Peroral Endoscopic Myotomy (POEM)

Peroral Endoscopic Myotomy (POEM) is an advanced, minimally invasive endoscopic procedure developed to treat achalasia cardia and other esophageal motility disorders that cause difficulty in swallowing. Achalasia is a rare condition in which the lower esophageal sphincter (LES) — the muscular valve connecting the esophagus and stomach — fails to relax during swallowing. As a result, food and liquids accumulate in the esophagus, leading to discomfort, regurgitation, and nutritional issues.

POEM offers a scar-free, highly effective alternative to traditional surgical myotomy. It restores the normal swallowing function by cutting the inner muscle fibers of the LES through a natural orifice — the mouth — without any external incisions.

Since its introduction in Japan in 2008, POEM has become a globally recognized standard of care for achalasia and related disorders due to its safety, precision, and durable results.

To appreciate the importance of POEM, it’s essential to understand how the esophagus works. Normally, when you swallow, a coordinated wave of muscle contractions pushes food downward. The LES relaxes momentarily to allow the passage of food into the stomach and then closes to prevent acid reflux. In achalasia, this coordination is lost. The LES remains abnormally tight, and the esophageal muscles fail to contract properly, causing food stasis and a feeling of obstruction. Over time, the esophagus becomes dilated and loses its tone.

Common symptoms include:

• Difficulty swallowing solids and liquids (dysphagia)
• Chest pain after eating
• Regurgitation of undigested food
• Unexplained weight loss
• Occasional coughing at night or aspiration

POEM directly addresses the root cause by relaxing the LES muscle permanently.

The procedure is performed by a gastroenterologist or interventional endoscopist trained in advanced endoscopic techniques. It usually takes 60–90 minutes and is done under general anesthesia for complete patient comfort.

• Endoscope insertion: A thin, flexible endoscope is gently inserted through the mouth and advanced down the esophagus.
• Mucosal incision: A small (about 1–2 cm) incision is made in the inner lining (mucosa) of the esophagus to access the submucosal layer.
• Creation of a submucosal tunnel: The endoscopist carefully creates a tunnel within the wall of the esophagus toward the LES. This pathway allows precise access to the muscle fibers without disturbing the outer layers.
• Myotomy (muscle cutting): Once the LES is reached, the inner circular muscle fibers responsible for the obstruction are selectively cut. This relaxes the sphincter and restores normal passage of food into the stomach.
• Closure: After the myotomy, the mucosal entry point is closed using small endoscopic clips. There are no stitches or external scars.
• Recovery and follow-up: After the procedure, patients are monitored for a short period and start with a liquid diet, gradually transitioning to soft and then regular food. Most experience marked improvement in swallowing within 24–48 hours.

POEM has transformed the management of esophageal motility disorders because it:

• Provides long-lasting relief from swallowing difficulty.
• Leaves no external incision or visible scar.
• Allows precise, tailored cutting of the affected muscle.
• Offers faster recovery compared to open or laparoscopic surgery.
• Is suitable for all types of achalasia, including complex or failed previous treatments.
• Preserves normal anatomy and minimizes trauma to surrounding tissues.

Studies worldwide have shown symptom improvement in over 90–95% of patients, with durable results lasting for years.

Though originally developed for achalasia, POEM is now used in several other esophageal and gastric motility disorders, such as:

• Spastic esophageal disorders (e.g., diffuse esophageal spasm)
• Jackhammer esophagus (hypercontractile esophagus)
• EGJ outflow obstruction
• Gastroparesis, where a modified version called G-POEM (Gastric POEM) helps improve stomach emptying

This adaptability makes POEM a versatile and future-forward technique in the field of therapeutic endoscopy.

After POEM, most patients notice immediate improvement in swallowing and meal comfort. A soft or semi-liquid diet is advised for a few days, followed by gradual progression to solids. Follow-up includes periodic evaluation with endoscopy or barium swallow studies to assess healing and long-term muscle function. Patients often describe POEM as life-changing — the ability to eat normally without discomfort restores confidence, nutrition, and quality of life.

Peroral Endoscopic Myotomy (POEM) is a gentle, modern way to treat swallowing problems and achalasia with precision and comfort. If you or someone you care about finds it hard to swallow or eat normally, don’t wait — early evaluation makes a big difference.

Book your appointment with Dr. Hitendra K Garg, Gastroenterologist & Interventional Endoscopist, to see if POEM is the right treatment for you.

Eat comfortably again, enjoy your meals, and get back the simple joy of living freely.