POEM procedure is often applied in achalasia. Achalasia is a condition in which the muscles at the junction of the esophagus and stomach are very tight and therefore food and even water cannot pass into the stomach. These patients usually present to us with complaints such as difficulty swallowing, a feeling of being stuck in the chest, regurgitation of food, waking up at night with a cough due to regurgitation of food, bad breath and weight loss. The disease can be seen not only in adults but also in children. Sometimes children can be brought to the hospital with recurrent lung infections due to food residues escaping into the lungs because they cannot fully express their difficulty in swallowing. Apart from achalasia, a similar application called “Z-POEM” is performed in a condition that causes pocketing in the esophagus called “Zenker’s Diverticulum”. In addition, in diseases called “gastroparesis” with gastric movement defects and difficulty in gastric emptying, applications that accelerate gastric emptying by applying incisions to the muscles in the gastric outlet hole called “G-POEM” are also performed.

Patients usually consult a doctor with dysphagia. In this case, the first step is endoscopic examination. During endoscopy, the first priority is to make sure that there is no tumor in the esophagus that may prevent swallowing. Apart from this, the specific finding of achalasia is that the area connecting the esophagus and stomach is narrow and the endoscopy tool is forced into the stomach. However, this can sometimes be overlooked in inexperienced hands and a normal endoscopy report may be given, which can lead to a delay in the diagnosis and treatment of patients, sometimes for years. In some cases, observation of food residues in the esophagus facilitates the diagnosis. Another important method used in the diagnosis is a medicated x-ray of the esophagus called “esophageal passage radiography”.

Here, it is seen that the esophagus is enlarged and the lower end is narrowed in the shape of a bird’s beak, which allows the diagnosis to be made. Finally, the pressure of the esophagus is measured using a manometer. This method is used to determine both the diagnosis and the type of achalasia.

POEM is an endoscopic procedure performed under anesthesia, lasting approximately 30 to 60 minutes. After the patient is asleep, the esophagus is accessed through the mouth with an endoscopy tool. An incision is made in the middle of the esophagus and the thin wall of the esophagus is entered. A tunnel is created downwards by applying millimetric incisions in the esophageal wall. On one side of this tunnel is the surface mucosa of the esophagus and on the other side are the esophageal muscles. After creating a tunnel down to the stomach, the muscles in the esophagus, especially in the area connecting the esophagus and the stomach, which are very tight and do not allow food to pass into the stomach, are endoscopically cut and loosened. Finally, the mouth of the tunnel at the entrance to the esophagus is closed with endoscopic sutures and the procedure is completed.

Usually 2 nights of hospitalization is required for POEM procedure. After the anesthetic effect wears off on the day of the procedure, patients are taken to their rooms and intravenous fluid and antibiotic treatment is started. There may be nausea and chest pain after the procedure, but intravenous painkillers and anti-nausea medications are administered and patients’ complaints are tried to be controlled. The next day after the procedure, clear fluid intake is started in the morning. Patients are discharged on the second day of the procedure.

What are the other methods of treating achalasia and how is POEM superior to these methods?

Methods other than POEM in the treatment of achalasia can be summarized as surgery, balloon dilation and Botox application. Botox application is an application based on the logic of relaxing those muscles by injecting botox into the very tight muscles at the lower end of the esophagus. Although it is the least effective method compared to other methods, the effect of the application lasts for 3 to 5 months. Another endoscopic application is dilatation by endoscopically inserting a balloon into the tight area. In this method, the muscles at the lower end of the esophagus are torn with a balloon and an expansion is achieved in this area. The most important disadvantage of this method is that the procedure can sometimes lead to uncontrolled tears and sometimes perforation. For this reason, it must be performed in competent hands. Another important disadvantage of balloon dilatation is that the effect of the procedure is not permanent and usually needs to be repeated every few years.

What are the other methods of treating achalasia and how is POEM superior to these methods?

Methods other than POEM in the treatment of achalasia can be summarized as surgery, balloon dilatation and Botox application. Botox application is an application based on the logic of relaxing those muscles by injecting botox into the very tight muscles at the lower end of the esophagus. Although it is the least effective method compared to other methods, the effect of the application lasts for 3 to 5 months. Another endoscopic application is dilatation by endoscopically inserting a balloon into the tight area. In this method, the muscles at the lower end of the esophagus are torn with a balloon and an expansion is achieved in this area. The most important disadvantage of this method is that the procedure can sometimes lead to uncontrolled tears and sometimes perforation. For this reason, it must be performed in competent hands. Another important disadvantage of balloon dilatation is that the effect of the procedure is not permanent and usually needs to be repeated every few years.

Achalasia was previously treated with surgery. During the surgery, the abdominal cavity was entered and the muscles at the lower end of the esophagus were cut. However, since this surgery would also cause reflux, a separate intervention for reflux was performed in the same session. Today, this surgery has been largely replaced by POEM, a non-surgical method. In this way, no surgery is performed, the abdominal cavity is not entered, and unwanted side effects such as infection and nerve incision that may occur during surgery are minimized. In addition, since the procedure is completed endoscopically, the hospital stay, food intake and recovery time are also very fast. Patients can start taking liquid food the day after the procedure. In addition, it is recognized as the most effective method today in terms of treatment success and the treatment offers a permanent result.

POEM is a very safe and low-risk procedure if performed by an experienced gastroenterologist. One of the risks associated with the procedure is bleeding that may occur in the incision areas. These bleeding can usually be controlled with some endoscopic interventions during the procedure. Another risk is air accumulation in the abdominal and chest cavity due to the carbon dioxide gas used during the procedure. Another risk is the risk of infection and this risk can be controlled with antibiotic applications. Finally, leakage in the esophagus may occur; however, this risk is extremely rare. In the results of studies, it has been reported that the life risks of the procedure are very low in experienced hands.