Per-Oral Endoscopic Myotomy (POEM)

Gastroenterology

Your Consultant / Doctor has advised you to have Per-Oral Endoscopic Myotomy (POEM). What is Per-Oral Endoscopic Myotomy (POEM)?

Per-Oral Endoscopic Myotomy (POEM) is a minimally invasive procedure whereby a flexible camera (endoscope) is advanced into the oesophagus (gullet). Through a small incision (cut) on the inner lining of the oesophagus the camera is tunnelled between the layers of the oesophagus. The muscular wall of the oesophagus is then identified and cut (myotomy) with a small needle to help resolve your symptoms.

This is another way to perform a myotomy (cutting the muscle) other than the surgical route. This procedure is being performed all over the world; the results so far are very encouraging with success of over 90% and appear to be as good as surgery.

What is the aim of POEM procedure?

The aim is to help alleviate the symptoms of difficulty swallowing, chest pain and regurgitation that are associated with Alchalasia. Achalasia is a disorder of the gullet where it loses the ability to move food along. The valve at the end of the gullet also fails to open and allow food to pass into your stomach.As a result, food gets stuck in your gullet and is often brought back up.

What are the benefits of having POEM?

The benefits of having POEM procedure are several.

1. It is minimally invasive and performed in the gastroenterology unit rather than an operation theatre.
2. No external scars of surgery.
3. When compared to surgery, the length of muscle layer accessible is long and therefore can be extended as required.
4. This procedure can also be performed in cases where other treatments have not produced the desired symptom relief.
5. Symptom improvement has been reported to be immediate.

What are the risks of having POEM procedure?

There is a small risk of bleeding or perforation (tear in the oesophagus or stomach) during the procedure. This is usually controlled with a forceps that is attached to a heat source at the time of the procedure. Very rarely surgery may be required for perforation or bleeding.

A day after the procedure a barium swallow (X-ray after drinking white liquid) test is performed to ensure no leak or perforation had occurred. If there is this can be controlled with antibiotics and with time it seals on its own. This may require a longer hospital stay.

Normally, air is used to open the gullet but with this procedure instead of air CO2 gas will be used. Sometimes this gas can enter into the neck and tummy. This may cause some discomfort (less so than air) but usually settles with time. Rarely, the gas inside the tummy can cause discomfort, this can however, be removed by passing a small needle into the tummy.

Weeks or months after the procedure, some patients (10-15%) may experience acid heartburn symptoms. This is usually controlled with strong acid suppression medications prescribed by your doctor.

Rarely the procedure may have to be stopped mid-way if there is difficulty in accessing the muscle layer due to scarring from previous treatment. In such a case further treatment options will be discussed with you by the doctor.

It is important to note most of these risks are also seen with other treatment options available for your condition.

Are there any alternatives available?

Treatment of achalasia involves relaxing the muscle or disrupting the muscle fibres to improve symptoms. This is can be attempted by several methods and each treatment option has its advantages and disadvantages.

1. Pneumatic Dilation: This involves passing a deflated balloon into the oesophagus; this is then inflated to high pressure to disrupt the muscle at the junction between the gullet and the stomach. This procedure needs to be performed frequently depending on the severity of the symptoms.
2. Surgical Heller’s Myotomy: This is a surgical procedure performed by keyhole or open approach to access the muscle layer from the outside and a cut is performed. This involves surgery and needs to be performed in the operating theatre.
3. Endoscopic Botulinum Toxin (Botox) injection: With the help of an endoscope a needle is passed into the oesophagus and at the junction between the gullet and the stomach botulinum toxin is injected. The response to this treatment is very unpredictable and variable.

Furthermore, this requires repeat procedures depending on the response.

What will happen if I decide not to have treatment?

This would be entirely your choice. Informed consent will be obtained before the procedure and the procedure would be explained to you in detail. If you decide not to have the procedure performed, the doctor will discuss with you the pros and cons of other treatment options that are available to help resolve your symptoms. Some of these options are outlined above.

What sort of anaesthetic will be given to me?

You will be given a general anaesthetic. General anaesthesia is drug-induced unconsciousness: it is always provided by an anaesthetist, who is a doctor with specialist training.

Unfortunately, general anaesthesia can cause side effects and complications. Side effects are common, but are usually short-lived: they include nausea, confusion and pain.

Complications are very rare, but can cause lasting injury: they include awareness, paralysis and death.

There is a risk of damage to teeth, particularly caps or crowns and veneers. Your anaesthetist will take every care, but occasionally damage can occur.

The risks of anaesthesia and surgery are lower for those who are undergoing minor surgery, and who are young, fit, active and well.

For more information, please ask for a copy of the leaflet “You and Your Anaesthetic” (PIF 344).You will be given an opportunity to discuss anaesthetic options and risks with your anaesthetist before your surgery.

If you are worried about any of these risks, please speak to your Consultant or a member of their team.

Getting ready for your operation

• You will usually be seen in the pre-operative clinic before you are admitted to hospital. Here you will have blood tests, and sometimes a heart trace or a chest X-ray. You will be assessed to see if you are fit for the anaesthetic.
• The staff will ask routine questions about your health, the medicine you take at the moment and any allergies you may have.
• You will be given instructions on eating and drinking before your operation.
• You will be able to discuss the operation with a doctor. You will be asked to sign a consent form to say you understand the procedure, and what the operation involves.

Preparation

To allow a clear view, your stomach must be empty. You are therefore asked to have nothing to eat or drink for at least six hours before the test.

You will be asked to remove any tight clothing, ties, dentures, spectacles and contact lenses.

Please do not bring large amounts of money or valuables with you, as the Trust cannot be held responsible for them

Important: If you have:

1. Diabetes

2. Are taking: (Warfarin tablets, Clopidogrel (plavix) tablets)

3. Anticoagulants:

   • Warfarin

   • Heparin/Fragmin/Clexane

   • Dabigatran

   • Rivaroxiban

   • Sinthrome

   • Apixaban

   • Fondaparinux

   • Edoxaban

4. Antiplatelet therapy:

   • Clopidogrel (Plavix)

   • Prasugrel (Efient)

   • Ticagrelor (Brilique)

   • Dipyridamole (Persantin) and aspirin

5. Are on dialysis

6. Have suffered a heart attack within the last three months

You must contact the Gastroenterology Unit as soon as you receive this information leaflet. Tel: 0151 706 2720

Text phone number: 18001 0151 706 2720 The day of your operation

• You will come into hospital on the day of your operation. Please make sure you contact the ward before you leave home to check bed availability.
• Please leave all cash and valuables at home. If you need to bring valuables into hospital, these can be sent to General Office for safekeeping. General Office is open between 8.30 and 4.30 Monday to Friday.
• Therefore, if you are discharged outside these times we will not be able to return your property until General Office is open. The Trust does not accept responsibility for items not handed in for safekeeping.
• Please bring any medication you take into hospital with you.
• Please bring in toiletries, nightwear and towels.
• You will be asked to remove jewellery - plain band rings can be worn but they will be taped.
• Please leave body piercings at home. False nails and nail polish will also need to be removed if worn.
• If you are on regular medication, you will be told to take this if necessary.
• You will be asked to put on a gown and disposable underwear.
• A bracelet with your personal details will be attached to your wrist.
• You may be prescribed some medication to take before your operation by the anaesthetist. A member of the nursing staff will give this to you.

What should I expect after my operation?

• After your operation you will be kept in the endoscopy recovery room before being transferred to the ward.
• A nurse will check your pulse, blood pressure, and breathing rate regularly.
• It is important that if you feel any pain you must tell the nursing staff, who can give you painkillers to help.
• The nursing staff will also advise you when you can start taking sips of water.
• Anaesthetics can make some people sick. If you feel sick we advise you not to drink until this feeling has passed. The nursing staff may offer you an injection to help this sick feeling go away.
• The first time you get out of bed, please make sure you ask a nurse to be with you. This is in case you feel dizzy.
• You will be admitted for observation overnight in the hospital.
• The following day a barium test will be performed to ensure the fluid enters the stomach with ease and rule out any tear.

Going Home

The day after the procedure and if the barium test is clear, then you will be allowed some liquids to drink and will be permitted to go home with follow up being arranged in the outpatient department.

Discharge Information Pain relief and medication

The nursing staff will advise you about painkillers before you leave the hospital. Please tell the nurses what painkilling tablets you have at home.

Getting back to normal

Remember that you have just had an operation. It is normal to feel more tired than usual for a few days afterwards.

Minor post procedure symptoms

You may experience a sore throat. This sometimes lasts a couple of days but more commonly passes off after a couple of hours.

Stomach ache is most likely due to the air that is introduced into the stomach during the procedure and will pass in its own time. You may feel discomfort under your breastbone due to the tube that has been passed.

Serious post procedure signs and symptoms

If you experience any severe pain in your abdomen, chest and neck this could be due to bleeding from a small operation that may have been necessary as part of the examination

You are advised to attend your nearest Emergency department (A&E) as soon as possible taking this information leaflet with you so as to let them know what treatment you have had.

Returning to work

You should be able to return to work a day after discharge from the hospital if there were no other issues.

Further Appointments

You will be given an appointment in the outpatient clinic to discuss the effect of the procedure and to address further issues if they arise.

You may also receive a phone call from the endoscopy team regarding your experience, procedure, symptoms and outcome.

Cancellations

If you are unable to keep this appointment, please let us know as soon as possible on Tel: 0151 706 2720 Text phone number: 18001 0151 706 2720.

We will be above to give your appointment to another patient and arrange a further one for you.

Transport

• Transport has not been arranged for this appointment so it will be necessary for you to make your own arrangements.
• If you have been referred to us from clinic and usually have an ambulance to bring you for your appointment, please contact us on Tel: 0151 706 2720 Text phone number: 18001 0151 706 2720 as soon as possible.
• If you have been referred to us by your family doctor, (GP) and need an ambulance please contact their surgery.
• Parking for patients and visitors is available at the Q-Park multistorey car park opposite the main hospital entrance on Prescot Street. The entrance by car is on Epworth Street off Erskine Street. The car park is open 24 hours a day, seven days a week. This is a private car park and charges apply. The car park is continually monitored by parking hosts, and CCTV. There are disabled spaces within the car park. If you need help, please speak with a parking host at the car park entrance.

Feedback

Your feedback is important to us and helps us influence care in the future.

Following your discharge from hospital or attendance at your outpatient appointment you will receive a text asking if you would recommend our service to others. Please take the time to text back, you will not be charged for the text and can opt out at any point. Your co-operation is greatly appreciated.