Case of the month: “Tackling Dysphagia in the Young: The POEMS Procedure”

This case was contributed by

Dr Raj Kumar Sarveson

Consultant Gastroenterologist

Linkedin

University Hospitals of NorthMidlands United Kingdom

Clinical scenario : A 42 year old male presented with history of dysphagia to solids and liquids of 2 years duration . It was associated with weight loss of around 12 kgms

On evaluation he had features of Achalasia cardia .

He underwent various investigations and was diagnosed to have Achalasia Type. 2

He underwent POEMS procedure as shown below in the video.

He had complete relief in his symptoms & his weight increased .

How is POEM procedure done ?

WATCH this brief video

The POEM (Peroral Endoscopic Myotomy) procedure for achalasia involves the following steps:

1. Pre-procedure Preparation

• Patient Selection: Ensure the patient has confirmed achalasia based on clinical evaluation, esophageal manometry, barium swallow, and/or endoscopy.
• Fasting: The patient is advised to fast for 8-12 hours before the procedure.
• Anesthesia: General anesthesia with endotracheal intubation is used to ensure patient comfort and minimize risks.

2. Endoscopic Assessment

• Perform an initial endoscopy to assess the esophagus, gastroesophageal junction (GEJ), and stomach.
• Confirm the absence of significant esophageal dilation, diverticula, or mucosal lesions that may complicate the procedure.

3. Submucosal Injection

• Inject saline mixed with methylene blue or indigo carmine into the submucosal layer approximately 6-10 cm above the GEJ. This creates a cushion for safe entry into the submucosal space.

4. Creation of a Submucosal Tunnel

• Use an endoscopic knife to make a small mucosal incision at the injection site.
• Insert the endoscope into the submucosal space and dissect a tunnel down toward the GEJ and into the proximal stomach (usually 2-3 cm below the GEJ).

5. Myotomy

• Perform myotomy of the circular muscle layer within the submucosal tunnel.
• Extend the myotomy to the lower esophageal sphincter and 2-3 cm into the gastric cardia to ensure effective relief of obstruction.

6. Closure of the Mucosal Entry

• Close the mucosal entry incision with endoscopic clips to prevent leakage and promote healing.

7. Post-procedure Care

• Observe the patient for complications such as pneumoperitoneum, pneumothorax, or infection.
• Start a liquid diet 24 hours post-procedure, followed by gradual advancement to a soft diet as tolerated.
• Prescribe proton pump inhibitors (PPIs) to minimize acid reflux post-procedure.

8. Follow-up

• Assess symptom improvement and monitor for complications or recurrence using symptom scores, esophageal manometry, and/or endoscopy as needed.

Key Notes:

• POEM is a minimally invasive and effective treatment for achalasia and other esophageal motility disorders.

Further Reading : Click the links below

1.ACG Clinical Guidelines: Diagnosis and Management of Achalasia

2.Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study.