POEM: Pre-procedural work-up and indications

Peroral endoscopic myotomy (POEM) is a transluminal endoscopic procedure which dissects the lower esophageal sphincter via access obtained through a submucosal tunnel. The procedure was first developed as a treatment for achalasia, but its indications have quickly spread. In addition to all the clinical subtypes of achalasia, its indications now include a subset of patients with esophagogastric junction outflow obstruction, distal esophageal spasm, jackhammer esophagus, and as retreatment following prior achalasia therapy. Current clinical practice suggests that the minimum work-up required prior to POEM should include upper endoscopy and high-resolution manometry. Here we review the growing body of literature regarding indications for POEM and the appropriate work-up including advanced diagnostic testing to identify those patients who are most likely to benefit from LES targeted therapy.