The Pulse | Thursday, August 8, 2019

New Endoscopic Procedures Offer Non-surgical Options for Complex Esophageal Diseases

By Darin Dufault, MD, Duke Health

The first procedure, per oral endoscopic myotomy (POEM), is a procedure with utility in the management of motility disorders of the esophagus, such as achalasia, jackhammer esophagus, and esophagogastric junction outlet obstruction (EGJOO). Breaking the name down, the process of the procedure is revealed: per oral (through the mouth), endoscopic (with a scope), myotomy (cut muscle). Indeed, POEM is a technique to cut the muscles of the esophagus with a scope through the mouth, in contrast to the surgical esophageal myotomy, performed through incisions in the abdomen or chest.

In brief, POEM is performed by taking advantage of the fact that the wall of the esophagus is composed chiefly of three layers, allowing us to make a small hole in the mucosa (inner layer), then “dig” a tunnel in the submucosa (middle layer) through careful dissection, which exposes the muscles (outer layer), allowing them to be cut safely. Lastly, the initial small hole in the mucosa is closed with several standard endoscopic clips, sealing the tunnel and closing any perforation. Patients generally stay overnight one night for observation and go home with a careful, progressive diet.

The second procedure, transoral incisionless fundoplication (TIF), is an endoscopic procedure offering an alternative to surgical fundoplication for the treatment of uncontrolled gastro-esophageal reflux disease (GERD). This procedure uses a specialized piece of equipment along with a standard endoscope to bolster, tighten and lengthen the gastro-esophageal junction by tethering the gastric fundus to the region. This is done in a similar fashion to a surgical fundoplication, but from the inside of the stomach using an endoscope, rather than through surgical incisions in the abdomen. Patients typically go home the same day with a similarly careful, progressive diet.

These two procedures have shown good results and, importantly, offer durable alternative management for patients who are not willing to pursue surgical options or are not ideal surgical candidates due to comorbid conditions. However, tremendous thought and care must be taken when establishing POEM and/or TIF programs at your institution. These procedures are sophisticated, tedious and challenging. Specialized training is mandatory, ideally for everyone involved, including nursing and technicians. Teamwork is critical, and having a small core of staff dedicated to these procedures is necessary to establish team rapport and avoid diluting the procedure volume to a level where no one maintains proficiency. At our institution for these procedures, our core group consists of two physicians, four nurses, and one technician for all POEM and TIF cases, as well as other advanced luminal endoscopic procedures such as endoscopic submucosal dissection (ESD), full thickness resection (FTR), and endoscopic suturing. Before engaging with these advanced methods, institutions must seriously consider the training, resources and staffing needed to successfully perform such procedures.

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