POEM (Peroral Endoscopic Myotomy) is an endoscopic procedure used to treat swallowing disorders, most commonly Achalasia, a rare disorder that makes it difficult for liquid and food to pass into the stomach. POEM is a minimally invasive procedure that provides long-term relief of symptoms, allowing patients to eat and drink without discomfort. Patients remain in the hospital overnight and are generally sent home the next day.

During the procedure, the endoscopist creates a small tunnel in the esophagus to target the muscle fibers of the lower esophageal wall and the point of connection between the stomach and the esophagus. This process helps permanently relax the tight esophageal muscles and open areas of the esophagus that have narrowed.

Z-POEM is an adaptation of POEM for achalasia that is used to treat Zenker’s diverticulum. Zenker’s diverticulum is a pouch that forms at the back of the throat, where the esophagus and pharynx meet. The cause is unknown but could result from increased pressure in the esophagus that causes the muscles to tear or malfunction. Eventually, a pocket forms in the throat and can lead to serious complications including trapped food, dysphagia (difficulty swallowing), weight loss and inhalation of gastric contents into the lower respiratory tract.

The Z-POEM procedure involves cutting the narrow band of muscle between the pharynx and esophagus, which helps the pouch flatten out and returns the esophageal wall to its normal state. Once the procedure is complete, the entry site is closed with clips. Patients remain in the hospital overnight and are generally released the following day after ensuring there is no leakage. Complications are rare and Zenker’s diverticulum symptoms generally completely resolve after three months.

Gastric Peroral Endoscopic Myotomy (G-POEM) is an innovative way to treat patients with gastroparesis using endoscopy. Gastroparesis is a debilitating disorder, with limited treatment options, that paralyzes the stomach and slows or stops digestion entirely. Symptoms of gastroparesis can include severe vomiting, bloating, abdominal pain, malnutrition and dehydration.

The endoscopist will use a thin, flexible endoscope to access the patient’s stomach. Then, they will make an incision and create a tunnel between the layers of the stomach to reach the pyloric muscle (the pylorus contracts when food and liquid need to get digested in the stomach, then opens to let food and liquid pass into the small intestine. In patients with gastroparesis, this mechanism is delayed or halted altogether). Once the channel is created, the endoscopist makes an incision on the muscle to create an opening for food to pass freely into the small intestine.

G-POEM can significantly improve patients’ symptoms and quality of life.

Endoscopic Mucosal Resection, also known as EMR, is a highly specialized procedure to remove or resect early-stage cancers, precancerous tissue or other abnormal cells from the lining of the digestive tract including the esophagus, small intestine, stomach and colon. EMR can help diagnose the stage of growth and remove diseased tissue, ideally eliminating the need for more invasive surgeries.

An EMR procedure is performed using an endoscope, a long, flexible instrument about 1/2 inch in diameter. The tip of the endoscope is equipped with a lens and a light source, allowing for close inspection of the tissue. Through the endoscope, instruments are then used to lift and remove the lesion.

Patients are generally discharged the same day of the procedure, and rarely need pain medications and/or an oral numbing solution. Patients may return to work the day after the procedure, although a modified diet is often recommended for the first few days after the procedure to allow for healing.

Your gastroenterologist may recommend EMR if you have any of the following:

• Barrett’s esophagus with high grade dysplasia or superficial esophageal adenocarcinoma (a type of esophageal cancer)
• Stomach polyps or masses
  Polyps or masses on the duodenum (part of the small intestine)
• Colon or rectal polyps

Endoscopic Submucosal Dissection (ESD) is a minimally invasive, advanced procedure that completely removes cancerous lesions from GI tract without removing the organ involved, allowing patients to recover faster and maintain quality of life.

ESD is performed by endoscopically marking the boarders of the lesion. A fluid is injected into the lining of the GI tract tissues to elevate the lesion. The lesion then then removed completely, typically in a single piece.

ESD is usually used for larger tumors that have a high likelihood of aggressive cancer invading the other submucosa tissue and for lesions that can’t be removed by EMR due to scarring or damage. EMR is beneficial for most pre-cancerous lesions, is simpler to perform and uses a smaller number of devices. The main disadvantage of EMR is that fragmentary resection (cutting out tissue) is required for larger lesions. As a result, some patients who are treated with EMR may require additional surgery. EMR also carries a higher recurrence rate than ESD. ESD allows for complete removal of lesions regardless of size, which provides a recurrence rate of less than one percent. However, ESD is requires specialized training as it is technically more demanding and is a longer procedure.

Submucosal Tunneling with Endoscopic Resection (STER) is a procedure used to treat gastrointestinal smooth muscle tumors, previously known as gastrointestinal leiomyoma or gastrointestinal stromal tumors. These tumors form in the deep muscle layer of the GI wall and are covered by mucous membrane. They can have malignant potential.

The endoscopist creates a tunnel between the mucosa and the smooth muscle, resecting the small muscle tumor in the channel while maintaining the mucosal covering. This method is an effective way to remove these types of difficult tumors with little trauma and fewer complications for the patient. This is an outpatient procedure and patients are typically discharged home the same day.

Endoscopic Full Thickness Resection, or EFTR, is a minimally invasive procedure to remove cancerous tissue penetrating the deeper layers of the submucosa or deep muscle of the GI tract. “Full thickness” refers to how much of the GI wall is removed. With procedures like EMR and ESD, only the superficial layers may be removed. EFTR, on the other hand, aims to resect deeper tissues to ensure complete tumor removal.

EFTR is typically an outpatient procedure, and many patients return home the next day. Patients who undergo EFTR generally have faster recoveries than those who undergo more invasive surgery.

There are many existing EFTR techniques and devices that the endoscopist may choose to use depending on the case. EFTR requires advanced training and technique.