POEM: PERORAL ENDOSCOPIC MYOTOMY - THE FUTURE OF THERAPY FOR ACHALASIA? - STEVEN R. DEMEESTER PROFESSOR AND CLINICAL SCHOLAR DEPARTMENT OF SURGERY
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POEM: PerOral Endoscopic Myotomy The Future of Therapy for Achalasia? Steven R. DeMeester Professor and Clinical Scholar Department of Surgery
Achalasia Treatment Concepts
• Disease leads to non-relaxing LES and loss of
peristalsis in the esophageal body
• Treatment aimed at relief of outflow obstruction at
LES
• No treatment restores function of LES
• All therapies move obstructed LES toward open
LES (from dysphagia toward GERD)
Outflow
GERD
obstruction
Achalasia Therapy • Botox: quick endoscopic procedure, BUT variable results, temporary • Achalasia balloon dilatation: fast endoscopic procedure, minimal pain and rapid recovery, BUT uncontrolled disruption of LES, frequent need for repeat procedure, larger balloon sizes associated with increased perforation risk, only for LES • Laparoscopic myotomy and partial fundoplication: precise division of LES, can extend myotomy well down onto stomach, usually definitive procedure, BUT although minimally invasive, pain, hospital stay and recovery greater than endoscopic procedure, limited upward myotomy (DES etc)
PerOral Endoscopic Myotomy
• Best of both techniques:
• Precision of laparoscopic myotomy with the advantages
of an endoscopic approach
• Can be used for primary achalasia, for treatment
failures after other approaches (balloon dilatation,
Botox or Heller myotomy) and for other conditions
that might benefit from long myotomy
• Technique applicable to other procedures
(resection GIST tumor, leiomyoma,
pyloromyotomy, cricomyotomy)
Onimaru, M, et al. J Am Coll Surg, 2013
Shiwaku H, et al. Gastrointest Endosc, 2013
Equipment Checklist • Advanced endoscopic procedure but doesn’t require much equipment • ERBE generator (common in GI labs but not OR) • High-definition single channel flexible gastroscope (Olympus GIF-H180 or 190) • Dissecting cap • CO2 insufflator to replace standard air • Knife (hybrid, IT or TT) ± injecting needle • Coagulation grasping forceps • Dilute indigo carmine for injection • Closure device (clips versus Overstitch)
POEM Step by Step • Place tape on EGD scope with arrow indicating anterior 3 cm distal to site of GEJ
POEM Step by Step • ~10 cm above GEJ at 2 o’clock position create submucosal weal Figure from Inoue H, et al. Endosc, 2010
POEM Step by Step • Create mucosotomy (~2 cm) and identify circular muscle fibers (MM often quite thick) Figure from Inoue H, et al. Endosc, 2010
POEM Step by Step • Cut down to circular muscle fibers
POEM Step by Step • Turn the corner and start tunnel, follow the circular muscle fibers and maintain orientation! Once beyond GEJ the myotomy is initiated about 3-5 cm below the mucosotomy Figure from Inoue H, et al. Endosc, 2010
Submucosal Tunnel and Myotomy
Verifying Extent of Tunnel / Myotomy Figure from Inoue H, et al. Endosc, 2010
Close Mucosotomy
Clips
Suture
Intra-op Issues: Bleeding
Bleeding
Bleeding
Intra-op Issues: Mucosal Injury
POEM: Safety • First human procedure in Sept 2008 • Worldwide over 1200 procedures performed • Single center reports and recent multi-center prospective study • No reported mortality • Surprisingly little morbidity for new procedure
POEM: Morbidity
Von Renteln D, et al. Gastro, 2013
• Literature summary
• Capnoperitoneum requiring decompression: 5-
10% (higher without CO2)
• Mucosal injury during tunnel creation: 10%
• Full-thickness esophageal injury (biliary balloon
dissection): 5-10%
• Bleeding in tunnel: 5%
Ren Z, et al. Surg Endosc, 2012
• Leak in closure: rare Swanstrom LL, et al. Ann Surg, 2012POEM: Efficacy
Eckardt Symptom Score
10
9
8 n=452
7
Series1
6 Series2
Series3
5 Series4
Series5
4
Series6
3 Series7
2
1
0
Pre-POEM
1
Post-POEM 2
1. Swanstrom LL, et al. Ann Surg, 2012; 2. Bhayani NH, et al. Ann Surg, 2014;
3. Costamagna G, et al. Dig Liver Dis, 2012; 4. von Rentein D, et al. Am J Gastro, 2012;
5. Hungness ES, et al. J Gastrointest Surg, 2012; 6 and 7. Li Q, et al. J Am Coll Surg, 2013POEM: Reflux Von Renteln D, et al. Gastro, 2013
POEM in Perspective
• Reflux is a problem after Heller myotomy even with
partial fundoplication (Multi-center RCT)
6-12Rawlings A, et
months post-op al. Surg Endosc, 2012POEM: Personal Experience
n=28
• Minimal morbidity
• 1 thermal injury to gastric mucosa, clipped
• 1 return to OR for EGD to evaluate ? leak in
tunnel by Ba swallow, closure intact
• No conversions
• No delayed hemorrhage
• Excellent dysphagia relief
• GERD ~40%, controlled with PPI in allSalvage POEM • 51 yr old male, HIV positive, 10 yrs dysphagia • Diagnosed with achalasia 2009, 4 achalasia balloon dilatations with short-lived relief after each • Lap myotomy with Dor Oct 2012 (OH) • Small mucosal tear repaired • Redo lap myotomy March 2013 (OH) with 3 cm esophageal mucosal tear, repaired with repeat Dor • Post-op leak, abscess, resolved with drainage • Minor improvement in symptoms, continues with significant dysphagia and nocturnal regurgitation and aspiration events
USC Evaluation LES pressure 12.7 mmHg
POEM 2/24/14; email 3/27/14 Dear Dr. DeMeester, Great news!... the POEM procedure you performed on me has GREATLY improved my ability to eat and swallow food, and I am so grateful for that! It’s about a 70% improvement at this moment! It’s still a little slow going, but I am now able to eat beef, chicken and other solid food for the first time in many years. Food no longer gets stuck in my esophagus. I hope it stays this way forever. I have already gained 14 LBS in 4 weeks since the POEM. I am so happy about this after so much eating difficulty the past couple years. I understand that I was your first “redo” patient to receive the POEM. Thanks for taking a chance and pushing through all of scar tissue and food that was trapped in my Esophagus. I was also told that I am to see you 3 months after the POEM surgery for an Endoscopy. Thank you very much! See you in a couple months. Very Best Regards,
Conclusion: POEM for Achalasia Roses are red….. Violets are blue, If you have achalasia…. The POEM procedure may be perfect for you!!
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