Peroral Endoscopic Myotomy (POEM)

Swallowing is something most people do without thinking about it. When it starts becoming difficult, the change is usually gradual at first. Patients often describe it as food “getting stuck” or taking longer to go down. Over time, this can progress to difficulty with both solids and liquids.

One of the better-known causes of this pattern is achalasia, a condition where the lower end of the oesophagus does not relax properly. Rather than relaxing appropriately, the sphincter remains contracted. This leads to delayed emptying, with food often retained within the oesophagus.

Peroral Endoscopic Myotomy (POEM) was developed as an endoscopic solution to this functional obstruction. The procedure enables direct access to the affected muscle through the oesophageal lumen using a flexible endoscope.
At Gleneagles Hospitals, this procedure is performed as part of advanced gastrointestinal care, usually after careful confirmation of the diagnosis and discussion of treatment options.

POEM is best understood as a targeted release of muscle tension. It does not remove tissue or treat a blockage in the usual sense. Rather, it involves addressing how the muscles of the oesophagus react.

In achalasia, the problem occurs at the lower part of the oesophagus, where the sphincter remains constricted rather than relaxing. This ring of muscle is supposed to relax when swallowing. When it doesn’t, pressure builds up above it. POEM works by cutting specific muscle fibres, thereby reducing this pressure.

What makes the technique different is how it is performed. There are no external cuts. Everything is done through the mouth. A flexible endoscope is passed into the oesophagus, and a small entry point is made in the inner lining. From there, a narrow tunnel is created within the wall of the oesophagus. Through this tunnel, the muscle layer is reached and divided as needed.

The small opening made at the start is then closed with clips. It usually heals on its own and does not leave a visible scar.
 

The POEM procedure is not needed for every patient with swallowing difficulty. The procedure is usually reserved for confirmed motility disorders, particularly when symptoms are affecting daily life.

The most common indication is achalasia. This includes:

• Newly diagnosed patients
• Those with long-standing symptoms
• Individuals who have had prior treatments but continue to have difficulty

It may also be considered in certain less common conditions, such as spastic disorders of the oesophagus, though this depends on individual assessment.

Patients often report a mix of symptoms rather than just one. Difficulty swallowing is usually the main complaint, but it may be accompanied by regurgitation, especially when lying down. Some people notice chest discomfort that does not seem related to exertion. Weight loss can occur, though not in every case.

The decision to proceed is rarely made on symptoms alone. It depends on objective testing.

Before POEM is even discussed as an option, the diagnosis needs to be clear. Several tests are used for this purpose.

• One of the most important is oesophageal manometry. This test will determine the pressure inside the oesophagus and thus confirm the presence of any abnormality in the oesophageal muscle's function.
• An endoscopy is performed primarily to rule out any structural problem that could be responsible for the symptoms.
• A barium swallow is another test sometimes performed in cases of achalasia. This is because it will show how quickly the food travels inside the oesophagus.
• Other than this, general blood tests are performed, as this is an anaesthetic procedure.

While less invasive than surgery, POEM remains a significant intervention and is not suitable in all cases.

People with significant heart or lung disease may not tolerate general anaesthesia comfortably. There are also cases where the oesophagus is already markedly dilated and functioning poorly, which can affect the expected benefit. Active infection or underlying bleeding problems usually need to be addressed before moving ahead.

In practice, these decisions are not made by a checklist alone. The decision ultimately depends on the individual patient and includes their condition, test results, and fitness level. This kind of assessment is done by qualified doctors in a professional setting. At Gleneagles Hospitals, different specialists are involved in planning the treatment approach.

Preparation

Most patients are advised not to eat for several hours before the procedure. Sometimes a liquid diet is recommended the day before, especially if there is concern about retained food in the oesophagus.

Medications are reviewed in advance. Blood thinners, if being taken, may need temporary adjustment. These instructions are usually given clearly in advance.

Inside the Procedure Room

POEM is performed under general anaesthesia. The patient is asleep throughout.

Once the endoscope is introduced:

• A small incision is made in the inner lining of the oesophagus
• A tunnel is created within the wall
• The muscle layer responsible for the tight sphincter is carefully cut
• The extent of cutting depends on the condition being treated
• The entry site is closed with clips

Depending on the case, the procedure may take about 1 to 2 hours to complete.

Immediately After

After the procedure, patients are observed in a recovery area. At this stage, breathing and heart rate are watched carefully, along with any early signs of complications. Food is not started immediately. Usually, imaging is done first to confirm there is no leak. Once everything is satisfactory, liquids are introduced, followed by a gradual return to soft foods.

Most patients stay in the hospital for a short period, often just a few days.

Recovery is generally straightforward, though not entirely effortless. Some discomfort in the chest or throat is common for a short time. This usually settles without much intervention. Energy levels may be lower for a few days. Patients are usually advised to take things a bit slowly at first rather than returning to their usual routine right away.

Diet is brought back step by step. It usually begins with the introduction of liquids, then progresses to soft foods, and ultimately returns to the patient's usual diet, which is well tolerated. These appointments will be made to monitor the process. Improvement in swallowing ability is often noticed by patients early on, even though it may take time to become fully comfortable. With POEM, the recovery process is carefully managed at the Gleneagles Hospitals through dietary advice.

The POEM procedure is safe, but it still carries risks.

Some complications are related to the technique itself. These include minor injuries to the lining of the oesophagus or bleeding within the wall. Air can sometimes track into surrounding spaces, though this is usually detected early and managed. A longer-term issue that might arise is acid reflux. Since the lower sphincter is loosened, stomach acid may move upward more easily. Not everyone experiences this, but it is common enough to be discussed beforehand. Medications are often effective in controlling it.
 

Over time, POEM has become more widely used, largely because it provides effective results without the need for open surgery.

Compared with traditional approaches:

• There are no external cuts
• Recovery is usually quicker
• The muscle can be targeted more precisely
• It can still be performed in patients who have had prior treatment

Another advantage is flexibility. The length and position of the myotomy can be adjusted to suit the condition. This level of flexibility is not always possible with other approaches.

Outcomes with POEM vary and are closely linked to the experience of doctors and other medical professionals involved. Careful patient selection and appropriate management around the procedure both play a role.

At Gleneagles Hospitals, patients are assessed in advance, with relevant investigations and specialist input as required. The procedure is carried out within a structured clinical setting, with coordinated input from the relevant teams. The procedure is supported by anaesthesia teams familiar with advanced endoscopic work, and follow-up care is planned from the start.

This kind of approach, along with thorough guidance from experienced doctors, helps keep treatment safe while also aiming for consistent outcomes.
 

POEM has gradually led to changes in the treatment of specific types of oesophageal diseases. Instead of treating the problem from outside, POEM enables treatment of the disease internally within the oesophagus, eliminating the need for invasive surgery. For people having trouble swallowing their food, for example, people with achalasia, it is helpful even if it doesn’t cure the problem. Outcomes are generally favourable when the diagnosis is clear and the procedure is performed in an appropriate setting.