BlueCross BlueShield of Tennessee Medical Policy Manual

Natural Orifice Transluminal Endoscopic Surgery (NOTES) and Peroral Endoscopic Myotomy (POEM)

DESCRIPTION

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a novel surgical technique being investigated as a less invasive surgical method. NOTES procedures are performed using instruments in one body cavity, usually the peritoneal cavity, having gained access to this space by means of a natural orifice rather than percutaneously. Hybrid NOTES procedures are those which combine a NOTES approach as well as direct transcutaneous access to the cavity, usually in combination with laparoscopic instrumentation. Initial NOTES developments were restricted to animal models. Proposed benefits of this technique include avoidance of external scarring, less pain and lower risk of post-operative infection and immobility.

Peroral endoscopic myotomy (POEM) is a novel endoscopic procedure that uses the oral cavity as a natural orifice entry point to perform myotomy or cutting of the muscle of the lower esophageal sphincter as treatment of esophageal achalasia; which is a disorder characterized by prolonged occlusion of the lower esophageal sphincter (LES) and reduced peristaltic activity. Traditionally esophageal achalasia is treated with a laparoscopic approach or Heller myotomy.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Well-designed studies in peer-reviewed journals that compare the natural orifice transluminal endoscopic surgery (NOTES) procedure to traditional surgery are not available. The literature on the efficacy of peroral endoscopic myotomy (POEM) for treatment of esophageal achalasia does not include long-term outcomes. Therefore, these procedures remain investigational.

SOURCES

American College of Gastroenterology (1999, December revised 2013, August) ACG clinical guideline: diagnosis and management of achalasia. Retrieved January 18, 2017 from National Guideline Clearinghouse. (NGC:009987)

BlueCross BlueShield Association. Medical Policy Reference Manual. (11:2016). Peroral endoscopic myotomy for treatment of esophageal achalasia (2.01.91). Retrieved January 18, 2017 from BlueWeb. (29 articles and/or guidelines reviewed)

Bulian, B., Knuth, J., Lehmann, K., Sauerwald, A., and Heiss, M (2015, October) Systematic analysis of the safety and benefits of transvaginal hybrid-NOTES cholecystectomy. World Journal of Gastroenterology; 21(38)10915-10925. (Level 3 evidence)

Patel, K., Abbassi_Ghadi, N., Markar, S., Kumar, S., Jethwa, P., & Zaninotto, G. (2015). Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis. Diseases of the Esophagus. Abstract retrieved July 16, 2015 from PubMed database.

Society of American Gastrointestinal and Endoscopic Surgeons. (2011, May). Guidelines for the surgical treatment of esophageal achalasia. Retrieved January 18, 2017 from National Guideline Clearinghouse. (NGC#008578)

Talukdar, R., Inoue, H., & Reddy, D.N. (2014). Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis. Surgical Endoscopy. Abstract retrieved July 16, 2015 from PubMed database.

Winifred S. Hayes, Inc. Medical Technology Directory. (2015, December; last update search December 2016) Peroral endoscopic myotomy for treatment of esophageal achalasia. Retrieved January 18, 2017 from: www.Hayesinc.com (58 articles and/or guidelines)

Xu, Bin., Xu, Bo, Wen-Yan, Z.,Hai-Yan, G., Wang, L, Zhen-Sun, S, & Bin, H. (2015). Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease: a meta-analysis. World Journal of Gastroenterology, 21 (17), 5393-5406. (Level 1 evidence)

Yang, J., Wang, C., Li, J., Yang, W., Cao, G., Wong, H.M., Zhai, H., & Liu, W. (2015). Complete endoscopic thyroidectomy via oral vestibular approach versus areola approach for treatment of thyroid diseases. Journal Laparoendoscopic & Advanced Surgical Techniques, 25 (6), 470-476. Abstract retrieved July 16, 2015 from PubMed database.

Zhang, Y., Wang, H., Chen, X., Liu, L., Wang, H., Lui, B., et. al. (2016, February) Per-oral endoscopic myotomy versus laparoscopic heller myotomy for achalasia. Medicine. Vol. 95, No. 6. (Level 1 evidence)

ORIGINAL EFFECTIVE DATE:  5/9/2009

MOST RECENT REVIEW DATE:  2/9/2017

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additional keyword(s): Transoral NOTES