Therapeutic flexible endoscopy replacing surgery: Part 3—Peroral esophageal myotomy

Peroral esophageal myotomy (POEM) is a novel endoscopic operation for achalasia, first performed clinically by Haru Inoue in Japan in 2008. Using techniques developed through experience in endoscopic submucosal dissection and natural orifice transluminal endoscopic surgery, during the POEM procedure a controlled surgical myotomy across the esophagogastric junction is created using a standard flexible gastroscope, thus eliminating all skin incisions. This article reviews the key steps of the procedure, and outlines the necessary skills, equipment, and instrumentation that are required to perform it. The existing literature regarding procedural and postoperative outcomes is reviewed, and recommendations are given regarding the symptomatic and physiological assessment of POEM patients going forward, so that the procedure can be objectively compared with the current standard of care, laparoscopic Heller myotomy.