Original article Clinical endoscopy| Volume 77, ISSUE 1, P29-38, January 2013

Download started.


Peroral endoscopic myotomy for treatment of achalasia: from bench to bedside (with video)

Published:October 08, 2012DOI:


      Peroral endoscopic myotomy (POEM) is a novel approach to performing esophageal myotomy through a long submucosal tunnel.


      This study aimed to investigate the feasibility and safety of POEM for treatment of achalasia.


      Preclinical animal study and prospective clinical study.


      Consecutive patients diagnosed with achalasia with high-resolution manometry.


      POEM was standardized for preclinical and clinical studies. After submucosal injection, a mucosal incision was made 15 cm above the gastroesophageal junction (GEJ). A long submucosal tunnel was created to extend below the GEJ. The endoscopic myotomy started 10 cm above and extended 2 cm below the GEJ. We first conducted a preclinical animal study to confirm the safety of POEM. POEM was then performed for the treatment of achalasia in humans.

      Main Outcome Measurements

      Relief from dysphagia assessed by the dysphagia score and Eckhardt score. High-resolution manometry and pH monitoring were performed to evaluate the posttreatment effects and esophageal acid exposure.


      Seven 30-kg porcine models underwent POEM in the survival study. All of the pigs survived except 1, which sustained pneumomediastinum. POEM was performed for the treatment of achalasia in 16 patients. The mean operating time was 117.0 ± 34.1 minutes. All patients tolerated food on day 2, with a contrast study confirming no leakage. The median follow-up was 176.5 days (range 98-230 days). The postoperative basal lower esophageal sphincter pressure was significantly reduced (mean reduction, 13.9 ± 14.5 mm Hg; P = .005) and 4-second integrated relaxation pressure of the GEJ (mean reduction, 10.1 ± 7.4 mm Hg; P = .001). Of these patients, 58.3% had a normalized 4-second integrated relaxation pressure, whereas 20% had excessive esophageal acid exposure after the procedure. There was a significant improvement in quality of life 6 months after POEM measured by the Short Form-36 questionnaire.


      Small sample size.


      POEM is a feasible, safe, and effective treatment for achalasia. (Clinical trial registration number: NCT01525732.)


      GEJ (gastroesophageal junction), HRM (high-resolution manometry), IRP (integrated relaxation pressure), LES (lower esophageal sphincter), POEM (peroral endoscopic myotomy)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Spiess A.
        • Kahrilas P.
        Treating achalasia: from whalebone to laparoscope.
        JAMA. 1998; 280: 638-642
        • Heller E.
        Extra mucous cardioplasty in chronic cardiospasm with dilatation of the esophagus [in German].
        Mitt Grenzgels Med Chir. 1913; 27: 141
        • Zaninotto G.
        • Constantini M.
        • Rizzetto C.
        • et al.
        Four hundred laparoscopic myotomies for esophageal achalasia: a single center experience.
        Ann Surg. 2008; 248: 986-993
        • Sumiyama K.
        • Gostout C.J.
        • Rajan E.
        • et al.
        Submucosal endoscopy with mucosal flap safety valve.
        Gastrointest Endosc. 2007; 65: 688-694
        • Pasricha P.J.
        • Hawari R.
        • Ahmed I.
        • et al.
        Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.
        Endoscopy. 2007; 39: 761-764
        • Inoue H.
        • Minami H.
        • Kobayashi Y.
        • et al.
        Peroral endoscopic myotomy (P.O.E.M.) for esophageal achalasia.
        Endoscopy. 2010; 42: 265-271
        • Ghosh S.K.
        • Pandolfino J.E.
        • Rice J.
        • et al.
        Impaired deglutitive EGJ relaxation in clinical esophageal manometry: a quantitative analysis of 400 patients and 75 controls.
        Am J Physiol Gastrointest Liver Physiol. 2007; 293: G878-G885
        • Pandolfino J.E.
        • Kwiatek M.A.
        • Nealis T.
        • et al.
        Achalasia: a new clinically relevant classification by high-resolution manometry.
        Gastroenterology. 2008; 135: 1526-1533
        • Kahrilas P.J.
        • Ghosh S.K.
        • Pandolfino J.E.
        Esophageal motility disorders in terms of pressure topography.
        J Clin Gastroenterol. 2008; 42: 627-635
        • Mellow M.H.
        • Pinkas H.
        Endoscopic laser therapy for malignancies affecting the esophagus and gastroesophageal junction: analysis of technical and functional efficacy.
        Arch Intern Med. 1985; 145: 1443-1446
        • Eckardt V.F.
        • Aignherr C.
        • Bernhard G.
        Predictors of outcome in patients with achalasia treated by pneumatic dilatation.
        Gastroenterology. 1992; 103: 1732-1738
        • Ortiz A.
        • Martinez de Haro L.F.
        • Parrilla P.
        • et al.
        Very long term objective evaluation of Heller myotomy plus posterior partial fundoplication in patients with achalasia of the cardia.
        Ann Surg. 2008; 247: 258-264
        • von Renteln D.
        • Inoue H.
        • Minamo J.
        • et al.
        Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study.
        Am J Gastroenterol. 2011; 107: 411-417
        • Rieder E.
        • Dunst C.M.
        • Kastenmeier A.S.
        • et al.
        Development and technique of per oral endoscopic myotomy (POEM) for achalasia.
        Eur Surg. 2011; 43: 140-145
        • Torquati A.
        • Richards W.O.
        • Holzman M.D.
        • et al.
        Laparoscopic myotomy for achalasia: predictors of successful outcome after 200 cases.
        Ann Surg. 2006; 243: 587-593
        • Stefanidis D.
        • Richardson W.
        • Farrell T.M.
        • et al.
        SAGES guidelines for the surgical treatment of esophageal achalasia.
        Surg Endosc. 2012; 26: 296-311
        • Triadafilopoulos G.
        • Boeckxstaens G.E.
        • Gullo R.
        • et al.
        The Kagoshima consensus on esophageal achalasia.
        Dis Esophagus. 2012; 25: 337-348
        • Patti M.G.
        • Pellegrini C.A.
        • Horgan S.
        • et al.
        Minimal invasive surgery for achalasia: an 8 year experience with 168 patients.
        Ann Surg. 1999; 230: 587-594
        • Richards W.O.
        • Torquati A.
        • Holzman M.D.
        • et al.
        Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial.
        Ann Surg. 2004; 240: 405-415
        • Grotenhuis B.A.
        • Wijnjhoven B.P.L.
        • Myers J.C.
        • et al.
        Reoperation for dysphagia after cardiomyotomy for achalasia.
        Am J Surg. 2007; 194: 678-682
        • Boeckxstaens G.E.
        • Annese V.
        • des Varannes S.B.
        • et al.
        Pneumatic dilatation versus laparoscopic Heller's myotomy for idiopathic achalasia.
        N Engl J Med. 2011; 364: 1807-1816