Per Oral Endoscopic Myotomy – How Do I Do It?

For the treatment of achalasia and other complex esophageal motility disorders, per oral endoscopic myotomy (POEM) has emerged as a minimally invasive treatment option that merges surgical dexterity with endoscopic precision. Since its introduction in 2010, POEM has evolved rapidly from an experimental procedure to a frontline modality, dramatically altering the standard of care for patients who previously had limited options. With advancements in instruments, training pathways, and expanding indications, POEM continues to evolve as a cornerstone of modern day third space endoscopy. This technical review outlines the essential steps of the procedure and practical considerations that are a prelude to a safe and effective POEM. The process begins with careful patient selection and preoperative assessment using high-resolution manometry, upper gastrointestinal endoscopy, and radiological studies. The use of in vivo functional assessment using endo-flip to enhance the procedural success is highlighted. Technically, POEM involves a mucosotomy followed by submucosal tunneling and finally a myotomy extending across esophago-gastric junction into gastric cardia. The emphasis is laid on critical maneuvers such as selection of optimal entry site and type of incision, successful and safe tunnel creation and performing a tailored myotomy—selective or full-thickness—based on the disease phenotype. The intra-procedural difficulties and complications are discussed with strategies for the prevention and optimal management. This synopsis provides clinicians with a comprehensive, experience and evidence-based roadmap for mastering POEM.