Long-term Outcomes of POEM-SSMD: A New Hope for Achalasia Patients With Severe Tissue Adhesions
Imagine struggling to swallow a bite of bread or a sip of water—for people with achalasia, this is daily life. Achalasia is a rare disorder where the lower esophageal sphincter (the muscle that opens to let food into the stomach) stays tight, making swallowing painful, slow, or even impossible. For over a decade, peroral endoscopic myotomy (POEM) has been a game-changer: it uses an endoscope to cut the tight muscle through a small tunnel under the esophageal lining, offering long-term relief for most patients. But there’s a catch: some patients have severe tissue scarring (called interlayer adhesions) between the esophageal layers that blocks the tunnel from being created—forcing doctors to abort the procedure.
Now, a study from the First Medical Center of Chinese People’s Liberation Army General Hospital offers a solution: POEM with simultaneous submucosal and muscle dissection (POEM-SSMD). Published in the Chinese Medical Journal in 2022, the research examines long-term outcomes for 22 achalasia patients with severe adhesions who underwent POEM-SSMD between 2014 and 2019. The goal? To see if this modified procedure could safely and effectively treat achalasia when standard POEM fails.
What Is POEM-SSMD?
POEM-SSMD adapts standard POEM to work around adhesions. Here’s how it works:
- Start the tunnel: Doctors inject fluid under the esophageal lining to create a “liquid mat” (to lift the lining) and make a small “inverse T” cut to start the tunnel.
- Extend until stuck: The tunnel is stretched as far as possible—until adhesions stop progress.
- Cut muscle and submucosa together: Instead of forcing the tunnel, doctors make a 1–3 cm full-thickness cut in the muscle. They then cut the submucosa (the layer under the lining) and muscle simultaneously down to 2–3 cm below the esophagus-stomach junction (EGJ)—while keeping the inner lining (mucosa) intact.
- Seal the incision: The mucosal cut is closed with metal clips, as long as bleeding is stopped and the endoscope can pass through the EGJ easily.
All procedures were done by endoscopists with over 5 years of POEM experience—critical for safety and success.
How Did Patients Do?
Over a mean follow-up of 28.7 months (range: 10–63 months), the results were promising:
- 83% clinical success: 15 of 18 patients (4 were lost to follow-up) had an Eckardt score ≤3—the gold standard for “success” in achalasia. The median Eckardt score (which measures swallowing difficulty, chest pain, regurgitation, and weight loss) dropped from 6.5 (severe symptoms) to 1 (mild or no symptoms) after surgery.
- Better quality of life: The AE-18 score—a 18-item survey measuring physical, emotional, and social well-being—jumped from a median of 69 to 87 (higher scores = better quality of life). 89% of patients reported improved daily functioning.
- Mild, manageable complications: Most side effects were minor. 27% had mild-to-moderate chest pain (resolved on its own), 9% developed neck swelling from trapped air (subcutaneous emphysema, absorbed naturally), and 14% had a small mucosal tear (fixed with glue and clips). No major complications (like severe bleeding or need for emergency surgery) occurred.
- Reflux risks: As with standard POEM, some patients had acid reflux. 33% reported symptomatic reflux (via the GerdQ score), and 2 had mild-to-moderate esophagitis (inflammation from acid). These were managed with proton pump inhibitors (PPIs)—common reflux medications.
Why Does This Matter?
For patients with severe adhesions, standard POEM isn’t an option—until now. POEM-SSMD fills a critical gap: it lets doctors treat achalasia even when scarring blocks the tunnel. The study’s lead authors, including Dr. Enqiang Linghu from the Chinese PLA General Hospital, note that POEM-SSMD aligns with “super minimally invasive surgery (SMIS)” principles—prioritizing small incisions, fast recovery, and better quality of life.
But there are limitations. The study was retrospective (looking back at past data), done at a single center, and followed patients for just over 2 years—longer follow-up is needed to confirm long-term durability. Only 5 patients had post-op manometry (a test to measure esophageal pressure), so more data on how POEM-SSMD affects muscle function would help.
What’s Next?
The results are clear: POEM-SSMD is safe, effective, and improves quality of life for achalasia patients with severe adhesions. But the authors stress that it should only be done by experienced endoscopists—adhesions make the procedure trickier, and skill matters. Future studies (prospective, multicenter, randomized) will help compare POEM-SSMD to other treatments like laparoscopic Heller myotomy (LHM), a surgical alternative.
About the Study
This research was conducted by a team from the Department of Gastroenterology and Hepatology at the First Medical Center of Chinese People’s Liberation Army General Hospital and the Medical School of the Chinese People’s Liberation Army. All procedures were approved by the hospital’s ethics committee, and patients gave informed consent.
The original study was published in the Chinese Medical Journal (2022;135(6):724–726) by Jiancong Feng, Ningli Chai, Wengang Zhang, Longsong Li, Xiaowei Tang, Jiale Zou, Lu Ye, and Enqiang Linghu.
For more details, access the full study here: doi.org/10.1097/CM9.0000000000001971
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