HOW I DO IT How I Do It: Per-Oral Endoscopic Myotomy (POEM) Jeffrey L. Ponsky & Jeffrey M. Marks & Eric M. Pauli Received: 7 December 2011 / Accepted: 5 March 2012 / Published online: 27 March 2012 # 2012 The Society for Surgery of the Alimentary Tract Abstract Introduction Laparoscopic Heller myotomy has become the therapy of choice for achalasia. In the last three years, clinical experience with a novel approach to this disease, Per-Oral Endoscopic Myotomy (POEM), has grown. Methods Herein, we describe the technical steps in the POEM procedure. Conclusion In our experience, the method appears to be a safe alternative to standard laparoscopic Heller myotomy, but further assessment is needed to understand long-term outcomes. Keywords POEM . Per-oral endoscopic myotomy . Achalasia . Endoluminal surgery . Heller myotomy Background Achalasia is a disease which is characterized by a progressive difficulty with swallowing. 1 It is caused by failure of relaxa- tion of the lower esophageal sphincter in concert with an essentially aperistaltic esophageal body. 2,3 The underlying pathology is a lack of ganglion cells in the myenteric plexus of the esophageal wall. 4 Therapies have included treatment with nitrates, pneumatic balloon dilation, injection of botuli- num toxin, and surgical division of the muscles of the lower esophageal sphincter (Heller myotomy). 5,6 The latter interven- tion has been most popular in recent years, owing to its great effectiveness and the availability of a laparoscopic approach which has reduced morbidity. 7,8 With this method, however, there is deconstruction of the phrenoesophageal ligament and alteration of the angle of His, both of which may predispose to postoperative gastro-esophageal reflux. 6 Most authors recom- mend the addition of an anti-reflux procedure (Toupet or Dor fundoplication) to ameliorate this problem. 7,9 Recently, a new endoscopic method for reducing lower esophageal sphincter pressure has been developed. This method, per-oral endoscopic myotomy (POEM) grew out of laboratory work performed in the United States and was first performed in humans in Japan. 10–12 It is now being performed clinically throughout the world 13,14 and by sur- geons in a number of centers in the United States. The technique utilizes a flexible endoscope to tunnel beneath the esophageal mucosa and divide the circular muscle fibers of the lower esophagus and upper stomach. While by no means yet the standard of care, this innovative technique is gaining favor amongst surgical endoscopists who are performing the procedure on a highly selected group of patients after dedicated practice in animal and, occasionally, cadaveric models. Preparation of the Patient It is imperative the diagnosis of achalasia be firmly estab- lished by endoscopy and esophageal manometry. A barium contrast study of the esophagus may also be useful. Because patients with achalasia frequently have residual food in the esophagus, a clear liquid diet is used for 2 days prior to the procedure in order to help clear debris from the esophagus. Preoperative assessment and blood work are performed just as for laparoscopic myotomy, and the operating room is prepared for laparoscopic intervention, should it be necessary. J. L. Ponsky (*) : J. M. Marks : E. M. Pauli Department of Surgery, CWRU School of Medicine, University Hospitals, Case Medical Center, Cleveland, OH, USA e-mail: jponsky@yahoo.com J Gastrointest Surg (2012) 16:1251–1255 DOI 10.1007/s11605-012-1868-8