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CHAPTER 19 POEM and Emerging NOTES Applications
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Figure 19.12 Submucosal tunnel. A submucosal tunnel is created in the
submucosal layer down to the stomach beyond the EGJ. Approximately
15 cm long submucosal tunnel consists of 12 cm esophageal side and
3 cm stomach side. This long tunnel is the working space for myotomy.
(From Inoue H [52], with permission from Georg Thieme Verlag KG.)
Pasricha et al. recently reported the possibility of submucosal
myotomy using a porcine model [51]. Their method was
modifi ed and adjusted to the clinical setting [52].
The POEM procedure received approval from the Institutional Review Board (IRB) of Showa University Northern
Yokohama Hospital (approval number 0805 –02, issued
August 15, 2008). Written informed consent was obtained
from all patients. All patients who underwent POEM were
registered in the University Hospital Medical Information
Network Japan (UMIN) database.
In this chapter our preliminary clinical experiences, particularly focusing on technical details, are reported.
Indications
All achalasia patients can be treated by POEM. In our early
series the indication of POEM was limited to non -sigmoid
type, but patient feedback on the results of POEM was better
than we expected. Then it was widened to all grades of
achalasia. More recently, the indication for POEM was
further extended to cases of failed laparoscopic or thoracoscopic surgical myotomy.
Figure 19.13 Endoscopic myotomy. Endoscopic myotomy is carried out
in the submucosal tunnel. Endoscopic myotomy starts at 2 cm distal to
mucosal incision. Only circular muscle is cut endoscopically. (From Inoue H
[52], with permission from Georg Thieme Verlag KG.)
Equipment used
A forward -viewing endoscope of outer diameter 9.8 mm,
which is designed for routine upper gastrointestinal screening, is used with a transparent distal cap attachment (MH 588, Olympus) (Figure 19.16). This distal attached cap is of
great importance for maintaining better endoscopic vision
even in submucosal space. With the oblique orifi ce, the
endoscope may be smoothly inserted into the submucosal
layer. All equipment including the endoscope itself is previously sterilized using ethylene oxide gas.
A triangle -tip knife (KD -640 L, Olympus) was used to
dissect the submucosal layer and also to divide circular
muscle bundles (Figure 19.17). The maximal insertion
portion diameter of the KD -640 L is 2.6 mm. For electrosurgical energy generator, a VIO 300D electrogenerator (ERBE,
Tübingen, Germany) is recommended. A coagulating forceps
(Coagrasper, FD -411QR, Olympus) is used to close larger
vessels prior to dissection and for hemostasis.
Carbon dioxide gas is used for insuffl ation during the
procedure with a CO
19.18). The CO
insuffl ator (UCR, Olympus) (Figure
2
insuffl ator with a regular insuffl ating tube
2
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Figure 19.14 Completed myotomy. Endoscopic myotomy continues
beyond EGJ to 2 cm distal to it. Complete dissection of lower esophageal
sphincter and gastric site muscle is a most important part of this
procedure. (From Inoue H [52], with permission from Georg Thieme
Verlag KG.)
Figure 19.16 Distal attachment cap. Oblique cut. This attachment is
mounted on the tip of a forward -view endoscope and then fi xed with
adhesive tape.
Figure 19.15 Closure of mucosal entry. Mucosal entry site is closed
with endoscopic hemostatic clips. (From Inoue H [52], with permission
from Georg Thieme Verlag KG.)
(MAJ-1742. Olympus) offers adequate gas feeding of 1.2 l/
min during the procedure. Endoscopic CO
insuffl ation is
2
benefi cial for reducing the risk of both mediastinal emphysema and air embolization. At that time it should be confi rmed that the ignition light of the air feeding button should
be kept off. Otherwise, air will also be supplied together with
CO
insuffl ation (Figure 19.19). For fi nal closure of the
2
mucosal entry site, hemostatic clips (EZ -CLIP, HX -110QR,
DFOlympus) are applied.
Procedure
Step 1: Intratracheal intubation and CO
2
insuffl ation
The procedure is done with the patient under general
anesthesia. A particular caution is that severe emphysema
may occur if POEM is done only with conscious sedation.
Positive pressure ventilation is defi nitely helpful in reducing
the risk of mediastinal emphysema. During POEM, pneumoperitoneum (not pneumomediastinum) occurred in eight
cases. In order to prevent abdominal compartment syndrome, the upper abdominal wall is prepared to be exposed,
206
Figure 19.17 Triangle -tip knife. This knife has three sharp angulations
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at its tip, which allow smooth irradiation of electric current to the tissue
with or without touching it.
CHAPTER 19 POEM and Emerging NOTES Applications
Figure 19.18 Carbon dioxide gas insuffl ator. During the POEM
procedure, CO
pneumomediastinum and/or subcutaneous emphysema.
is insuffl ated through the endoscope. It potentially avoids
2
Figure 19.19 Confi rmation of air insuffl ation button being “off. ” The
air insuffl ation button is located on the center panel of the processor.
Please be careful to turn it off. If it was “on,” air would be insuffl ated
through the endoscope.
then checked periodically during the POEM procedure
(Figure 19.20). When the abdominal wall is excessively distended, puncture of the abdominal cavity using an injection
needle is effective to reduce abdominal pressure.
Step 2: Creation of a submucosal tunnel
Mucosal entry
Submucosal injection of about 10 ml saline with 0.3% indigo
carmine is given before opening the mucosal surface (see
Figure 19.11). The position of the entry usually lies in the
anterior wall. Incision in the 2 o ’clock direction directly connects to the lesser curve of the stomach, which enables
continuous dissection into cardial muscle and potentially
avoids injury to sling muscle.
Submucosal injection is generally done fi rst at the level of
the mid -esophagus, approximately 13 cm proximal to the GE
Figure 19.20 Patient position. Keep patient in supine position. Upper
abdomen should be exposed in order to check the patient is not
becoming pneumoperitoneum.
junction. It is a level just below the carina (approximately
29 cm from the patient ’s incisors). In this situation the estimated length of tunnel becomes 16 cm (29 cm–45cm). A
2 cm longitudinal mucosal incision is made on the mucosal
surface to create a mucosal entry to the submucosal space
(energy source at dry cut mode, 50 W, effect 3) (Figure
19.21, Video 19.1).
If the patient has abnormal contraction of the esophageal
body, then a much longer myotomy is expected. Longer
myotomy can effectively control chest pain caused by spasm
of hypertrophied circular muscle.
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Figure 19.21 Mucosal incision. Submucosal injection creates mucosal
bleb. Aproximately 2 cm longitudinal mucosal incision is made on the
mucosal bleb surface.
Submucosal tunnel
The tunnel is made downwards using a technique similar to
esophageal submucosal dissection (ESD), passing over the
esophago-gastric junction (EGJ) and entering the proximal
stomach for about 3 cm (Videos 19.2 and 19.3). Using a
triangle-tip knife (see Figure 19.17), the submucosal tissue
is dissected with spray coagulation mode, 50 W, effect 2 on
an ERBE 300D. The dissecting maneuver looks similar to
argon plasma coagulation, but this setting supplies more
cutting energy. The dissecting plane is just beneath the
muscle layer surface (Figures 19.12 and 19.22). Caution is
taken never to dissect close to the mucosal layer, because
the mucosal layer is the only barrier between the esophageal
lumen and mediastinum after completion of myotomy.
The length of the submucosal tunnel is usually approximately 15 cm, but should depend on the individual condition. If a patient complains of chest pain because of abnormal
contraction of the esophageal body, much longer submucosal tunneling is required. Our longest tunnel was 25 cm.
Repeating of submucosal injection makes submucosal tissue
dissection easier whenever the demarcation line between
the submucosal layer and the muscular layer becomes
obscure. The width of the tunnel is about one third of the
circumference of the tubular esophagus. The palisade vessel
in the submucosal layer is helpful in identifying the EGJ
(Figure 19.23). Once the tip of the endoscope is getting into
the cardia, the submucosal space will be opened widely
(Figure 19.24). The distal margin of the tunnel can be
checked with a retrofl exed view from the cardia by the blue
submucosal tattoo (Figure 19.25). Larger vessels in the submucosa were coagulated using the forceps in soft coagulation mode (80 W, effect 5).
Figure 19.22 Submucosal tunnel. The submucosal tunnel is created at
approximately 15 cm length. The top half of the image is the surface of
the muscle layer. The bottom half of the image is the back of the
mucosa.
Figure 19.23 Palisade vessel. The palisade vessel is located at the distal
end of the esophagus. It can be identifi ed inside the submucosal tunnel.
Identifi cation of gastroesophageal junction
Another interesting issue with the POEM technique concerns identifi cation of the gastroesophageal junction (GEJ)
in the submucosal space. To clearly identify the GEJ, the
following indicators should be checked. The fi rst indicator is
the insertion depth of the endoscope from the incisors. The
position of the GEJ junction in the lumen of the esophagus
itself was therefore recorded accurately before we inserted
208
Figure 19.24 Gastroesophageal junction (GEJ). The GEJ is identifi ed in
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the submucosal tunnel as a dramatic change of lumenal space. Once the
endoscope gets into the stomach, the submucosal space promptly
becomes large.
CHAPTER 19 POEM and Emerging NOTES Applications
Figure 19.26 Endoscopic myotomy in submucosal tunnel. Myotomy
starts at 2 cm distal to the mucosal incision. Using a triangle -tip knife, a
circular muscle bundle is separated and then cut by electrocautery.
stomach’s submucosal area. The working space in the submucosal tunnel also becomes gradually narrower when
the endoscope approaches closely to the lower esophageal
sphincter (LES). At the LES segment, movement of the
endoscope is obviously limited with high resistance. Once
the endoscope has passed through this narrow segment, the
submucosal space promptly widens adjacent to the stomach.
The third indicator is endoscopic visual identifi cation of palisade vessels in the submucosal layer. Palisade vessels are
located at the distal end of the esophagus. These vessels were
endoscopically identifi ed in all cases. Finally, the fourth indicator is a change of vasculature in the submucosal layer. In
the esophageal submucosal space few vessels are observed
in the submucosal layer, but when the stomach is reached
the submucosal vasculature suddenly becomes rich like a
spider’s web.
Figure 19.25 Color change in cardia mucosa in retrofl ex view in the
stomach. It is easily checked whether the submucosal tunnel has reached
the stomach by the color change in cardia mucosa.
the endoscope into the submucosal tunnel, since the insertion depth of the endoscope in the submucosal space is
almost the same as the accurate position of the endoscope
in the true lumen. The submucosal tunnel created ends at
least 3 cm distal to the estimated GEJ. The second indicator
is a marked increase of resistance when the endoscope
approaches the GEJ, followed by a prompt easing when the
endoscope passes through the narrow GEJ and enters the
Step 3: Endoscopic myotomy
Dissection of sphincter muscle
Dissection of the circular muscle bundle is begun at 2 cm
distal to the mucosal entry, approximately 10 cm above the
GEJ (see Figure 19.13). The sharp tip of the triangle -tip knife
is used to fi rst catch a couple of circular muscle bundles and
then to lift them up toward the esophageal lumen (Figure
19.26). The captured circular muscle bundle is cut by spray
coagulation current (50 W, effect 2). At the beginning of
myotomy, nobody knows how thick the inner circular
muscle is. Only the transverse muscle bundle should be
caught and then cut by electrocautery (Videos 19.4 and
19.5). By several cuts of transverse muscle bundles a longitudinal muscle bundle plane is identifi ed at the bottom of
the myotomy site (Figure 19.27).
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Figure 19.27 Preservation of longitudinal muscle. At the bottom of the
cutting edge longitudinal muscle bundles are observed as the surface of
longitudinal muscle plane. Longitudinal muscle should be preserved.
Figure 19.28 Slide triangle plate of triangle -tip knife between two
muscle layers. Only the circular muscle layer is caught and then cut by
electrocautery.
Division of the sphincter muscle is continued from the
proximal side toward the stomach until the endoscope
passed through the narrow segment of the LES (Figure
19.28). The longitudinal muscle layer should be carefully
preserved during the dissection procedure. The longitudinal
muscle layer is actually thin like a sheet of paper. It is easy
to tear, and then mediastinal tissue is often exposed to the
submucosal tunnel (Figure 19.29) (Video 19.5). Even if this
happens, no negative clinical effects occur. However, by
trying to preserve a longitudinal muscle sheet intact, unnecessary tissue injury of structures adjacent to the esophagus
can be potentially avoided.
Figure 19.29 Anterior vagus nerve. The preserved longitudinal muscle
bundle often separates just by insuffl ation through the endoscope. The
anterior vagus nerve is sometimes observed.
Anterior myotomy in the 2 o ’clock segment in the supine
position seems most appropriate, as this leads to the lesser
gastric curvature. In contrast, the angle of His is located in
the 8 o ’clock direction. Anterior myotomy potentially avoids
damage to the angle of His, which may be a natural barrier
to postoperative refl ux of gastric content. The related topic
of gastroesophageal refl ux disease (GERD) should be discussed. In surgical myotomy an anti -refl ux measure, such
as a Dor procedure, is also carried out in order to avoid
postoperative GERD, since adjacent structures surrounding
the distal esophagus are inevitably dissected, which may
impair natural anti -refl ux mechanisms. With POEM no anti refl ux procedure is carried out, since the endoscopist never
touches the surrounding structures. However, complete
myotomy potentially may have a risk for post -therapeutic
GERD.
When the tip of the endoscope reaches the stomach
region, the submucosal space suddenly becomes wider. The
thickness of the inner circular muscle layer is different in
individual cases. Muscle layer cutting is continued for at
least 2 cm distal to the GEJ (Figures 19.14 and 19.30). Complete division of the circular muscle bundle is confi rmed by
the endoscopic appearance (Videos 19.6 and 19.7). Any
muscle bundle that runs transversely should not remain.
Complete hemostasis is also achieved using coagulating
forceps. After completion of the myotomy smooth passage
of an endoscope through the GEJ with minimal resistance
is confi rmed.
One of the major advantages of POEM is the ability to set
myotomy length as long as is necessary. We generally put
approximately more than 10 cm myotomy. Particularly in
the patient who complains of chest pain that may be caused
by abnormal contraction of hypertrophied muscle in the
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CHAPTER 19 POEM and Emerging NOTES Applications
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Figure 19.30 Myotomy at gastric site. In cardia the longitudinal muscle
layer often becomes unclear. Full muscle layer dissection is often carried
out.
Figure 19.31 Closure of mucosal entry. Mucosal entry site is closed
with endoscopic clips, starting at the distal end of the incision and then
approaching the proximal end.
esophageal body, longer myotomy is used. In our series the
longest myotomy was 24 cm.
Step 4: Closure of mucosal entry
Before closing the mucosal entry, 80 mg gentamicin is
injected into the submucosal tunnel. The mucosal entry site,
usually 2 –3 cm long, is closed with about 5 –10 hemostatic
clips (Figures 19.15 and 19.31) (Video 19.8). Sometimes the
mucosal entry may enlarge after the procedure but this has
no negative effect. Even when mucosal entry is elongated
over to the myotomy site, tight mucosal closure only by clips
avoids leakage of esophageal lumenal content. Successful
Figure 19.32 Complete closure of mucosal entry. Clips are arranged
tightly at every 2 mm of incision.
closure of the mucosal entry is confi rmed by the endoscopic
appearance (Figure 19.32). At the end of the procedure, the
endoscope is again inserted into the natural lumen down to
the stomach, to confi rm smooth passage through the GEJ.
Examinations before POEM
Barium swallow and manometric study is essential to make
correct diagnosis of esophageal achalasia. CT scan is used not
only to judge the degree of esophageal dilatation, but also
to provide information from the anatomical features of adjacent structures.
Preparation before POEM
The day before the procedure
Patients are given Sennoside (2 tablet, 12 mg) to swallow
with liquid at bedtime. The purpose of using this laxative is
to reduce the movement of the gastrointestinal tract, and
the time lapse of its effect onset is 6 –10 hours after intake.
Endoscopic clearance of esophageal content and liquid diet
is suggested particularly for sigmoid type achalasia on the
day before POEM.
Procedure day
The patient is kept fasting. Gastroscopy in the morning of
the POEM day is of great importance. During the procedure
a clear endoscopic view will be guaranteed without food and
liquid residue in the esophagus. An empty esophagus also
avoids aspiration during induction of anesthesia.
Patient care on the day after the procedure
Gastroscopy
The aim is to confi rm the mucosal integrity. If no mucosal
damage is found, then gradual initiation of diet is allowed;
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if mucosal defect exists, then the patient should continue
fasting for a few more days until confi rmation of defect
closure. Fortunately in our series there was no evidence of
mucosal damage. It is important to remember that after
complete myotomy, the mucosal layer is the only barrier
between the esophageal lumen and the mediastinum.
Contrast media swallow
Barium swallow is also important to confi rm smooth passage
of contrast media through the GEJ with no leakage and no
stasis. Mucosal integrity is the premise of starting diet intake.
It begins with drinking liquid on the evening of day 1; soft
meals can be started on day 2 post -POEM, and normal diet
on day 3 post -POEM.
Antibiotics
All cases received intravenous infusion of antibiotics for 3
days followed with 4 days of antibiotic tablets.
How to avoid compartment syndrome during
POEM
Pneumoperitoneum during the procedure occurred in eight
cases, but just tapping the abdominal wall using an injection needle was suffi cient for relief from high abdominal
pressure.
Clinical results in more than 100 cases
The fi rst case was done on September 8, 2008. To date, 105
consecutive cases including 16 sigmoid achalasia have
received POEM. In all cases symptom score recovered dramatically. In most of the patients, chest pain was reduced
or totally disappeared. No major complications including
mediastinitis, mass bleeding, and mucosal necrosis occurred,
although some minor complications occurred. In this series,
a long myotomy with a long submucosal tunneling was
done in most of the patients, but none showed clinical manifestation of mediastinitis. This suggests that the tight closure
of the mucosal entry site using the endoscopic clipping
device securely avoids the development of severe mediastinitis. Even though minor pneumomediastinum was seen
by CT scan just after POEM, it was not related to any signifi cant clinical symptoms. One patient had local peritonitis
limited to the lesser omentum, which was controlled conservatively by prolonged prescription of antibiotics. In one
case, a chest tube was temporarily inserted to control pneumothorax. In this case air was insuffl ated during the POEM
procedure together with CO
maintained without any additional treatment. No patients
received additional therapy for achalasia except one who
received only a single balloon dilatation with a 20 mm
balloon. Eighteen patients developed endoscopically detected
GERD. Six of them demonstrated symptoms of GERD. All
GERD cases responded well to PPI prescription. Seven cases
. The improved condition was
2
of failure to surgical procedure (six laparoscopic myotomies
and one thoracoscopic myotomy) were consecutively treated
by POEM. Symptom score was also improved dramatically
in those patients.
In conclusion, POEM is a novel less -invasive treatment for
esophageal achalasia with no skin incision. POEM can be
applied to any grade of achalasia, and short -term results are
excellent.
Future of emerging applications
The revolution of minimally invasive surgery over the past
two decades continues to move forward. Since the fi rst
descriptions of NOTES, there has been a concerted effort to
refi ne the techniques of this exciting fi eld because the
potential benefi ts to patients are manifold. Despite the
potential benefi ts of NOTES, to date there are still few
studies demonstrating clear benefi t over standard laparoscopy. Experimental and clinical studies still demonstrate
that, above all else, evolution of technology is needed to
expand the application of NOTES, allowing safety and effi cacy to be demonstrated in new innovative procedures.
And, maybe, natural orifi ce surgery will not be the fi nal
goal or defi nitive conqueror of modern medicine. Current
therapies point toward even less aggressive procedures:
rectal cancer may be cured by adjuvant therapy alone
[53,54], adrenal tumors can be eradicated by radiofrequency
ablation [55], along with the POEM technique [52] for
esophageal achalasia, and possibly many other diseases will
fi nd appropriate responses from researchers aiming at perfecting surgical therapy.
Chapter video clips
Video 19.1 Per -oral endoscopic myotomy (POEM) technique
for esophageal achalasia.
Video 19.2 Per -oral endoscopic myotomy (POEM) technique
for esophageal achalasia.
Video 19.3 Per -oral endoscopic myotomy (POEM) technique
for esophageal achalasia.
Video 19.4 Per -oral endoscopic myotomy (POEM) technique
for esophageal achalasia.
Video 19.5 Per -oral endoscopic myotomy (POEM) technique
for esophageal achalasia.
Video 19.6 Per -oral endoscopic myotomy (POEM) technique
for esophageal achalasia.
Video 19.7 Per -oral endoscopic myotomy (POEM) technique
for esophageal achalasia.
Video 19.8 Per -oral endoscopic myotomy (POEM) technique
for esophageal achalasia.
212
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