How I Do It? Per-oral Endoscopic Myotomy (POEM) Ping-hong ZHOU, MD. Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, China

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1 How I Do It? Per-oral Endoscopic Myotomy (POEM) Ping-hong ZHOU, MD Endoscopy Center, Zhongshan Hospital Fudan University, Shanghai, China

2 The 2 nd World Congress on CONTROVERSIES IN GASTROENTEROLOGY Prof. Pinghong ZHOU Zhongshan Hospital, Fudan University, Shanghai, China Per-oral Endoscopic Myotomy (POEM) Disclosure of Interest: Nothing to Disclose

3 Treatment No curative option! Objective Reduction of the gradient across the LES for relieving symptoms improving esophageal emptying preventing development of megaesophagus Pharmacological treatment Disruption of the LES Endoscopic botox injection Calcium channel blockers Surgical myotomy Pneumatic dilation Endoscopic myotomy

4 History of POEM NOTES has inspired endoscopists to creat less invisive treatment even for achalasia. Pasricha et al. performed submucosal endoscopic esophageal myotomy on 4 pigs and found it feasible, safe and effective. It provided experimental evidence for peroral endoscopic myotomy later on. Pasricha et al. Endoscopy, 2007

5 Inoue et al. reported a novel endoscopic surgery: peroral endoscopic myotomy (POEM) for treating esophageal achalasia Significant improvement in dysphagia score (preop 10 to 1.3 postop (P<0.001) Improvement in LES pressure (mean preop 52.4mmHg 19.9mmHg postop (P<0.001) It is a milestone event of tunnel endoscopic surgery Inoue,et al. Endoscopy 2010; 42:

6 July 2010, Hongkong

7 First case (16-Aug-2010) Operative time: 85 minutes

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9 POEM - Clinical setting Instruments Gastroscope with jet system Hook, TT Knife (Olympus, Japan) Hybrid Knife (T-type, ERBE, Germany) Distal attachment: transparent cap Diathermy: VIO 300D (ERBE, Germany) Forced Coag, Effect 2,45W, CO 2 insufflation

10 Preparation of esophageaus

11 POEM - Clinical setting All performed under GA

12 Tips for POEM procedure When coagulating the blood vessel, the coagulation forceps are suggested to be close to the muscular side to avoid mucosal injury

13 Tips for POEM procedure The fibrosis at the EGJ is common for pre-treatment patients Sufficient submucosal cushion is important to prevent mucosal rupture

14 Judgement of EGJ 1)Length of insertion; 2)Resistance of gastroscopy; 3)Typical vessels; 4)Color change in cardia mucosa

15 Bleeding during myotomy

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17 Water-jet assisted POEM in comparison to conventional myotomy technique for treatment of esophageal achalasia Presidental plenary session, DDW, 2012, San Diego

18 Water-jet assisted POEM lead to significantly shorter operation time, lower bleeding rate and a lower frequency of usage of coagulation forceps The water-jet assisted procedure simplifies the POEM procedure and makes it safer push and pull technique

19 Full-thickness myotomy A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during POEM But the longitudinal muscle fibers of the esophagus are extremely thin and fragile

20 Full-thickness myotomy Reduced the procedure time Did not increase the procedurerelated adverse events Did not increase clinical reflux complications Zhou PH et al. J Am Coll Surg, 2013

21 UEG Week 2012, Amsterdam

22 Results presented at the UEGW 2012 Familiari Zhou V. Rentile Maselli Charton Patients 22 46* Success 91% 93% 96% 100% 95% Major complications GERD occurrence % 0 31% * Paediatric N = 21 Prior LM N = 12 Sigmoid type N = 13

23 POEM for failed HM Reasons for operation failure Incomplete myotom Healing of myotomy edges by fibrosis Hypertensive fundoplication Esophageal diverticula Gastro-esophageal reflux disease

24 Management of failed HM Controversy exists regarding the therapy of failed HM Pneumatic dilation was associated with unpredictable outcomes and significant complications Laparoscopic remyotomy was still an invasive procedure with an increased risk of failure and complications Peroral endoscopic myotomy (POEM) POEM may offer another option for failed HM Subsequent POEM may be more challenging because of scars and tissue adhesions No systematic data HM have yet been published

25 The patient once had thoracoscopic HM 10 years ago, but the symptom was recurrent due to imcomplete myotomy around the cardia POEM was performed at the opposite side of the esophagus

26 POEM seems to a promising new treatment for failed HM resulting in short-term symptom relief in > 90% of cases Previous HM may make subsequent endoscopic remyotomy more challenging, but does not influence subsquent POEM procedure

27 POEM for sigmoid type The S type was considered to be the advanced stage of achalasia The esophageal lumen was dilated, tortuous and stored with lot of effusion

28 Strategy for S type Treatment of S type is still controversial Interventional treatments (balloon dilation, botox et al.) are ineffective Esophagectomy has historically been considered as standard treatment Some recommend a myotomy as the first step several studies have examined successful treatment of achalasia with laparoscopic Heller myotomy POEM may offer another option for S type A new way of myotomy Less invasive Effective in primary cases

29 S type POEM difficulties Easy to be lost in the tunnel Tortuous lumen fibrosis in SM layer thickened and disordered muscle fiber It is very difficult and time-consuming to make the tunnel for sigmoid type achalasia

30 During follow-up, the esophageal lumen is still dilated, but no more effusion Clips sometimes remains and cardia is loose

31 Severe fibrosis in sm layer Gentleman, 98 years old 31

32 Child, 3 years old

33 Child, 2 years old

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35 Re-myotomy after POEM POEM was performed in another hospital 4 monthes ago, but dysphagia was not relieved due to imcomplete myotomy around the cardia Thorough myotomy was achieved by Hybrid Knife

36 Gas-related complications Subcutaneous emphysema mediastinal emphysema Pneumoperitoneum Puncture with 20G needle Pneumothorax Small-caliber thoracic tube

37 Delayed bleeding Early manifestations Hematoma on CT scan Progressive retrosternal pain Vomited fresh blood Hemostasis Emergency endosopy Sengstaken Blakemore tube Zhou PH et al. GIE, 2013

38 Orlando, 2013 DDW

39 Delayed bleeding in the submucosal tunnel Vomiting of fresh blood and progressive retrosternal pain were the major early manifestations Emergency endoscopic diagnosis and hemostasis should be taken as early as possible A Sengstaken Blakemore tube is particularly effective for hemostasis by compression

40 Esophageal leakage Clinical signs Chest CT scan Endoscopy chest pain continuous high fever dyspnea pleural effusion mediastinal emphysema pneumonia and segmental atelectasis of the lungs esophageal leakage

41 GI tract leakage Metallic clips falling off from entry of the tunnel and endoscopic observation revealing orificium fistulae which were successfully clipped with metallic clips A satisfactorily healing was seen at 2-3 weeks follow-up endoscopy

42 Sealant Pocrine Fibrin Kit (fibrinogen+thrombin) 42

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44 String suture with endoloop and meatllic clips 44

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46 Retroperitoneal Infection Body Temperature: 39.1 Gastroscopy: leakage of mucosa in EGJ purulent secreta in tunnel Washing the tunnel with NS Position: semireclining NGT drainage Antibiotics and PPI Day 3 after Procedure

47 Body Temperature: 38.5 Complain of pain at right lower back CT Scan Drainage of the retroperitoneal abscess Day 10 after Procedure

48 Discharged: Day 29

49 Current Status promises to be as effective as laparoscopic myotomy (LM) or pneumatic dilation (PD) less invasive than LM (no injury of surrounding tissue) at least as safe as PD more durable than PD could be effective in failures or predictable negative outcome of LM or PD

50 Summary When, whom, how long and which direction for POEM? POEM allows myotomy in any direction and any length POEM for achalasia type I-III POEM for tortuous achalasia POEM for children POEM for failure after surgery Re-myotomy for failure after POEM POEM for EVERYBODY! is still investigational

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