POEM - Per-Oral Endoscopic Myotomy

Diet

• 5 days before the procedure: semi-solid food.
• 2 days before the procedure: liquid food.

From midnight before the procedure: do not take anything by mouth.

Discuss with the doctor whether you should stop taking blood thinners.

The doctor makes an incision in the inner lining of the esophagus to make a tunnel. The endoscope is used to make this tunnel up to the level of transition from the esophagus to the stomach. This tunnel is located between the mucous membrane and the muscle layers. The doctor can then cut the muscle of the esophagus precisely at any level. There are two types of muscles in the esophagus. With a POEM, they can be cut selectively and individually. At the end of the procedure, the doctor closes access to the tunnel with endoscopic clips.

Cutting the esophageal muscle may cause discomfort. Therefore, after the procedure, all patients receive an infusion with a painkiller. You can control the administration yourself: if you want extra pain relief, push a button yourself. This is an effective method to make you as comfortable as possible after the procedure. You must stay sober until the morning after the POEM procedure. We do this to protect the delicate tunnel that we created during the procedure. You can put some water on a sponge to moisten your mouth, but definitely don't swallow the water. The doctor prescribes antibiotics to protect the tunnel. You should take it for five days after the procedure. Please inform us in advance if you are allergic to antibiotics. The day after the procedure, we arrange a swallowing test with a liquid that is visible on x-rays, so we can check that the tunnel that the doctor made is completely closed. If so, you may drink clear drinks for the next two hours. If that works, we will follow a one-day liquid diet. On day two after the procedure, we will start with a soft diet. You must follow this up to 14 days after the procedure. If all goes well, you may go back to a normal diet after 14 days.

Recovery after a POEM can take up to one month. Most people are able to return to work after two weeks. We recommend that you do not exercise intensively or lift heavy loads until two weeks after the procedure. If you continue to have pain or bleeding, notify the Endoscopic Unit as soon as possible. Acid reflux can also be a problem after the procedure (affects up to one in three people). In that case, the doctor prescribes acid inhibitors (e.g. Pantoprazole) in a high dose. You should take it twice a day for four weeks. The dose is then reduced to 40 mg once a day. Only 2 to 3 percent of people with acid reflux after a POEM do the medication not work. An endoscopic procedure is being developed to combat reflux in this situation. Talk to your doctor about it.

As with any interventional procedure, a POEM also involves risks. Here are the most frequent ones:

• Persistent perforation of the esophagus that cannot be closed. This can be a repeated endoscopy and revision of the metal clips (1%), placement of a stent.
• Tunnel bleeding that cannot be controlled endoscopically or requires a new endoscopy (< 1%).
• Accumulation of gas in the abdomen (10%). This is quite normal during the procedure. We can solve this by placing a needle in the abdomen. You will then have a patch on your stomach after the procedure.
• Accumulation in the neck of gas used during the procedure (10%). This improves quickly after the procedure and is not dangerous.
• Pulmonary damage (< 1%).
• Very rarely, the problem is not fully resolved after a POEM (percentage varies according to the type of movement disorder, previous treatment, etc.). Discuss this with your doctor before the test
• Symptoms of Acid Reflux