2. THERAPY FOR ACHALASIA CARDIA
FIRST SPACE
PNEUMATIC DILATATION (good efficacy)
BOTULINUM TOXIN
STENTS ( no role currently)
LAP HELLERS MYOTOMY (standard:
durable symptom relief)
THIRD SPACE
PER ORAL ENDOSCOPIC MYOTOMY
(challenging hellers myotomy)
3. THE THIRD SPACE : The Submucosal space
ā¢ The new frontier of surgery
ā¢ Natural orifice transluminal
endoscopic surgery (NOTES)
Technology
Intuitive and multi-role
therapeutic endoscopes
Ever expanding
minimally invasive
armamentarium
5. IS POEM EFFECTIVE?
INVESTIGATOR,YEAR n Myotomy length Decrease in
Eckardt score
LES pressureā
(mmHg)
Follow up
(months)
Efficacy
Inoue et al. 2010, 2015 500 14(3-25) 5 13.7 36 91 (1-2 yrs)
88.5 (>3) yrs
Von Rentein et al. 2012 16 12(8-17) 7 15.4 3
Costamagna et al 2012 11 10 6 28.2 3
Swanstrom et al. 2012 18 9(7-12) 6 28.2 6
Minami et al. 2013 28 14(10-18) 6 50.2 16
Lee et al 2013 13 8.5(6-13) 6 15 6.9
Von Renstein et al 2013 70 13(5-23) 5.9 18.7 12
Stavropoulos 2013 66 9(3-17) 7.7 27.1 13
Verlaan et al. 2013 21 - 7 13.7 3
Wang et al 2013 46 6.8 8.4 39.4 3
Chiu et al. 2013 16 10.8 (7-15) 5.5 13.8 3
Nabi et al 2017 502 13 6 30 20 90.9 (1 year)
Zhang et al 2017 318 28-33 95.7 and 95.1
Kumbhari et al 282 12 94.3
Ngamruengphong et al 2017 205 31 91
Teitelbaum et al 2018 41 7/1 22/9 12 92%
Highly efficacious
(>90%)
Excellent short
term results
Excellent mid and
long term results
Effective in sigmoid
esophagus or failed
LHM/PD
6. Is Lap Hellerās myotomy (LHM) ideal?
Safety and outcomes of laparoscopic re
operation for achalasia
ā¢ Recurrence of achalasia after LHM ā 20%
ā¢ Commonest cause is incomplete myotomy
Zaninotto G Ann Surg 2002
LHM although a gold standard
for many years, IS NOT the
IDEAL procedure for achalasia
Overall complications: National outcomes of
laparoscopic LHM: Operative
complications and risk factors for
adverse events.
Overall complications : 4.8%
Major : 2.8%,
Intra-operative mucosal injury : 4%
Readmissions : 3.1%,
reoperations : 2.3%
LOS ā 2.8d +/- 5.5d
Advanced age, co-morbid illness associated with
increased operating time, complications & LOS
Ross SW Surgical endoscopy 2015
Reoperations after hellerās esophagomyotomy
18%: Due to failures or complications
9%: Due to incomplete myotomy
Li J Surg Laparosc Endosc Percutan Tech. 2012
7. Comparison of laparoscopic myotomy to POEM
J Vis Surg 2017;3:122
Primary
investigator,
year
Procedure n Myotomy
length, mean
(range)
Follow up
(month)
Decrease in
Eckardt score
Decrease
in LES
pressure
Hughness et
al. 2013
LHM
POEM
55
18
8.5
9
6
6
-
6
-
-
Bhayani et al.
2014
LHM
POEM
64
37
9
9
6
6
4.2
4.2
30
20
Sanaka et al
2016
LHM
POEM
142
36
7.5
6.5
2
2
5.7
5.6
27.5
33.1
Scheider et al
2016
LHM
POEM
25
25
6
6
40
9
6.6
5.4
28.1
26.05
Peng et al
2017
LHM
POEM
18
13
7.3
7.5
54.2
46.2
4.9
4.5
Total LHM
POEM
304
129
7.7
7.6
21.6
13.8
5.4
5.2
28.6
28.05
SIMILAR OUTCOMES IN RELIEVING DYSPHAGIA AND REDUCTION OF ECKARDT
SCORES
CONCLUSION (ALL STUDIES):
EQUAL EFFICACY
SIMILAR ADVERSE EVENTS
MULTIPLE META-ANALYSIS (8):
EQUAL EFFICACY
SIMILAR ADVERSE EVENTS
8. REDUCED PAIN
SCORES
Surg Endosc 2016
Surgery 2013
ā¢ SHORTER
OPERATIVE
TIME
ā¢ LESS BLOOD
LOSS
J Thorac Dis 2017
Surg Endosc 2016
Surgery 2013
Gastroenterology &
Hepatology 2018
Ann Surg 2014
COST EFFECTIVE
POEM IS MORE
EFFECTIVE IN
TYPE 3
ACHALASIA
TAILOR MADE
MYOTOMY
ACCORDING TO
REQUIREMENT
Endosc Int Open.
2015 Jun
ā¢ SHORT
HOSPITAL
STAY
ā¢ EARLY
RESUMPTION
OF WORK
Ann Surg 2014
COMPARED TO LAP HELLERS
9. POEM allows for a longer myotomy than LHM, which may result in improved clinical outcomes.
POEM appears to be an effective and safe alternative to LHM in patients with type III achalasia.
Endosc Int Open. 2015 Jun; 3(3): E195āE201
10. Completeness of myotomy
ā¢ Grossly assessed by direct visualization
and passage of the gastroscope.
ā¢ Endo FLIP (Endoluminal functional
lumen imaging probe catheter)
Measures the compliance
Provides 4 measurements:
compliance
diameter
cross sectional surface area and
distensibility
J Vis Surg 2017;3:122
12. GERD
ā¢ Achilles heel
ā¢ Incidence
Symptomatic GERD: 0-37%
Reflux esophagitis: 65%
ā¢ Endoscopic antireflux procedures
ā¢ Importance of ---- fibres of
stomach
DYSPHAGIA
ECKARDT SCORE
LES PRESSURE
INCOMPLETE
ESOPHAGEAL EMPTING
GERD
Inoue et al (500 patients0 : 64% had e/o endoscopic esophagitis, 17% had
symptomatic reflux.
EASILY CONTROLLED WITH A SINGLE DOSE OF PPIs
J Am Coll Surg 2015;221:256-64
13. Is Abnormal Acid Reflux Different From Hellers Myotomy
Trend toward a significant reduction in the development of
symptomatic GERD with LHM
14. Adjunct endoscopic therapies
ā¢ To decrease GERD
ā¢ Transoral incisionless fundoplication
ā¢ Stretta procedure : Radiofrequency ablation to GEJ.
ā¢ Surgical Fundoplication
Journal of Thoracic Disease, Vol 9, No 10 October 2017
15. Treatment-naiĢve achalasia patients versus prior
treatment failure achalasia
Study N Median
follow up
Complications % Technical success % Clinical success
%
Jones et al 45 10 NaĆÆve:27
PTF: 40
100 100
Orenstein et al. 40 10 NaĆÆve: 16.7
PTF: 12.5
-
Louie et al 38 7 NaĆÆve: 31.6
PTF: 8.3
NaĆÆve: 100
PTF: 100
Sigmoid/PBD/HM: 87.5
100
100
62.5
Sharata et al 40 6 NaĆÆve: 3.5
PTF: 16.7
100 100
Kristensen et al 66 24 - 100 100
Ngamruengphong et
al
180 8.5 8
13
98
100
81
94
Nabi et al 502 20 NaĆÆve: 35.8
PTF: 33.1
NaĆÆve: 98.1
PTF: 97.1
94.9
91.9
POSSIBLE
SAFE
EFFICACIOUS
BETTER QOL
16. Redo LHM compared to primary LHM
ā¢ More complications due to scarring and fibrosis due to previous intervention
ā¢ Redo Heller:
ā¢ More conversion to open (up to 7%)
ā¢ Longer procedure time
ā¢ Lower efficacy
ā¢ More postoperative complications: gastrointestinal perforations (1.5% to
20%), pneumothorax (1.9% to 6.7%), pulmonary complications (1.3% to 4%
of patients)
ā¢ Wang L, Li YM, World J Gastroenterol 2008
ā¢ Rosemurgy AS, J Am Coll Surg. 2010
ā¢ Lynch KL, Am J Gastroenterol 2008
ā¢ James, D. R. Minim Invasive Ther Allied Technol 2012
17. Is POEM effective for straight-type esophageal
achalasia
Yes
Is POEM effective for sigmoid-type esophageal
achalasia
Yes (Technical challenging)
Both for S1 ans S2
Inoue Endoscopy 2010, Hu JW Surg endosc 2015, Eleftheriadis N Ann
Gastroenterol 2014
Is POEM an effective procedure for treating esophageal
achalasia after failed surgical Heller myotomy?
Yes
Is POEM effective for other esophageal motility disorders apart
from achalasia?
Limited data
Is POEM effective for patients with esophageal achalasia as
compared with pneumatic balloon dilation or surgical
myotomy?
Type 1 and 2 achalasia: Similar efficacy
Type 3 achalasia: POEM is better.
Is POEM an effective treatment for elderly patients with
esophageal achalasia?
Yes (Safe and effective)
18. Summary of available data
ā¢ LHM > Single Pneumatic dilatation
ā¢ LHM = Graded Dilatation (Type I, II)
ā¢ POEM = LHM
ā¢ POEM >= LHM (Type III, spastic
disorders)
ā¢ POEM vs PD ā No literature
Should it be the first line of treatment ?
Yes
If I am in a institute where expertise is available
If my patient is non compliant for repeated
dilatation
If patient desires minimally invasive & one time
treatment
If patient has type III achalasia
Editor's Notes
Treatment of achalasia has always been palliative and has been directed solely at the muscular anatomy of the LES rather than the underlying neuromuscular disorder
So far, treatments including Botox injection and balloon dilation have been commonly performed as first-line endoscopic treatments for achalasia [2,3]. If those are ineffective, laparoscopic procedures are generally selected as the next step [4]. Peroral endoscopic myotomy (POEM) has been developed as a further endoscopic treatment that is effective and less invasive
In the European achalasia trial, LHM and graded PBD were equal in efficacy at 2 and 5 years follow-up.āHowever, a quarter of patients in the PBD group required additional dilatationsĀ 5. Therefore, it appears that the response to PBD is less durable than that for LHM and reintervention requirement is frequent
The concept of natural orifice transluminal endo- scopic surgery (NOTES) [1] has inspired endoscopists and endoscopic surgeons to create less invasive treatment even for esophageal achalasia and approach myotomy from the 3rd space (new frontier)
The intent of an endoscopic myotomy began in the 1980ās when Ortega et al. (12), motivated to avoid thoracotomy for open Heller myotomy and the complications of forceful pneumatic dilation began experimental work using a customized electrosurgical knife to perform an endoscopic transmucosal myotomy on dogs. They then expanded upon that initial work applying the same technique on seventeen humans with achalasia
Endoscopic myotomy was then reported by Pasricha et al. in a porcine model ā developed mucosal flap valve and submucosal space
The first human clinical application of third-space endoscopy was described in 2010 in a report from Japan, wherein Inoue et al demonstrated that one could safely enter the potential submucosal space and perform an esophageal myotomy in patients with achalasia cardia.
Following Inoue report, POEM was rapidly embraced, becom- ing the primary form of treatment in many centers.
The available evidence suggests excellent short- and mid-term results with E-POEM in treatment-naive cases of achalasia.4,6,7 However, the data are limited regard- ing the long-term efficacy of E-POEM.8-10 In 2 studies evaluating long-term response, the clinical success at 5-year follow-up was 83% and 87.1%, respectively.8,9
In the European achalasia trial, LHM and graded PBD were equal in efficacy at 2 and 5 years follow-up.āHowever, a quarter of patients in the PBD group required additional dilatationsĀ 5. Therefore, it appears that the response to PBD is less durable than that for LHM and reintervention requirement is frequent
In comparison to LHM with or without fundoplication, POEM has demonstrated similar outcomes in relieving dysphagia as evidenced by the similar decreases in Eckardt score and LES pressures when compared to LMH
Utilizing 10 mg of PO morphine as our control and an equianalgesic table, we demonstrated the LHM group required an average of 115 mg of pain medication and the POEM group needed 25.83 mg of narcotic pain during their hospital stay.
Ā Clinical response was significantly more frequent in the POEM cohort (98.0ā% vs 80.8ā%;Ā Pā=ā0.01). POEM patients had significantly shorter mean procedure time than LHM patients (102āmin vs 264 min;Ā Pā<ā0.01) despite longer length of myotomy (16ācm vs 8 cm;Ā Pā<ā0.01). There was no significant difference between POEM and LHM in the length of hospital stay (3.3 days vs 3.2 days;Ā Pā=ā0.68), respectively. Rate of adverse events was significantly less in the POEM group (6ā% vs 27ā%;Ā Pā<ā0.01).
Completeness of the myotomy confirmed when the sphincter easily opens with gentle insufflation
Endoflip: more objective method is to assess the LES and sess of completeness of myotomy.
This device measures the compliance of the tissue it opposes and
Endoflip image taken at the GEJ on a patient with achalasia prior to POEM. Note the narrow waist consistent with a tight GEJ. GEJ, gastroesophageal junction; POEM, per oral endoscopic myotomy.
Endoflip image taken at the GEJ on a patient with achalasia after myotomy and POEM was completed. Note the widening of the waist. GEJ, gastroesophageal junction; POEM, per oral endoscopic myotomy.
pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema as common post-operative findings (33). Many of these issues are minimized with the use of carbon dioxide insufflation, which allows for quicker dissipation of excess gas (34)
The treatment of achalasia is a balance between the relief symptoms particularly dysphagia and the development of complications particularly GERD.
One of the major concerns as POEM was introduced was the fact that there was no partial fundoplication to provide some evidence of a reflux barrier.
It was argued that by leaving the native esophageal hiatus intact and only dividing the inner circular muscle that this might limit the degree of reflux
The development of reflux and PPI use does not appear to be significantly different between LHM and POEM (46,48). However, these series have small numbers and these outcomes may change when larger studies are conducted.
BHAYANI: Postoperative esophageal acid expo- sure is the same for both
A recent meta-analysis concluded that there was a trend toward a significant reduction in the development of symptomatic GERD with LHM (50). The larger concern are that many patients do not perceive reflux symptoms yet have positive objective pH scores and reflux esophagitis. Because of this, we believe it is imperative to evaluate all patients post myotomy with pH testing to confirm a
diagnosis of GERD (48)
Potential adjunct endoscopic therapies to prevent reflux following POEM include transoral incisionless fundoplication (TIF) and radiofrequency ablation to theLES with the Stretta procedure
TIF and Stretta both offer 3. less invasive options to replace surgical fundoplication,have fewer adverse effects and do not limit future treatment options.
TIF procedure repairs the anti-reflux barrier through creation of a valve 2 to 4 cm in length with a 270degree or greater circumferential wrap endoscopically (17).Stretta utilizes radiofrequency ablation to the LES to create 5. thermal lesions below the mucosa at the gastroesophageal junction and restore a reflux barrier
POEM is safe and equally effective for treatment-naiĢve patients and for those in whom prior treatment has failed. Emerging data suggest that E-POEM is equally effective in treatment-failure cases with achalasia.11-15 In a large study that included 502 patients, clinical success at 3 years was 87.1% and 76.3% in treatment-naive and treatment- failure cases, respectively.
POEM should be considered the treatment of choice in patients in whom prior treatment has failed.