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Approach to the challenging POEM. Lessons learned from salvage POEM after prior failed myotomy
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Stavros Nicholas Stavropoulos |
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Mount Sinai-South Nassau Hospital |
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| Although Heller myotomy (HM) is an effective treatment for achalasia, failures do occur in 10-20% of HMs even at expert centers. This percentage may be even higher nowadays as a majority of HMs in the US are now performed in low-volume centers. This may also occur with POEM as a limited number of cases is distributed over progressively more institutions/operators thus diluting each institution's/operator's experience. A failed prior Heller has been identified in several studies as a strong predictor of POEM difficulty and aborted POEM. This can be probably also extrapolated to a failed prior POEM. We will review the underlying causative factors for the increased difficulty in this setting. These include long-standing disease associated with fibrosis due to stasis and prior myotomy as well as adverse anatomic changes including sigmoidization of the esophagus and blown-out-myotomy (BOM) diverticula. We will review data that support POEM as the optimal salvage approach in this setting. We will also review the excellent outcomes of salvage POEM after failed Heller in large published series including our own. Finally, we will review technical tips and tricks to overcome the challenges of salvage POEM. Specifically, we will review techniques that help overcome submucosal fibrosis, facilitate closure of accidental mucosotomies surrounded by devitalized mucosa (often encountered in salvage POEM) and techniques the permit successful myotomy in the setting of "blow-out diverticula" and severe esophageal sigmoidization. |
Index Term 1: POEM
Index Term 2: HELLER-MYOTOMY
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