ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)
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THIRD SPACE ENDOSCOPY PER ORAL MYOTOMY POEM VS LAP HELLERS MYOTOMY
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ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)
- 1. ACHALASIA CARDIA ENDOSCOPY MANAGEMENT DR AMIT DANGI DEPARTMENT OF SURGICAL GASTROENTEROLOGY KING GEORGE MEDICAL UNIVERSITY LUCKNOW, INDIA
- 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 • The new frontier of surgery • Natural orifice transluminal endoscopic surgery (NOTES) Technology Intuitive and multi-role therapeutic endoscopes Ever expanding minimally invasive armamentarium
- 4. The evolution……. • Ortega • Parischa • Inoue
- 5. IS POEM EFFECTIVE? INVESTIGATOR,YEAR n Myotomy length Decrease in Eckardt score LES pressure↓ (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 Heller’s myotomy (LHM) ideal? Safety and outcomes of laparoscopic re operation for achalasia • Recurrence of achalasia after LHM – 20% • 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 – 2.8d +/- 5.5d Advanced age, co-morbid illness associated with increased operating time, complications & LOS Ross SW Surgical endoscopy 2015 Reoperations after heller’s 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 • SHORTER OPERATIVE TIME • 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 • SHORT HOSPITAL STAY • 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): E195–E201
- 10. Completeness of myotomy • Grossly assessed by direct visualization and passage of the gastroscope. • 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
- 11. Complications • Mucosal injury • Delayed mucosal closure failure : 0.8% • Delayed bleeding : 0.2% • Hydrothorax : 0.5% require intervention • Pneumothorax : 1.5% require intervention • Pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema: common post-operative findings. • Concerning issue: Learning Curve Surg Endosc 2017;31:2187-20
- 12. GERD • Achilles heel • Incidence Symptomatic GERD: 0-37% Reflux esophagitis: 65% • Endoscopic antireflux procedures • 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 • To decrease GERD • Transoral incisionless fundoplication • Stretta procedure : Radiofrequency ablation to GEJ. • Surgical Fundoplication Journal of Thoracic Disease, Vol 9, No 10 October 2017
- 15. Treatment-naïve achalasia patients versus prior treatment failure achalasia Study N Median follow up Complications % Technical success % Clinical success % Jones et al 45 10 Naïve:27 PTF: 40 100 100 Orenstein et al. 40 10 Naïve: 16.7 PTF: 12.5 - Louie et al 38 7 Naïve: 31.6 PTF: 8.3 Naïve: 100 PTF: 100 Sigmoid/PBD/HM: 87.5 100 100 62.5 Sharata et al 40 6 Naïve: 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 Naïve: 35.8 PTF: 33.1 Naïve: 98.1 PTF: 97.1 94.9 91.9 POSSIBLE SAFE EFFICACIOUS BETTER QOL
- 16. Redo LHM compared to primary LHM • More complications due to scarring and fibrosis due to previous intervention • Redo Heller: • More conversion to open (up to 7%) • Longer procedure time • Lower efficacy • More postoperative complications: gastrointestinal perforations (1.5% to 20%), pneumothorax (1.9% to 6.7%), pulmonary complications (1.3% to 4% of patients) • Wang L, Li YM, World J Gastroenterol 2008 • Rosemurgy AS, J Am Coll Surg. 2010 • Lynch KL, Am J Gastroenterol 2008 • 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 • LHM > Single Pneumatic dilatation • LHM = Graded Dilatation (Type I, II) • POEM = LHM • POEM >= LHM (Type III, spastic disorders) • POEM vs PD – 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. However, a quarter of patients in the PBD group required additional dilatations 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 1980’s 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 – 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. However, a quarter of patients in the PBD group required additional dilatations 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.
- Clinical response was significantly more frequent in the POEM cohort (98.0 % vs 80.8 %; P = 0.01). POEM patients had significantly shorter mean procedure time than LHM patients (102 min vs 264 min; P < 0.01) despite longer length of myotomy (16 cm vs 8 cm; P < 0.01). There was no significant difference between POEM and LHM in the length of hospital stay (3.3 days vs 3.2 days; P = 0.68), respectively. Rate of adverse events was significantly less in the POEM group (6 % vs 27 %; P < 0.01).
- 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 the LES 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 270 degree 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-naïve 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.