A Novel Endoscopic Treatment for Achalasia Is the POEM mightier than the sword?

Transcription

1 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

2 Consultant Boston Scientific Medtronic Disclosures

3 Outline Background Diagnosis Treatment Advances: Per Oral Endoscopic Myotomy Outcomes

4 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

5 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

6 Clinical symptoms Achalasia - Diagnosis Endoscopic Radiographic Manometry

7 Achalasia - Subtypes

8 Achalasia Eckardt Scoring System Eckardt AJ, Eckardt VF - Nat Rev Gastroenterol Hepatol 2011

9 Chronic condition Achalasia - Treatment No cure Therapy focuses on Symptom control Halting progression Preserve esophageal function/structure

10 Achalasia - Treatment Pharmacotherapy CCB, long acting nitrates Botulinum toxin 66% initial response, high relapse 1 Pneumatic dilation Most effective non-surgical therapy 32% treatment failure at 3 years 2 Myotomy Efficacy 88-95% 3 1. Gastroenterology. 1996;110(5): World J Surg. 2015;39(3): JAMA. 2015;313(18):

11 Achalasia - Myotomy First Myotomy 1913 Transthoracic 1958 Laparoscopic 1991 Thoracoscopic 1992 Extramukose cardioplastik bein chronischen Cardiospasmus mit Dilatation des Oesophagus

12 Achalasia - Myotomy First Myotomy 1913 Transthoracic 1958 Laparoscopic 1991 Thoracoscopic 1992 Endoscopic 2008 Extramukose cardioplastik bein chronischen Cardiospasmus mit Dilatation des Oesophagus

13 Endoscopy 2007;39:761-4

14 Achalasia Esophageal Anatomy

15 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

16 Equipment HD gastroscope Distal attachment cap CO2 insufflation Needle knife Coagrasper Modern ESU Injection needle Endoclips/Endoscopic suturing

17 Achalasia POEM: Mucosal Entry Creation Endoscopy 2010; 42: 265

18 Achalasia POEM: Submucosal Tunnel

19 Achalasia POEM: Myotomy

20 Achalasia POEM: Mucosotomy Closure

21 POEM Initial Experience Endoscopy 2010; 42:

22 J Am Coll Surg 2015; 221:

23 Inoue Series POEM Results J Am Coll Surg 2015; 221:

24 POEM US Experience

25 J Gastrointest Surg (2015) 19:

26 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:

27 Swanstr m Series Complications J Gastrointest Surg (2015) 19:

28 POEM Adverse Events Aspiration Capnomediastinum/Capnoperitoneum Mucosal tunnel injury Bleeding Mediastinitis

29 Heller vs. POEM

30 Heller vs. POEM Meta-analysis 4 non-randomized comparative studies 317 patients (192 LHM, 125 POEM)

31 Heller vs. POEM 1. Length of myotomy 2. Operation time 3. LOS 4. Preop Eckardt 5. Postop Eckardt 6. Complications

32 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

33 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:

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35 GERD after POEM

36 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

37 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:

38 POEM - Advantages Incisionless Less pain Faster recovery Shift from OR to Endoscopy Unit Broadening indications Failed Heller Sigmoid esophagus Spastic esophageal motility disorders

39 UPENN 2014

40 LAHEY 2016

41 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

42 Length of Stay, mean 1.3 days The Lahey Experience 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

43 Prior to POEM POD 1

44 Prior to POEM POD 1

45 Achalasia - Treatment Algorithm POEM 2013 AGA Practice Guidelines

46 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

47 A POEM Rose are red, Violets are blue, If you have achalasia, POEM might be for you!

48 Thank You