ASGE Peroral Endoscopic Myotomy (POEM) Pearls to Practice: LIVE and Virtual | July 2022-Draganov

Draganov - POEM Tool Box and Methods

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In this document, the author discusses the toolbox and techniques for performing endoscopic submucosal dissection (ESD) and peroral endoscopic myotomy (POEM) procedures. The toolbox includes equipment such as endoscopes, carbon dioxide insufflation, injection solutions, electrosurgical equipment, needle type knives, triangle tip knives, other knives, and coagulation forceps. The author also mentions the importance of room setup for these procedures.<br /><br />The techniques discussed include mucosal incisions (longitudinal and transverse) and closure methods (clips, suturing, X-tack, OTSC, stent). The direction and orientation of the myotomy are also considered, with options including proximal to distal or distal to proximal and anterior (2 o'clock), posterior (5 o'clock), or angle of His.<br /><br />The concept of an "adequate" myotomy is examined in terms of dysphagia relief and gastroesophageal reflux disease (GERD). Different factors are considered, such as anterior vs posterior myotomy, full thickness vs circular (selective) vs partial full thickness myotomy, and optimal myotomy length in the esophagus and cardia. The author notes that there is a lack of high-quality studies on these topics and further research is needed.<br /><br />The author also discusses the results of studies comparing anterior vs posterior myotomy, full thickness vs circular (selective) vs partial full thickness myotomy, and short vs long esophageal myotomy. The document also addresses the optimal length of myotomy in the cardia and various methods of measuring it.<br /><br />In summary, the author emphasizes the importance of having a dedicated toolbox for POEM procedures and the need for technique refinements to reduce GERD while maintaining the clinical efficacy of POEM.

Keywords

endoscopic submucosal dissection

peroral endoscopic myotomy

toolbox

techniques

equipment

mucosal incisions

closure methods

myotomy direction

adequate myotomy

GERD