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POEM A Light in A Tunnel
The document details a case presentation regarding the diagnosis and treatment of achalasia, highlighting guidelines on diagnostic procedures like endoscopy and esophageal motility testing. It discusses treatment options including POEM (per oral endoscopic myotomy) and pneumatic dilation, summarizing their indications, efficacy, and recommendations. The document also refers to an Egyptian experience with training and implementing the POEM technique, presenting clinical outcomes and success rates.
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POEM A Light in A Tunnel
- 1. POEM A Light inA Tunnel By Shaimaa Elkholy Mohamed EL-Sherbiny Kareem Essam Mohamed Nabil Alkady Ahmed EL-Meligy
- 2. POEM A Light inA Tunnel
- 3. Room 4: Endoscopysession Amun Ballroom (Level 1)POEM … A Light in A Tunnel Moderators Ping-Hong Zhou (China) Mohamed El-Sherbiny (Cairo University) Experts Essam El-Nezamy (Cairo University) Karim Essam (Cairo University) Geina Gamal (Ain shams University) Shaimaa Elkholy (Cairo University) Mohamed Nabil Alkady (Cairo University) Ahmed Khairy (Cairo University) Doaa Mansour (Cairo University) Lin Miao (China) Li Feng (China) Wen-Bo Mg (China) Lei Zhang (China) Xiao-Liang Zhu (China) Xun Li (China) Ying-Cai Ma (China) Jie Chen (China) Ahmed El-Meligy (Cairo University)
- 4. Case presentation • 28years old female patient • Presented with progressive dysphagia of one year duration • She started to notice significant weight loss in the last 6 months • She had no significant medical history
- 5. What to donext? a. Endoscopy b. Gastrographin swallow c. Barium swallow d. CT Scan
- 6. We proceeded togastroscopy
- 7. What to donext? a. Take biopsy to exclude pseudo-achalasia b. Diagnose as achalasia & proceed for management c. Barium swallow d. Manometry e. Manometry & Barium swallow
- 9.
- 10. What do theguidelines say? Comment by Dr.Ahmed El-Meligy
- 11. Guidelines in diagnosisof Achalasia All patients with suspected achalasia who do not have evidence of a mechanical obstruction on endoscopy or esophagram should undergo esophageal motility testing before a diagnosis of achalasia can be confirmed (strong recommendation, low-quality evidence)
- 12. Guidelines in diagnosisof Achalasia The diagnosis of achalasia is supported by esophagram findings including dilation of the esophagus, a narrow esophagogastric junction with “ bird-beak ” appearance, aperistalsis, and poor emptying of barium (strong recommendation, moderate-quality evidence)
- 13. Guidelines in diagnosisof Achalasia Barium esophagram is recommended to assess esophageal emptying and esophagogastric junction morphology in those with equivocal motility testing (strong recommendation, low-quality evidence)
- 14. Guidelines in diagnosisof Achalasia Endoscopic assessment of the gastroesophageal junction and gastric cardia is recommended in all patients with achalasia to rule out pseudoachalasia (strong recommendation, moderate-quality evidence)
- 15. Guidelines in theDiagnosis of Achalasia -High-resolution manometry is the test of choice for the diagnosis of achalasia (compared to conventional manometry) -The Chicago Classification is a useful tool to define the clinically relevant phenotypes of achalasia -The timed barium esophagram offers an objective evaluation of the diseases and of the outcome after treatment (compared to traditional barium esophagram)
- 16. Guidelines in theDiagnosis of Achalasia -Endoscopy should be performed in patients with suspected achalasia to exclude malignancy of the esophagogastric junction -The Eckardt score is a simple tool to measure symptom severity in achalasia patients, but it should be integrated with objective measures such esophagogram and manometry
- 17. Manometry Dr Geina willspeak about manometry for 10 mins
- 18. What to donext? a. Botulinum injection b. Medical treatment c. Endoscopic pneumatic dilation d. Heller’s surgical myotomy e. POEM (per oral endoscopic myotomy)
- 19. What do theguidelines say? Comment by Dr.Mohamed Nabil Alkady
- 20. Guidelines in treatmentof Achalasia,2018 MEDIAL TREATMENT: -No convincing evidence that nitrates is effective for symptomatic relief -No convincing evidence that with calcium blockers is effective for (short term) symptomatic relief -No evidence that phosphodiesterase inhibitors is effective for symptomatic relief
- 21. Guidelines in treatmentof Achalasia BOTULINUM TOXIN INJECTION (BTI): -Limited application in young (<50 years) -Reserved for unfit for surgery or as a bridge -Repeat BTI are safe, but less effective -There is no evidence for injecting in lower esophageal body (+LES) in type III achalasia -There is no evidence that patients should be treated with increasing dosage
- 22. Guidelines in treatmentof Achalasia PNEUMATIC DILATION (PD): -Graded PD is an effective terms of improvement of symptoms & swallowing function (Patients wishing longer term remission may opt for surgery) -Best post procedural test to assess perforation is Gastrografin swallow (after 4 hrs only if symptomatic)
- 23. Guidelines in treatmentof Achalasia PNEUMATIC DILATION (PD): -Limited evidence that PD may be used as first-line therapy in megaesophagus (No recommendation) -No evidence for PPI use after PD unless symptomatic or +ve at pH-monitoring (Against)
- 24. However, we proceededto pneumatic dilation
- 25. Clinical Scenario • Thepatient showed marked improvement, she gained wait • She became pregnant • After 3 months of her delivery she started to develop the symptoms again in the form of dysphagia • She developed failure of lactation • Endoscopy : dilated oesphagus with spastic cardia
- 26. What to donext? a. Another session of Endoscopic pneumatic dilation b. Heller’s surgical myotomy c. POEM (per oral endoscopic myotomy)
- 27. However, we proceededto POEM Prof. Haruhisa Inoue
- 28.
- 31. POEM When to do? All patients diagnosed with achalasia can be a candidate ! Various types of achalasia Sigmoid Esophagus Prior endoscopic intervention or surgical myotomy Other abnormalities
- 32. POEM When not todo? -Marked submucosal fibrosis like after radiotherapy, radiofrequency ablation or EMR -Bleeding tendency -Portal hypertension
- 35. POEM • Sequel 97 %technical success 93% -- 98 % clinical success
- 37.
- 38. Comparison to surgery -Nosignificant difference in the outcome however; *POEM is an ‘incisionless procedure’ *Longer myotomy *Initial treatment or after failure of other *Non-achalasia esophageal motility disorders such as nutcracker esophagus, jackhammer esophagus, or diffuse esophageal spasm
- 39. What do theguidelines say? Comment by Dr.Mohamed Nabil Alkady
- 40. Guidelines in treatmentof Achalasia POEM (Per Oral Endoscopic Myotomy): -POEM, results in similar outcomes on swallowing functions compared (Heller myotomy or PD), at least at medium term follow-up (2–4 years) -POEM is an appropriate treatment for symptom persistence/recurrence after laparoscopic myotomy
- 41. Guidelines in treatmentof Achalasia POEM (Per Oral Endoscopic Myotomy): -No evidence that previous treatment with PD or Botox reduces the technical feasibility of POEM or results in poorer outcomes -Attaining proficiency with the POEM procedure involves a stepwise approach to education and a defined learning curve for both medical and surgical endoscopists
- 42. Guidelines in treatmentof Achalasia POEM (Per Oral Endoscopic Myotomy): Treatment of achalasia with POEM is associated with a higher incidence of GERD compared to alternative therapies (Heller myotomy with fundoplication or PD) Options should be discussed with the patients (Strong Recommendation)
- 43. Guidelines in treatmentof Achalasia POEM (Per Oral Endoscopic Myotomy): Treatment of achalasia with POEM is associated with a higher incidence of GERD compared to alternative therapies (Heller myotomy with fundoplication or PD) Options should be discussed with the patients (Strong Recommendation)
- 44. Guidelines in treatmentof Achalasia LHM (Laparoscopic Heller’s Myotomy): -Best results in (Chicago) type I & type II -LHM should include a myotomy 6 cm into the esophagus and 2 to 3 cm into the stomach for effective symptom control -LHM with a partial fundoplication is as effective as LHM -LHM, POEM or PD should be considered as the first-line option in sigmoid esophagus (compared to esophagectomy)
- 45. • 6 monthslater the patient started to complain again from dysphagia
- 46. So, we proceededdirectly to endoscopy
- 47. What to donext? a. Back to dilation b. re-POEM c. Is it time for surgery d. Oesphagectomy ?!
- 48. Recurrent Achalasia • Nouniversal definition, however the symptoms are the main stay for assessment of success or failure • Failed cases should undergo repeat objective testing (endoscopy, barium, manometry + PH metry )
- 49. Recurrent Achalasia • FailedPD >>> LHM /POEM • Failed LHM >> POEM / PD • Failed POEM >> PD, no LHM, little evidence of re POEM (further research is requested)
- 50. What are thebit falls?
- 51. POEM (Per Oral EndoscopicMyotomy) Egyptian Experience
- 52. Exposure Training Preparation Launching of ourprogram Steps
- 53. Endoscopy work shop/yearsince 2004 2018 2017 2016
- 54.
- 55.
- 57. So we startedour cooperation with the help of ERBE china
- 58.
- 59.
- 60. Master Class ofGIT Endoscopy 2015 Vienna, Austria
- 61. Master Class ofGIT Endoscopy 2017 Nijmegen, Netherlands
- 62.
- 63.
- 65.
- 66. Egyptian trainees inShanghai
- 67.
- 68.
- 72.
- 74. 2nd – 4thof October 2018
- 75. Patient Characteristics (16) Age18-68 yrs Gender 8 (47.05%)Females 9 (52.9%)Males Duration 8 months – 10 years Co-morbidities (1) 3 As Previous dilation 8 No of dilations 1-3 Eckardt score 7-12 LES 24-72 mmHg Dr. Ming-Yan Cai 16 7OEM cases
- 76. Procedure details Duration 86-267min Technical Success 100% Procedure complications No Mucosal Injury 3 No of Clips 5-7 Clinical Success 16/17 (94.6%)
- 77.
- 82. Eckardt score (Pre):7-12 Eckardt score (Post): 0-3 0 2 4 6 8 10 12 ECKARDT_PRE ECKARDT_POST P- value 0.0156
- 86.
Editor's Notes
- #9 Aprestalitic oesphagus & the catheter could not pass through the cardia
- #16 Endoscopy should be performed in patients with suspected achalasia to exclude malignancy of the esophagogastric junction. 98.1% We recommend performing UGI endoscopy in adult with the suspected diagnosis of achalasia to exclude neoplastic pseudoachalasia. Good practice recommendation. 5 The Eckardt score is a simple tool to measure symptom severity in achalasia patients, but it should be integrated with objective measures such esophagogram and manometry
- #17 Endoscopy should be performed in patients with suspected achalasia to exclude malignancy of the esophagogastric junction. 98.1% We recommend performing UGI endoscopy in adult with the suspected diagnosis of achalasia to exclude neoplastic pseudoachalasia. Good practice recommendation. 5 The Eckardt score is a simple tool to measure symptom severity in achalasia patients, but it should be integrated with objective measures such esophagogram and manometry
- #21 All in adults
- #22 BTI has limited application in young patients (<50 years) -BTI should be reserved for patients who are unfit for surgery or as a bridge to more effective therapies(surgery or PD) -Repeat treatments with Botox are safe, but less effective than initial treatment -There is no evidence for supporting the injection of Botox in the lower esophageal body (+LES) in type III achalasia patients -There is no evidence that patients undergoing repeat BTI of the LES should be treated with increasing dosage of BT
- #23 90.4% We recommend graded pneumatic dilatations as an effective treatment (control of symptoms including dysphagia) for esophageal achalasia. Strong recommendation GRADE: moderate. Patients wishing longer term remission may opt for surgical treatment.
- #24 90.4% We recommend graded pneumatic dilatations as an effective treatment (control of symptoms including dysphagia) for esophageal achalasia. Strong recommendation GRADE: moderate. Patients wishing longer term remission may opt for surgical treatment.
- #32 It can be done to all types of patients and all types of achalasia and also Sigmoid Esophagus (surgical myotomy can’t be done) . Also Others Esophageal abnormalities (diffuse oesphgeal spasm or jackhammer oesphagus
- #35 So what about the sequel, few papers where published to collectively have a meta analysis or a review about the POEM but this paper published 2014 by nageshawer reddy
- #37 These table contains several publications that mentions the efficacy of POEM you can see here the eckardt score which is made to ass the degree of severity for patients with achalasia maximum is 9 and maximum is 12 ……. You can see the mean of the score pre & post… And then go to the LES there is technical success in about 97% while clinical success in 93-98% …………….
- #41 All in adults
- #42 All in adults
- #43 All in adults
- #44 All in adults
- #45 The best outcomes for LHM are achieved in (Chicago) type I & type II achalasia patients. 90.4% We recommend laparoscopic Heller myotomy for control of symptoms in Chicago type I and type II achalasia. Strong recommendation. GRADE: moderate. 26 Laparoscopic Heller myotomy should include a myotomy 6 cm into the esophagus and 2 to 3 cm into the stomach as measured from the GEJ, for effective symptom control in achalasia patients. 94.2% We recommend that Laparoscopic Heller cardiomyotomy should be extended at least (6 cm proximal to the GEJ and at least 2 cm distal to the GEJ. Conditional recommendation. GRADE: low. 27 Partial fundoplication should be added to laparoscopic myotomy in patients with achalasia to reduce the risk of subsequent gastroesophageal reflux. 94.2% We recommend that a partial (posterior or anterior fundoplication) but not a complete 360◦ wrap should be added to reduce the long-term risk (5 years) of developing gastroesophageal reflux and dysphagia after myotomy. Strong recommendation. GRADE: moderate. 28 Laparoscopic Heller myotomy with a partial fundoplication is as effective at improving swallowing function as laparoscopic Heller myotomy alone. 82.7% We recommend a partial fundoplication should be used when performing Heller myotomy to prevent subsequent development of gastroesophageal reflux without compromising the adequate control of dysphagia.We recommend against LHM alone due to the risk development of gastro-esophageal reflux. Strong recommendation. GRADE: High. 29 LHM (or other therapies as POEM or PD) should be considered as the first-line treatment option in achalasia patients with sigmoid esophagus (compared to esophagectomy). 86.5% We recommend standard endoscopic or surgical therapies in surgically na¨ıve achalasia patients with sigmoid-shaped esophagus, leaving esophagectomy as secondary option in case of failure of first line therapy. Conditional recommendation. GRADE: very low.
- #49 35 Patients with achalasia who do not respond to initial treatment with graded PD, should be referred for Heller myotomy or POEM. 94.2% We recommend that in patients who are fit for surgery and have symptomatic recurrences after several pneumatic dilations, Heller myotomy, or POEM should be considered. Conditional recommendation. GRADE: of evidence low. 36 Laparoscopic esophageal myotomy is a safe, feasible and effective treatment after failed Botox injection for achalasia. 96.2% We recommend LHM as an effective therapy for symptom recurrence after primary treatment with BTI. Conditional recommendation. GRADE: very low. 37 PD, compared with repeat myotomy or POEM, is the first option for treatment after failed Heller myotomy for achalasia. 80.8% We recommend pneumatic dilation as a safe and effective treatment of symptom recurrences after LHM. Conditional recommendation. GRADE: Low. 38 There is insufficient evidence that laparoscopic myotomy or redo POEM offer better results than PDs after failed POEM. 82.4% We make no recommendation about laparoscopic myotomy or redo POEM offering better symptomatic relief than pneumatic dilations after failed POEM. Further research is recommended to provide high-quality data and guide clinical decisions. Diagnosis and treatment of end stage achalasia 39 Barium swallow esophagram, compared with manometry, is the best diagnostic method for defining end stage achalasia (i.e. that which requires esophagectomy). 94.1% We recommend the use of barium swallow as the most accurate investigation to properly define end-stage achalasia. Good practice recommendation. 40 Esophagectomy is indicated in patients with persistent or recurrent achalasia after failure of previous less invasive treatments (PD, POEM, LHM) and radiologic progression of the disease. 80.8% We recommend esophagectomy in patients with end-stage achalasia who have failed other less invasive interventions. Conditional recommendation. GRADE: Low.
- #50 35 Patients with achalasia who do not respond to initial treatment with graded PD, should be referred for Heller myotomy or POEM. 94.2% We recommend that in patients who are fit for surgery and have symptomatic recurrences after several pneumatic dilations, Heller myotomy, or POEM should be considered. Conditional recommendation. GRADE: of evidence low. 36 Laparoscopic esophageal myotomy is a safe, feasible and effective treatment after failed Botox injection for achalasia. 96.2% We recommend LHM as an effective therapy for symptom recurrence after primary treatment with BTI. Conditional recommendation. GRADE: very low. 37 PD, compared with repeat myotomy or POEM, is the first option for treatment after failed Heller myotomy for achalasia. 80.8% We recommend pneumatic dilation as a safe and effective treatment of symptom recurrences after LHM. Conditional recommendation. GRADE: Low. 38 There is insufficient evidence that laparoscopic myotomy or redo POEM offer better results than PDs after failed POEM. 82.4% We make no recommendation about laparoscopic myotomy or redo POEM offering better symptomatic relief than pneumatic dilations after failed POEM. Further research is recommended to provide high-quality data and guide clinical decisions. Diagnosis and treatment of end stage achalasia 39 Barium swallow esophagram, compared with manometry, is the best diagnostic method for defining end stage achalasia (i.e. that which requires esophagectomy). 94.1% We recommend the use of barium swallow as the most accurate investigation to properly define end-stage achalasia. Good practice recommendation. 40 Esophagectomy is indicated in patients with persistent or recurrent achalasia after failure of previous less invasive treatments (PD, POEM, LHM) and radiologic progression of the disease. 80.8% We recommend esophagectomy in patients with end-stage achalasia who have failed other less invasive interventions. Conditional recommendation. GRADE: Low.
- #68 natural-orifice-transluminal-endoscopic-surgery-notes
- #82 After 48 hours
- #83 Eckardt score significantly droped