POEM, WAS: New study - endoscopic myotomy

[Guest guest]

More on this topic.

Over a week ago I received a private email about POEM. As some of you

know my private mail box gets my lowest priority for response. I also

had modem troubles and a new job so I am only now getting to this.

Thank-you for suggesting I take another look.

I had said:

> POEM is just another way to get in the body to do the myotomy. Instead

> of making holes (incisions) on the outside they go in through the

> mouth and make them on the inside. The work is still done

> endoscopically, as are laparoscopic and VATS (video-assisted thoracic

> surgery) myotomies. So, much like the other endoscopic myotomies but

> without visible incisions.

The surgeons doing POEM claim that a fundoplication is not needed

because there is no need to dissect structures surrounding the abdominal

esophagus. This is a lot like the claims made by surgeons doing VATS

myotomies. In fact POEM really is a type of VATS. Many laparoscopic

(lap) surgeons don't buy these claims. It has even been suggested that

the reasons are really just excuses to justify using a method that makes

doing fundoplications much more difficult. With VATS is has also been

suggested that the myotomy can be done more on the esophagus making it

require less on the stomach. Often this meant that the myotomy was

extended only 1cm onto the stomach. With lap 2cm was standard and now 3

or more is often used. When a myotomy fails because it was not long

enough it is normally extended more onto the stomach. With POEM surgeons

have been doing 2cm onto the stomach. VATS has been said to not require

a fundoplication because more of the myotomy is above the stomach and

less is on it but POEM seems to have just as much on the stomach as many

lap surgeons use. Not all lap surgeons believe that lap myotomy needs or

should have a fundoplication. So far, some patients who had either lap

or VATS have had problems with acid reflux. Some who had fundoplications

also had acid problem in spite of the fundoplication. So far no one is

reporting patients with acid problems after POEM. Is that because the

studies are small, new or the criteria use do define acid reflux is set

high or POEM is better? Time will tell. I remain skeptical. It looks to

me like VATS done through the mouth.

Going through the mouth raises another issue. The GI tract from lips to

anus is not considered a clean place. Certainly not sterile. Yet, in

POEM the surgical instruments will need to pass through your mouth and

upper esophagus to get to where they need to make incisions. Is this a

bit like going in and spitting on the instruments before surgery? So far

this does not seem to be a problem with POEM. Time will tell.

There is an aspect of POEM that I had missed before that is interesting

and different from the other myotomies. Normally a heller myotomy cuts

through both the longitudinal and the ring layers of muscles. It is the

ring muscles that are the problem in achalasia. With POEM, because of

the way it tunnels between layers the ring muscles can be selectively

cut without cutting the longitudinal muscles. It sounds like a good

thing but does it allow the ring muscles to separate enough so that they

do not grow, or scar, back together over time? Maybe. Time will tell.

In the mean time I am going to continue to not universally push, lap,

VATS, POEM, dilatation or what have you. There is, in my opinion no one

size fits all, or right answer, just good guess. I will still suggest

that everyone find the best doctors they can and then do your homework

and decide with them what to do. Lap, VATS, POEM, dilatation,

fundoplication, no fundoplication, I am fine with all of them, if you

understand and want them. There are reason for and against all of them.

For more see:

GeneralSurgeryNews.com

Transoral Myotomy Makes for Striking Video, Effective Therapy

“Scarless” Achalasia Surgery Efficacious And Safe in Series of 100 Patients

http://www.generalsurgerynews.com/ViewArticle.aspx?d=In+the+News & d_id=69 & i=Augus\

t+2011 & i_id=756 & a_id=18804

Dr. Inoue said. “In 105 consecutive cases, short-term results have been

excellent. Now the indication of POEM is to all achalasia patients. POEM

is definitely the way of the future.”

Maybe, but I will let you decide.

notan