POEM is an advanced & novel highly skilled endoscopic procedure done for the relief of Difficulty in Swallowing & chest pain due to Achalasia Cardia & Esophageal motivative diseases or disorders.

Lower Esophageal Sphincter (LES) is an natural state of contraction tp prevent gastro esophageal reflux disease. LES relaxes with each swallow to allow the food bolus to enter stomach. In Achalasia Cardia there is failure of LES to relax on swallowing resulting in difficulty in swallowing. Sometimes Achalasia is associated with excessive spasm of muscle fibers in the body of esophagus causing chest pain & painful dysphagia. (Achalasia Type II & Type III)

The conventional treatment is

1. Balloon Dilatation of LES which randomly breaks circular muscle fibers decreasing the LES tone. It is uncontrolled procedure with variable results, risk of perforation & recurrence of symptoms.
2. Laparoscopic Myotomy: This Myotomy is possible mainly for abdominal part of esophagus. In Type 2 Achalasia we need to extend Myotomy upto mid thoracic esophagus which is not possible by abdominal approach.

POEM is a novel endoscopic method where in per orally a High  Definition Gastroscope is passed in between the layers of thin esophageal wall to access muscle layer. The Esophageal wall has four layers. Mucosa. Submucosa, circular & longitudinal muscle layers. The sub mucosa has loose areolar tissue & it is expandable. This layer is expanded to more than 2cm wide by infiltrating saline mixed with Methylene Blue. Then musosal incision is taken to pass the endoscope in the expanded submucosal plane. By repeatedly infiltrating saline in submucosa & breaking the fibers of loose areolar tissue a 15 cm long submucosal tunnel is created going across the esophago gastric junction into stomach [SUB MUCOSAL TUNNELING TECHNIQUE]. Once the submucosal tunnel is created we have intact mucosa on one side & muscle layer on other side. The circular muscle fibers are cut with cautery beginning at about 3cm distal to mucosal incision. Myotomy is extended distally to cut LES & beyond. At the end, the mucosal incision is closed by endoclips. Patient is allowed oral feeds after 48 hours & discharged on 3^rd day.

At Antrang we have done Large Number of POEM Cases successfully. POEM is done in very few selected centers all over India.

The technique of submucosal tunneling & Myotomy is also used to treat repeated vomiting due to Gastroparesis & server constipation in children due to Hirschsprung disease.