POEM (Per Oral Endoscopic Myotomy) is a rising well known treatment for Achalasia ....... in this ppt we discuss the feasibility of POEM versus dilation and Heller's myotomy
3. Room 4: Endoscopy session Amun Ballroom
(Level 1)POEM … A Light in A Tunnel
Moderators
Ping-Hong Zhou
(China)
Mohamed El-Sherbiny
(Cairo University)
Experts
Essam El-Nezamy
(Cairo University)
Karim Essam
(Cairo University)
Geina Gamal
(Ain shams University)
Shaimaa Elkholy
(Cairo University)
Mohamed Nabil Alkady
(Cairo University)
Ahmed Khairy
(Cairo University)
Doaa Mansour
(Cairo University)
Lin Miao
(China)
Li Feng
(China)
Wen-Bo Mg
(China)
Lei Zhang
(China)
Xiao-Liang Zhu
(China)
Xun Li
(China)
Ying-Cai Ma
(China)
Jie Chen
(China)
Ahmed El-Meligy
(Cairo University)
4. Case presentation
• 28 years old female patient
• Presented with progressive dysphagia of one year duration
• She started to notice significant weight loss in the last 6 months
• She had no significant medical history
5. What to do next?
a. Endoscopy
b. Gastrographin swallow
c. Barium swallow
d. CT Scan
7. What to do next?
a. Take biopsy to exclude pseudo-achalasia
b. Diagnose as achalasia & proceed for management
c. Barium swallow
d. Manometry
e. Manometry & Barium swallow
10. What do the guidelines say?
Comment by Dr.Ahmed El-Meligy
11. Guidelines in diagnosis of Achalasia
All patients with suspected achalasia who do not have evidence of a
mechanical obstruction on endoscopy or esophagram should undergo
esophageal motility testing before a diagnosis of achalasia can be
confirmed
(strong recommendation, low-quality evidence)
12. Guidelines in diagnosis of Achalasia
The diagnosis of achalasia is supported by esophagram findings
including dilation of the esophagus, a narrow esophagogastric
junction with “ bird-beak ” appearance, aperistalsis, and poor
emptying of barium
(strong recommendation, moderate-quality evidence)
13. Guidelines in diagnosis of Achalasia
Barium esophagram is recommended to assess esophageal emptying and
esophagogastric junction morphology in those with equivocal motility testing
(strong recommendation, low-quality evidence)
14. Guidelines in diagnosis of Achalasia
Endoscopic assessment of the gastroesophageal junction and gastric
cardia is recommended in all patients with achalasia to rule out
pseudoachalasia
(strong recommendation, moderate-quality evidence)
15. Guidelines in the Diagnosis of Achalasia
-High-resolution manometry is the test of choice for the diagnosis of achalasia
(compared to conventional manometry)
-The Chicago Classification is a useful tool to define the clinically relevant
phenotypes of achalasia
-The timed barium esophagram offers an objective evaluation of the diseases
and of the outcome after treatment (compared to traditional barium
esophagram)
16. Guidelines in the Diagnosis of Achalasia
-Endoscopy should be performed in patients with suspected achalasia to
exclude malignancy of the esophagogastric junction
-The Eckardt score is a simple tool to measure symptom severity in achalasia
patients, but it should be integrated with objective measures such
esophagogram and manometry
18. What to do next?
a. Botulinum injection
b. Medical treatment
c. Endoscopic pneumatic dilation
d. Heller’s surgical myotomy
e. POEM (per oral endoscopic myotomy)
19. What do the guidelines say?
Comment by Dr.Mohamed Nabil Alkady
20. Guidelines in treatment of Achalasia,2018
MEDIAL TREATMENT:
-No convincing evidence that nitrates is effective for symptomatic relief
-No convincing evidence that with calcium blockers is effective for (short
term) symptomatic relief
-No evidence that phosphodiesterase inhibitors is effective for symptomatic
relief
21. Guidelines in treatment of Achalasia
BOTULINUM TOXIN INJECTION (BTI):
-Limited application in young (<50 years)
-Reserved for unfit for surgery or as a bridge
-Repeat BTI are safe, but less effective
-There is no evidence for injecting in lower esophageal body (+LES) in type III
achalasia
-There is no evidence that patients should be treated with increasing dosage
22. Guidelines in treatment of Achalasia
PNEUMATIC DILATION (PD):
-Graded PD is an effective terms of improvement of symptoms & swallowing
function (Patients wishing longer term remission may opt for surgery)
-Best post procedural test to assess perforation is Gastrografin swallow (after 4
hrs only if symptomatic)
23. Guidelines in treatment of Achalasia
PNEUMATIC DILATION (PD):
-Limited evidence that PD may be used as first-line therapy in megaesophagus
(No recommendation)
-No evidence for PPI use after PD unless symptomatic or +ve at pH-monitoring
(Against)
25. Clinical Scenario
• The patient showed marked improvement, she gained wait
• She became pregnant
• After 3 months of her delivery she started to develop the symptoms
again in the form of dysphagia
• She developed failure of lactation
• Endoscopy : dilated oesphagus with spastic cardia
26. What to do next?
a. Another session of Endoscopic pneumatic dilation
b. Heller’s surgical myotomy
c. POEM (per oral endoscopic myotomy)
31. POEM
When to do ?
All patients diagnosed with achalasia can be a candidate !
Various types of achalasia
Sigmoid Esophagus
Prior endoscopic intervention or surgical myotomy
Other abnormalities
32. POEM
When not to do?
-Marked submucosal fibrosis like after radiotherapy,
radiofrequency ablation or EMR
-Bleeding tendency
-Portal hypertension
38. Comparison to surgery
-No significant difference in the outcome however;
*POEM is an ‘incisionless procedure’
*Longer myotomy
*Initial treatment or after failure of other
*Non-achalasia esophageal motility disorders such as nutcracker
esophagus, jackhammer esophagus, or diffuse esophageal spasm
39. What do the guidelines say?
Comment by Dr.Mohamed Nabil Alkady
40. Guidelines in treatment of Achalasia
POEM (Per Oral Endoscopic Myotomy):
-POEM, results in similar outcomes on swallowing functions compared
(Heller myotomy or PD), at least at medium term follow-up (2–4 years)
-POEM is an appropriate treatment for symptom persistence/recurrence
after laparoscopic myotomy
41. Guidelines in treatment of Achalasia
POEM (Per Oral Endoscopic Myotomy):
-No evidence that previous treatment with PD or Botox reduces the technical
feasibility of POEM or results in poorer outcomes
-Attaining proficiency with the POEM procedure involves a stepwise approach
to education and a defined learning curve for both medical and surgical
endoscopists
42. Guidelines in treatment of Achalasia
POEM (Per Oral Endoscopic Myotomy):
Treatment of achalasia with POEM is associated with a higher incidence of
GERD compared to alternative therapies (Heller myotomy with fundoplication
or PD)
Options should be discussed with the patients (Strong Recommendation)
43. Guidelines in treatment of Achalasia
POEM (Per Oral Endoscopic Myotomy):
Treatment of achalasia with POEM is associated with a higher incidence of
GERD compared to alternative therapies (Heller myotomy with fundoplication
or PD)
Options should be discussed with the patients (Strong Recommendation)
44. Guidelines in treatment of Achalasia
LHM (Laparoscopic Heller’s Myotomy):
-Best results in (Chicago) type I & type II
-LHM should include a myotomy 6 cm into the esophagus and 2 to 3 cm into the
stomach for effective symptom control
-LHM with a partial fundoplication is as effective as LHM
-LHM, POEM or PD should be considered as the first-line option in sigmoid
esophagus (compared to esophagectomy)
45. • 6 months later the patient started to complain again from dysphagia
47. What to do next?
a. Back to dilation
b. re-POEM
c. Is it time for surgery
d. Oesphagectomy ?!
48. Recurrent Achalasia
• No universal definition, however the symptoms are the main stay for
assessment of success or failure
• Failed cases should undergo repeat objective testing (endoscopy,
barium, manometry + PH metry )
49. Recurrent Achalasia
• Failed PD >>> LHM /POEM
• Failed LHM >> POEM / PD
• Failed POEM >> PD, no LHM, little evidence of re POEM (further
research is requested)
Aprestalitic oesphagus & the catheter could not pass through the cardia
Endoscopy should be performed in
patients with suspected achalasia to
exclude malignancy of the
esophagogastric junction.
98.1% We recommend performing UGI endoscopy
in adult with the suspected diagnosis of
achalasia to exclude neoplastic
pseudoachalasia. Good practice
recommendation.
5 The Eckardt score is a simple tool to
measure symptom severity in achalasia
patients, but it should be integrated with
objective measures such esophagogram
and manometry
Endoscopy should be performed in
patients with suspected achalasia to
exclude malignancy of the
esophagogastric junction.
98.1% We recommend performing UGI endoscopy
in adult with the suspected diagnosis of
achalasia to exclude neoplastic
pseudoachalasia. Good practice
recommendation.
5 The Eckardt score is a simple tool to
measure symptom severity in achalasia
patients, but it should be integrated with
objective measures such esophagogram
and manometry
All in adults
BTI has limited application in young patients (<50 years)
-BTI should be reserved for patients who are unfit for surgery or as a bridge to more effective therapies(surgery or PD)
-Repeat treatments with Botox are safe, but less effective than initial treatment
-There is no evidence for supporting the injection of Botox in the lower esophageal body (+LES) in type III achalasia patients
-There is no evidence that patients undergoing repeat BTI of the LES should be treated with increasing dosage of BT
90.4% We recommend graded pneumatic dilatations as
an effective treatment (control of symptoms
including dysphagia) for esophageal achalasia.
Strong recommendation GRADE: moderate.
Patients wishing longer term remission may opt
for surgical treatment.
90.4% We recommend graded pneumatic dilatations as
an effective treatment (control of symptoms
including dysphagia) for esophageal achalasia.
Strong recommendation GRADE: moderate.
Patients wishing longer term remission may opt
for surgical treatment.
It can be done to all types of patients and all types of achalasia and also Sigmoid Esophagus (surgical myotomy can’t be done) . Also Others Esophageal abnormalities (diffuse oesphgeal spasm or jackhammer oesphagus
So what about the sequel, few papers where published to collectively have a meta analysis or a review about the POEM but this paper published 2014 by nageshawer reddy
These table contains several publications that mentions the efficacy of POEM you can see here the eckardt score which is made to ass the degree of severity for patients with achalasia maximum is 9 and maximum is 12 ……. You can see the mean of the score pre & post…
And then go to the LES there is technical success in about 97% while clinical success in 93-98% …………….
All in adults
All in adults
All in adults
All in adults
The best outcomes for LHM are achieved
in (Chicago) type I & type II achalasia
patients.
90.4% We recommend laparoscopic Heller myotomy for
control of symptoms in Chicago type I and type
II achalasia. Strong recommendation. GRADE:
moderate.
26 Laparoscopic Heller myotomy should
include a myotomy 6 cm into the
esophagus and 2 to 3 cm into the stomach
as measured from the GEJ, for effective
symptom control in achalasia
patients.
94.2% We recommend that Laparoscopic Heller
cardiomyotomy should be extended at least (6 cm
proximal to the GEJ and at least 2 cm distal to
the GEJ. Conditional recommendation.
GRADE: low.
27 Partial fundoplication should be added to
laparoscopic myotomy in patients with
achalasia to reduce the risk of subsequent
gastroesophageal reflux.
94.2% We recommend that a partial (posterior or
anterior fundoplication) but not a complete 360◦
wrap should be added to reduce the long-term
risk (5 years) of developing gastroesophageal
reflux and dysphagia after myotomy. Strong
recommendation. GRADE: moderate.
28 Laparoscopic Heller myotomy with a
partial fundoplication is as effective at
improving swallowing function as
laparoscopic Heller myotomy alone.
82.7% We recommend a partial fundoplication should
be used when performing Heller myotomy to
prevent subsequent development of gastroesophageal
reflux without compromising the
adequate control of dysphagia.We recommend
against LHM alone due to the risk development
of gastro-esophageal reflux. Strong
recommendation. GRADE: High.
29 LHM (or other therapies as POEM or PD)
should be considered as the first-line
treatment option in achalasia patients with
sigmoid esophagus (compared to
esophagectomy).
86.5% We recommend standard endoscopic or surgical
therapies in surgically na¨ıve achalasia patients
with sigmoid-shaped esophagus, leaving
esophagectomy as secondary option
in case of failure of first line therapy. Conditional
recommendation. GRADE: very low.
35 Patients with achalasia who do not respond
to initial treatment with graded PD, should
be referred for Heller myotomy or POEM.
94.2% We recommend that in patients who are fit for
surgery and have symptomatic recurrences after
several pneumatic dilations, Heller myotomy, or
POEM should be considered. Conditional
recommendation. GRADE: of evidence
low.
36 Laparoscopic esophageal myotomy is a
safe, feasible and effective treatment after
failed Botox injection for achalasia.
96.2% We recommend LHM as an effective therapy for
symptom recurrence after primary treatment with
BTI. Conditional recommendation. GRADE:
very low.
37 PD, compared with repeat myotomy or
POEM, is the first option for treatment
after failed Heller myotomy for achalasia.
80.8% We recommend pneumatic dilation as a safe and
effective treatment of symptom recurrences after
LHM. Conditional recommendation. GRADE:
Low.
38 There is insufficient evidence that
laparoscopic myotomy or redo POEM
offer better results than PDs after failed
POEM.
82.4% We make no recommendation about laparoscopic
myotomy or redo POEM offering better
symptomatic relief than pneumatic dilations after
failed POEM. Further research is recommended
to provide high-quality data and guide clinical
decisions.
Diagnosis and
treatment of end
stage achalasia
39 Barium swallow esophagram, compared
with manometry, is the best diagnostic
method for defining end stage achalasia
(i.e. that which requires esophagectomy).
94.1% We recommend the use of barium swallow as the
most accurate investigation to properly define
end-stage achalasia. Good practice
recommendation.
40 Esophagectomy is indicated in patients
with persistent or recurrent achalasia after
failure of previous less invasive treatments
(PD, POEM, LHM) and radiologic
progression of the disease.
80.8% We recommend esophagectomy in patients with
end-stage achalasia who have failed other less
invasive interventions. Conditional
recommendation. GRADE: Low.
35 Patients with achalasia who do not respond
to initial treatment with graded PD, should
be referred for Heller myotomy or POEM.
94.2% We recommend that in patients who are fit for
surgery and have symptomatic recurrences after
several pneumatic dilations, Heller myotomy, or
POEM should be considered. Conditional
recommendation. GRADE: of evidence
low.
36 Laparoscopic esophageal myotomy is a
safe, feasible and effective treatment after
failed Botox injection for achalasia.
96.2% We recommend LHM as an effective therapy for
symptom recurrence after primary treatment with
BTI. Conditional recommendation. GRADE:
very low.
37 PD, compared with repeat myotomy or
POEM, is the first option for treatment
after failed Heller myotomy for achalasia.
80.8% We recommend pneumatic dilation as a safe and
effective treatment of symptom recurrences after
LHM. Conditional recommendation. GRADE:
Low.
38 There is insufficient evidence that
laparoscopic myotomy or redo POEM
offer better results than PDs after failed
POEM.
82.4% We make no recommendation about laparoscopic
myotomy or redo POEM offering better
symptomatic relief than pneumatic dilations after
failed POEM. Further research is recommended
to provide high-quality data and guide clinical
decisions.
Diagnosis and
treatment of end
stage achalasia
39 Barium swallow esophagram, compared
with manometry, is the best diagnostic
method for defining end stage achalasia
(i.e. that which requires esophagectomy).
94.1% We recommend the use of barium swallow as the
most accurate investigation to properly define
end-stage achalasia. Good practice
recommendation.
40 Esophagectomy is indicated in patients
with persistent or recurrent achalasia after
failure of previous less invasive treatments
(PD, POEM, LHM) and radiologic
progression of the disease.
80.8% We recommend esophagectomy in patients with
end-stage achalasia who have failed other less
invasive interventions. Conditional
recommendation. GRADE: Low.