POEM Procedure for. Esophageal Achalasia

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1 POEM Procedure for Esophageal Achalasia POEM (Per-Oral endoscopic myotomy) is an incisionless procedure to treat esophageal achalasia, totally performed by endoscopy, without cutting the surface of the body. Esophageal Achalasia It is a dysfunction of the esophagus, with difficult esophageal transit of food and drink, or both, due to the failure of esophageal peristalsis (the peristalsis is done by the muscle movements) in opening and closing the cardiac portion (joint between the esophagus and stomach), called the esophago-gastric junction (EGJ). The cause, it is thought, is the degeneration of the nerve that controls the esophageal muscles; familiarity and hereditary are not particularly. Symptom Weight loss, chest pain, vomiting (regurgitation)

2 Course It is common to have repeated periods with or getting better or worsening symptoms; basically it deteriorates gradually. On rare occasions it also can be complicated by esophageal cancer. <POEM Questions and Aswers> Q What is the difference between POEM treatment and general surgery? A In POEM no surgical skin incisions are performed; it is a totally endoscopic treatment. In POEM, also, the operator can freely determine the length and location of the myotomy, in order to conform with the tightening of the esophagus, different by each patient. In surgery he/she has to follow a fixed myotomy length (about 7 cm of myotomy) Q How long will I complain for chest pain after POEM? A Although there are individual differences, in most of the patient chest pain completely disappeared within 1 month. Q A Do I have to be careful after discharge? During the 1 week after discharge please refrain from strenuous exercise, long bath and alcohol Q A Which complications may occur after treatment? It rarely may cause gastric acid reflux and esophagitis (inflammation of the esophagus), but symptoms are promptly improved by antiacid therapy. Q What s about the outcomes of POEM? A Up to now, POEM has been performed in more than 200 patients (March 2012). Major complications have been not experienced. There are no recurrences.

3 POEM: detailed procedure explanation Preoperative examination Esophageal manometry Barium Swallow study Blood Test X-ray examination (chest, abdomen) Respiratory function tests, cardiac ultrasonography CT (with contrast) (chest, abdomen) Endoscopic image Barium swallow study The procedure will be performed in the operating room, under general anesthesia. POEM surgical steps: 1. An endoscopy of the upper gastro-intestinal tract will be performed to determine the length of the required incision of the muscle layer (myotomy). The esophagus is composed of two layers: the muscle (outer layer) and the mucosa (inner layer); after injection of a saline solution under the mucosa, a submucosal tunnel is created to let the endoscope enter under the mucosa. 2. After creating the tunnel, the inner muscle layer is cut all along its length (myotomy). 3. An antibiotic solution is sprayed in the tunnel and finally the mucosal entry is closed by clips. (Clips will be out in about a month usually)

4 Esophageal Mucosa Submucosa ucosa Muscle layer Stomach Create a submucosal tunnel Myotomy Clip closure Expected Symptoms the day after surgery Fever (up to 38 ) Chest pain (due to the muscle layer incision performed) Throat Discomfort 1 Day after surgery: 1 Endoscopy examination: to confirm that no laceration is present on the mucosa and to control the closure of the esophageal mucosa by endoscopic clip. 2 Barium Swallow study: To confirm the presence or absence of therapeutic effects and complications. Notes on post-discharge: 1 week after discharge, please avoid vigorous exercise, intake of alcohol. The risk of bleeding is high and these things alter blood pressure. If after discharge you still complain for chest pain, don t worry, it will get better and better as the days passed. Even if there is a good passage of the meal, in any case be careful.

5 Showa University Northern Yokohama Hospital Digestive Disease Center Esophageal achalasia treatment group

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