll Surg, 2015

5-yr and Longer Follow-up after POEM• 27 patients that had POEM in Portland prior to

February 2012• Symptomatic success at 5 years was 83%• Significant continued reduction in Eckardt

score (6.4 pre-POEM vs 1.7 current; p<0.001)• No patients required re-intervention during the

5 years of follow-up• EGD at 5 years in 16 patients showed

esophagitis in 2 (13%) and Barrett’s without dysplasia in one patient

Teitelbaum EN, et al. SAGES, 2017

5+ Year Outcomes after POEMPreop baseline 5 years postop

Eckardt score (range 0 – 12) 6.2 ± 2.6 1.7 ± 1.6*

Dysphagia (range 0 – 3) 2.4 ± 0.8 0.9 ± 1*

Regurgitation (range 0 – 3) 1.4 ± 1.1 0.3 ± 0.5*

Chest pain (range 0 – 3) 0.8 ± 1.1 0.5 ± 0.8*

Weight loss (range 0 – 3) 1.6 ± 1.4 0 ± 0*

*: p-value < 0.001

Teitelbaum EN, et al. SAGES, 2017

POEM: What We Have Learned• Safe with a low complication rate• Provides long-term, sustained dysphagia relief

equivalent to other achalasia therapies including Heller myotomy

• More reflux symptoms and esophagitis compared to other therapies, but all therapies associated with GERD potential• Avoid POEM in patients with hiatal hernia or

complications of GERD such as Barrett’s esophagus at the time of diagnosis of achalasia

• Long-term follow-up including EGD essential in all achalasia patients after therapy

POEM Concepts Extended

• Zenker’s and cricopharyngeal dysfunction

• Gastroparesis for pyloroplasty

• Endoscopic resection of gastric and esophageal intramural lesions (leimyomaand GIST)

Endoscopic Leiomyoma Resection

Endoscopic Leiomyoma Resection

Gastric GIST Resections

Endoscopic GIST Resection• Ability to perform procedure well demonstrated,

infrequent conversions• Mixture of endoscopic enucleation and

endoscopic full thickness resection techniques• Minimal complications• Ideal for tumors at GEJ and in esophagus• Long-term outcome uncertain (limited follow-up

typically under 2 years

Li QT, et al. Gastrointest Endosc, 2012He Z, et al. J Gastro Hepatol, 2013Jeong H, et al. Surg Lap Endo Perc Tech, 2012Andalib I, et al. Surg Endosc, 2017

Li QT, et al.Gastrointest Endosc,2012

Lap vs Endoscopic GIST Resection

Jeong H, et al. Surg Lap Endo Perc Tech, 2012

Lap vs Endoscopic GIST Resection

Jeong H, et al. Surg Lap Endo Perc Tech, 2012

Conclusions• POEM and endoscopic resection techniques are

here to stay, and offer advantages over other minimally invasive procedures including laparoscopy and VATS for a variety of foregut motility disorders and benign to low-grade malignant intramural tumors

• Safety, recovery and efficacy data thus far makes endoscopic approaches appealing to patients

• Thoracic surgeons need to be on the forefront of these techniques to maintain a leading role in the management of foregut disease