a novel endoscopic treatment for...2016/11/05 · a novel endoscopic treatment for achalasia – is...
TRANSCRIPT
A Novel Endoscopic Treatment for Achalasia –
Is the POEM mightier than the sword?
Pavlos Kaimakliotis, MD
Department of Gastroenterology
Lahey Hospital and Medical Center
Assistant Professor of Medicine
Tufts University School of Medicine
Disclosures Consultant
Boston Scientific
Medtronic
Outline Background
Diagnosis
Treatment
Advances: Per Oral Endoscopic Myotomy
Outcomes
Achalasia - Background
Motility disorder of the esophagus
Affects the esophageal smooth muscle and LES
Impaired relaxation of the LES
Impaired peristalsis
First described by Sir Thomas Willis in 1672
Patient with difficulty swallowing liquids
Treated with a sponge tipped carved whale bone dilator
Term “Achalasia” coined by Hurst and Rake in 1929
Greek for failure to relax
Achalasia – Epidemiology Incidence 1-2 cases per 100,000 individuals
Prevalence 10 in 100,000 individuals
No sex or race predilection
Peak incidence between the ages of 30 and 60 years
Achalasia - Diagnosis Clinical symptoms
Endoscopic
Radiographic
Manometry
Achalasia - Subtypes
Achalasia – Eckardt Scoring System
Eckardt AJ, Eckardt VF - Nat Rev Gastroenterol
Hepatol 2011
Achalasia - Treatment Chronic condition
No cure
Therapy focuses on
Symptom control
Halting progression
Preserve esophageal function/structure
Achalasia - Treatment
Pharmacotherapy
CCB, long acting nitrates
Botulinum toxin
66% initial response, high relapse1
Pneumatic dilation
Most effective non-surgical therapy
32% treatment failure at 3 years2
Myotomy
Efficacy 88-95%3 1. Gastroenterology. 1996;110(5):1410-1415.
2. World J Surg. 2015;39(3):713-720.
3. JAMA. 2015;313(18):1841-1852
Achalasia - Myotomy
Extramukose cardioplastik bein chronischen
Cardiospasmus mit Dilatation des Oesophagus Thoracoscopic 1992
Laparoscopic 1991
Transthoracic 1958
First Myotomy 1913
Achalasia - Myotomy
Extramukose cardioplastik bein chronischen
Cardiospasmus mit Dilatation des Oesophagus Endoscopic 2008
Thoracoscopic 1992
Laparoscopic 1991
Transthoracic 1958
First Myotomy 1913
Endoscopy 2007;39:761-4
Achalasia – Esophageal Anatomy
Achalasia – Per Oral Endoscopic
Myotomy
First human procedure by Inoue in 2008
Worldwide over 5000 cases performed to
date
Initially performed in classic achalasia
Currently being performed in all subtypes
of achalasia and for a variety of spastic
disorders of the esophagus
Equipment HD gastroscope
Distal attachment cap
CO2 insufflation
Needle knife
Coagrasper
Modern ESU
Injection needle
Endoclips/Endoscopic suturing
Achalasia – POEM: Mucosal Entry
Creation
Endoscopy 2010; 42: 265
Achalasia – POEM: Submucosal Tunnel
Achalasia – POEM: Myotomy
Achalasia – POEM: Mucosotomy
Closure
POEM – Initial Experience
Endoscopy 2010; 42: 265-271
J Am Coll Surg 2015; 221: 256-64
Inoue Series POEM Results
J Am Coll Surg 2015; 221: 256-64
POEM – US Experience
J Gastrointest Surg (2015) 19:161–170
Swanstr⍤m Series POEM Results
Postoperative timed barium swallow
(TBS)
Median % emptying at 1 minute
Pre POEM 40% (4-100%)
Post POEM 90% (70-100%) (p=0.003)
J Gastrointest Surg (2015) 19:161–170
Swanstr⍤m Series – Complications
J Gastrointest Surg (2015) 19:161–170
POEM Adverse Events Aspiration
Capnomediastinum/Capnoperitoneum
Mucosal tunnel injury
Bleeding
Mediastinitis
Heller vs. POEM
Heller vs. POEM Meta-analysis
4 non-randomized comparative studies
317 patients (192 LHM, 125 POEM)
Heller vs. POEM
1. Length of myotomy
2. Operation time
3. LOS
4. Preop Eckardt
5. Postop Eckardt
6. Complications
GERD after Myotomy LHM absolutely requires an antireflux procedure be performed
Is there GERD after LHM with fundoplication?
Multicenter randomized trial comparing LHM with Dor vs Toupet FP
24 hour pH testing performed
Abnormal acid reflux
Dor 42%
Toupet 21%
Surg Endosc (2012) 26:18–26
GERD after Myotomy
Other recent multi-center randomized trial
Boeckstaens 2015 (Heller/Dor vs. PD)
Heller group
18% esophagitis (Grade A and Grade B)
34% GERD symptoms with abnormal acid exposure
What about POEM?
Gut 2016;65:732–739
GERD after POEM
GERD after POEM Follow up of 70 patients after POEM for achalasia
Eckardt scores 5.7 to 0.7 post POEM
Symptomatic GERD
5 patients (7%)
Reflux esophagitis
11 patients (16%)
Grade B 8 patients
Grade C 3 patients
All symptoms effectively controlled with proton pump inhibitors
GERD - Swanstr⍤m Series
73/100 patients 6-month postop EGD
27% (20/73) patients with esophagitis
15 LA Grade A, 3 LA Grade B, 2 LA Grade C
68/100 postop 24-h pH testing
38% (26/68) Positive DeMeester score
19% (13/26) symptomatic reflux
All patients with abnormal pH studies responded to H2 blockers or PPIs
J Gastrointest Surg (2015) 19:161–170
POEM - Advantages
Incisionless
Less pain
Faster recovery
Shift from OR to Endoscopy Unit
Broadening indications
Failed Heller
Sigmoid esophagus
Spastic esophageal motility disorders
UPENN 2014
LAHEY 2016
The Lahey Experience Patient Characteristics (n = 10)
Age, y, mean 58 (range, 38 – 80)
Sex ratio, M:F 7:3
Eckardt score, mean 7
Chicago Classification, n
Type I 3
Type II 6
Type III 0
Other conditions
Hypercontractile esophagus 1
Degree of dilation, n
Grade 1 (< 3.5cm) 6
Grade 2 (3.5 – 6 cm) 2
Grade 3 (>6cm) 1
Sigmoid, n 1
The Lahey Experience Length of Stay, mean 1.3 days
Complications
1 patient with contained leak, managed conservatively
Efficacy (follow up 4-26 weeks)
Pre-op Eckardt score, mean 7
Post-op Eckardt score, mean 0.8
GERD
1 patients with GERD symptoms and Grade A esophagitis
Managed effectively with proton pump inhibitor
Prior to POEM POD 1
Prior to POEM POD 1
Achalasia - Treatment Algorithm
2013 AGA Practice Guidelines
POEM
Summary Per Oral Endoscopic Myotomy (POEM) is a safe, effective endoscopic
technique for management of achalasia
It requires advanced endoscopic skills and a multidisciplinary team
Clinical results similar to Heller myotomy
Indications expanding for other esophageal motility disorders
Need for additional long term outcomes studies
A POEM
Rose are red,
Violets are blue,
If you have achalasia,
POEM might be for you!
Thank You