a novel endoscopic treatment for...2016/11/05  · a novel endoscopic treatment for achalasia – is...

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