[The role of peroral endoscopic myotomy (POEM) in achalasia]

Achalasia is a rare motility disorder of the oesophagus. Classic achalasia is characterised by a lack of propulsive peristalsis of the distal oesophagus and incomplete relaxation of the lower oesophageal sphincter (LES). Traditionally achalasia is treated either endoscopically by pneumatic balloon dilatation or laparoscopically by Heller's myotomy. Both therapeutic procedures show a comparable effectiveness. Recently, peroral endoscopic myotomy was introduced as a new definitive treatment option. So far, this minimally invasive therapy was evaluated in a few clinical studies only. In this survey, peroral endoscopic myotomy is presented and compared to the well established surgical treatment. The diagnosis of achalasia is based on the patient's medical history and analysis of symptoms and particularly on oesophageal manometry. In addition, a barium swallow (oesophagram) and upper endoscopy are performed to rule out other reasons causing dysphagia. The patient's complaints should be recorded by use of a symptoms score. The POEM procedure starts with an incision of the mucosa at the level of the mid-oesophagus. Then, a submucosal tunnel is created distally passing approximately 2 cm over the oesophagogastric junction. After this step, myotomy of (at least) the circular muscle bundle of the distal oesophagus is performed and should be extended to a distance of 2 cm over the cardiac. Finally the mucosal entry site at the level of the mid-oesophagus is closed with endoscopic clips. First results of this technique are very promising with significant symptom relief and reduction of the mean LES pressure. In conclusion, POEM is a new, minimally invasive therapeutic option for the treatment of oesophageal achalasia. First results are very promising; long-term results and results of comparative clinical trials with established treatment methods must be awaited.