Okay, so we'll get started. I see a bunch of questions coming up. We'll try to get to those in between the cases. So we have a few cases lined up for you. Again, these are real life cases with some images, videos, so that we can have a good interaction amongst the panelists. So Mohan, please go ahead. Thank you, Amrita, Monica, and Professor, for inviting me to speak at the postgraduate course. Okay, so case presentation. Forty-year-old gentleman with dysphagia to solids, regurgitation, and weight loss, no chest pain, and Eckert score of 9. Symptoms present for two years and symptoms progressed recently, BMI 23, no prior treatment. So this is the high-resolution manometry. We have the composite swallow and swallow number 7. I ask Michael, is that enough for you to tell what this patient has? Yeah, pretty much. I mean, that's type 2 echolasia based on what you're showing. It fits the patient's symptomatology. Again, you got to make sure that it fits patient's symptoms. So you have a patient with dysphagia, regurgitation, type 2 echolasia is most likely the diagnosis. Yeah, so the type 2 echolasia and IRP was pretty high at 58. I don't think you can see the numbers there, but it was pretty high. Prateek, any comment on the manometry? No, I'd like to have David Katska. Dave, if you want to come on up, please. I know we are one chair short, but please bring your own chair. So I'm just, please come on up. Okay, so what is your recommended treatment? Again, for the panel, let's see if we can get a consensus here. So diet modification, calcium channel blocker, Botox injection, pneumatic dilation, Heller, POEM or POEM with phantoplacation, POEM F. I might have missed it, but did this patient, you said, had a hiatal hernia also? No hiatal hernia. You know, so you have a younger male with dysphagia, regurgitation. You have type 2 echolasia. Dietary modification has already failed because patient's lost a lot of weight. Calcium channel blocker, Botox, you would not recommend in this case. Those are not definitive therapies. So you're really left with pneumatic dilation, Heller myotomy and POEM. The problem with pneumatic dilation, as I do them, is in younger males, they're not effective if you start with a 30. So if you wanted to do pneumatic starting with 35, not 30, and then the option of Heller versus POEM, I think all three of those would be good options. So I would just talk with them about the risks and benefits of each one of them. And I would offer either pneumatic at 35 starting, Heller myotomy and or POEM. And sometimes patients pick one or the other depending on what they feel comfortable. Thomas? Murray, I think similar. When younger people, you rather go for myotomy. And then some patients have concern with reflux and there's nothing wrong with Hellers. Okay. So just to highlight the ASG guideline on management of echolasia, the guideline endorsed all three treatments as acceptable options. Heller, pneumatic dilation, and POEM. The recommendation was against Botox for obvious reasons. So DE and F are acceptable options for this patient as was mentioned by the experts. Also, as Thomas was mentioning, the risk of reflux, especially in a patient who is young and has to deal with reflux for the rest of their life. So these are some images of what we've seen after POEM, severe reflux esophagitis, high Heller grades. We've seen this adenocarcinoma that we published in GUT. This is the first reported case after POEM. Four years after POEM with a new incident, Barrett's with adenocarcinoma. Fortunately, treated successfully with endoscopy. But we take reflux after POEM very seriously. And the ASGE suggests that patients after POEM are counseled regarding the increased risk of post-procedural reflux based on patient preference. Post-procedure management includes either one of the three options. One, objective testing for esophageal acid exposure, long-term acid suppression, or surveillance after endoscopy. So in this case, we chose to do POEM F. This is the newest kid on the block. One question in between. I mean, that's much more care than in a normal reflux patient. Why? Sorry? It's much more surveillance and being afraid than in a normal reflux patient without Echolacea. Why? Yeah, so we didn't endorse yearly reflux, yearly EGDs, but these patients, when they get exposed to acid, there's no clearance of acid. So there is increased time of basically the esophageal bathing in acid. So they might be even at increased risk of acid-related complications compared to a usual GERD patient. Am I saying things correctly, Mike? Yeah, so they're going to be at increased risk. The question becomes what to do, right? So would you treat everybody with empiric therapy, post-myotomy, and POEMs especially, right? I don't normally test them and then treat. Because I know the rate is pretty high, 50%, 60% at times, I just empirically treat them. But that's exactly right. They have no peristaltic activity, so any exposure to acid that they have, they can't clear it well. Therefore, it's almost like a scleroderma-type esophagus. They get pretty severe esophagitis. Okay, so due to time limitations, I'm going to show you the technical aspects of the procedure. So this is the typical POEM, about 10 centimeters above the GE junction. Here, this is an anterior approach, but we know anterior and posterior are equally effective, and it doesn't seem that reflux rates are different. So mucosal bleb, just simply with saline and methylene blue. This is one of the knives that is commonly used for POEM, triangular tip knife. We make about a centimeter and a half longitudinal incision, and then followed by the tunneling. Tunneling, basically, is submucosal dissection, and we tunnel on the surface of the muscle. In submucosal endoscopy, just taking care of the mucosa is very important. Mucosal injury is what constitutes a perforation with submucosal endoscopy, because we're cutting the muscle, right? So mucosa has to stay intact. So after we tunnel towards the LES, we continue tunneling towards the gastric cardia. This step is very important, so having adequate tunnel on the gastric side is important. We usually tunnel two to three centimeters. There's some data from the surgical literature comparing one and a half to three centimeters, and three centimeters was more effective. I would say at least two centimeters on the gastric side. At the same time, it's believed to be that an extra long gastric myotomy is associated with increased risk of reflux, so we like to extend it, but not by too much. Smaller vessels, we can just coagulate them with the same knife. You can see that we are working on the surface of the muscle. Once you cross the LES, the tunnel widens, indicating that we are on the other side. Here we're seeing the LES, and we see in retroflexion on the luminal side that we crossed the LES down to the gastric cardia. And then we start performing the myotomy, same knife. We just about three hits with a spray coagulation to make a little hole in the muscle to capture the muscle. And in the upper esophagus, we like to preserve the longitudinal muscle just as a safety net away from the mediastinal structures. Once we approach the lower esophageal sphincter, then we turn it into a full thickness myotomy, and that continues to the gastric side. Typically six centimeters on the esophageal side to three centimeter on the gastric side. Here you see we turned it into a full thickness myotomy. We're always keeping this thin layer of adventitia on the esophageal side and cirrhosis on the gastric side intact. If you don't do that, then you're going to have gas-related complications, even if you use CO2, which is a must, needless to say that. This is cutting the LES and into the gastric cardia. We like to use some coagulation mode here to avoid bleeding. So we'll move to the last part of the procedure, which is a new thing we introduced recently at our hospital, which is notes fundoplication. As Michael said, very high incidence of reflux after POEM. He doesn't even test these patients. You expect that they will have reflux. But in a patient this young, maybe an endoscopic fundoplication to mimic what surgeons do is a good thing. This procedure is in its infancy. We're using instruments that are not going to hold the fundoplication for a long time, but I think the principle is there, and hopefully we can work on a suturing apparatus to make this last. Do I have a couple of minutes, Pratik, to finish this? Yeah, just a minute. So here we are capturing the anterior gastric wall, pulling it into the esophagus, and basically checking on the luminal side if we are creating good fundoplication. And if it does, then we mark that area with some spray. And this is where we're going to get the end loop with clips, attach them to this side. So we already simulated the fundoplication by pulling on the stomach. So now we're going to actually tie the fundoplication. So we attach an end loop to the marked area. We like to place three clips or four clips here. And then we pull back to the esophagus, to the cut muscle, and put four more clips. And then basically close the end loop and cut the end loop here. And I want to show you the end result. We have actually a fundoplication. And then we close the incision. So these are the results of the endoflip. Before the myotomy, 0.8. The distance ability was 0.8. After myotomy, it was 9.4. And after fundoplication, it was 3.2. So this is a nice response to the fundoplication. John, do you have anything? Yeah. What makes you think that this might be better than our approach of doing a TIF afterwards if needed, just in terms of longevity? Yeah. So I think the answer to that is long, and Pratik is going to kick me out of the stage here soon. So maybe we'll leave that to the discussion. We can have a discussion. Good question. You can make your comment from there. And just the outcomes of this case, the total procedure time was 94 minutes, length of stay one day, esophogram no leak. Six weeks after the procedure, patient continues to do very well. Thank you. Thank you. Nicely done, Mohan. And maybe as we are talking about that, a few questions are coming in also. So maybe Michael and David, if you can approach this, is postporm GERD, right? I mean, why not give PPIs? Why not, you know, just wait and see what happens rather than like Mohan going crazy and pulling the peritoneum and the liver from every place that he can do it. So any comments on that, guys? Thanks, Pratik. If I can make a comment, a few comments. First is reinforce what Michael said. Remember, when you do a POM, you're basically creating the perfect model of reflux, as opposed to idiopathic reflux. Particularly if you go along the greater curve, you get some of the sling fibers. You've almost completed it, other than hyperacidity. So the degree of reflux these patients will get is far more than your average reflux patient. Remember, you're trying to bring the sphincter pressure to zero, basically, which is not what happens in a patient with reflux. So that's number one. Number two, the use of fundoplication originally for this was not only because of reflux with just a myotomy alone, but descriptions of adenocarcinoma in 1940. So there's very good reason for fundoplication. Having said that, though, I think Mohan's approach is great. And Tom, John DeWitt had a nice abstract yesterday showing that TIF could be a very good rescue therapy in these patients. But remember, too, most of these patients are asymptomatic because there's sensory dysfunction in addition to motor dysfunction. So part of the big problem here is they don't feel it, which is why you have to go back and scope them at some point after you've done a myotomy. After that, you've got to weigh the long-term risks of what could be reflux in a 20-year-old for the next 60 years, whether PPIs will adequately control that or not. So I think it's a very difficult situation. But I think the future will be procedures such as Mohan described or doing a TIF because I think this uncontrolled reflux for many, many years may have some severe consequences in the future. That's my impression. Just a quick comment, Pradeep. I think where we're going with this, and I hope that's where we're going, is really to tailor the treatment, right? So the all-or-none approach of cutting the whole muscle, cutting part of the muscle, and guessing at it is going to be problematic. I think that's where endoflip could really be useful, where you target where and how much you cut to reduce reflux, that balance, that threshold that you need to not have reflux but yet have cut enough to relieve the dysphagia symptoms. I hope that's where we'll be going. Okay. We'll go to Uzma, but there's a question from the audience. Thomas, perhaps you can address it based on the RCT. So the question is, does pneumatic dilation interfere with a future poem? No, basically not. So you can do poem almost after every other intervention. Okay. Thank you. Uzma, please. All right. This may not be as exciting, but I think dealing with esophageal strictures can definitely provide a clinical challenge for those of us who have to deal with these on a regular basis. And especially, you know, there's always a lot of questions surrounding what diameter do I start dilating? How much do I dilate to? And obviously, it depends on the type of stricture you're dealing with. So this was a patient referred to me. He had a history of a G-junction cancer, had neoadjuvant chemoradiation, and then a distal esophagectomy. He started having dysphagia after a few months, and then he was scoped by an outside endoscopist a few times. They did find an esophagogastric anastomotic stricture dilated with a balloon to 12 millimeters. The patient said they didn't have a response and came back a couple months later. They continue to have dysphagia. And so when I scope the patient, you see this stricture where you can just barely get the scope through with a little bit of mucosal trauma. But I don't know, John, if you wanted to describe what the type of stricture you're seeing, just in terms of the mucosa and diameter, or how you would approach this? Well, you've already gone through with the scope. I think that it's hard to just sort of guess the diameter, unless if you wanted to use a balloon to actually gauge the diameter through the scope balloon, choosing in purpose a smaller size, taking into account the diameter of the scope. If you've had much resistance, you may have just sort of backed out and started with the balloon before going ahead and doing it. But I think that's how it would. It's not a very long stricture. It doesn't look like either. Are you worried because you know it's an anastomotic stricture, it's going to be very fibrotic, and perhaps? And a higher risk of perforation. I probably would be a little bit more relaxed in not trying to do too much at the same time. Okay, so for the panel, we have a couple options. So since you got the scope through, you could do nothing, because you were able to get it through. What about the role of steroids? David? Yes, well, these are tough strictures. I think part of what we need to do is figure out what the etiology is, if possible. Oftentimes, we'll approach these patients with sort of a regularized approach. But you have to decide, is most of this reflux? Is it poor blood supply from the esophagectomy? Or is there something like a staple there that's giving you an inflammatory reaction? I think some of your treatment has to be directed in that way. If we think it's inflammatory, perhaps injection of steroids would be useful. But I think it's very important to make sure these patients have adequate acid suppression as well, if you think reflux may be part of it. So don't forget the medical therapy that's involved in these, as you're doing dilation and injecting steroids. But I think injecting steroids would be very reasonable in this patient. But, David, you wouldn't do it at the first setting, correct? Not at first setting. I mean, you would want to. Well, what's the downside of doing it at the first setting? It's pretty well-tolerated. Unless it's a radiation-induced stricture, where you can get fistula formation, I think there's really no downside. And you know anastomotic strictures are usually fibrotic, very tough to treat. So sometimes I will do it up front. But so you can dilate. And then, Prateek, would you do a savory or a balloon dilation? Does it matter? No, I don't think it really matters. Use whatever you're comfortable with. I mean, this is a focal stricture, so a balloon would be as good as a savory. Sometimes I like the feel that I get with the savory, so that I know how much resistance there is. So it all depends. If it's the first time, I prefer usually a savory, just so that I can get that tactile sensation, which I don't get with a balloon. But RCTs show that both are equally effective. Usually I like savories when it's a proximal stricture. This one's distal, so I did choose a balloon. Oops, I told you what size. But since I got the scope through, and the scope's around 9, 10 millimeters, I dilated with a 12 to 15 millimeter balloon. And then after dilation, you can see that things have opened up. But now, Michael, would you stop dilating at this point? Because now you can get the scope through. Yeah, so I see a lot of these patients, unfortunately. For them, my practice is to dilate them as aggressively as I can. When I was at the Cleveland Clinic, we had Tom Rice, our surgeon, who would take a Maloney that's 56 or 58 and just put it through and say, either you dilate or you don't. So this idea of 12 millimeter dilation in these is really problematic. I would not recommend that if you're in private practice. You can do that in academics when you have support. He's a thoracic surgeon. So what I do for these is start with a 15 and get a sense for what 15 does. Then slowly go up, bring them back. As far as injecting them, I would do that either at the first, or especially if they're referred and they've failed so many times. Remembering a lot of these are ischemic because they've had surgery. They're ischemic. So repetitive serial dilation, starting with 15, going as high as you can. And I've had pretty good success doing it. And then increasing the interval going from once a month to two to four to six. That tends to work. I think you brought up two great points. One, you want to achieve some decent mucosal disruption. And then the second point is that with these strictures, again, knowing that these might be a little bit more difficult, bring the patient back in a short interval, maybe one to two weeks for multiple sessions. Because when it's so fibrotic, it just wants to shrink back down if you wait too long, and then you have to start all over. So I didn't know the person you mentioned, but I'm with them, and I try to be a little bit more aggressive with the dilation. Okay, so we decided to dilate a little bit more. And then now when you're looking at your anastomosis. Yeah, that's perfect. Yeah. You know, sometimes people see that and they get scared, right? You do. If you dilate and you don't see a disruption, then you've done nothing, right? So you want to dilate and you want to see the disruption. So you've achieved disruption. The key is whether or not it's too deep of a disruption. I know. You're either, oh, man, this is too deep, or, oh, fantastic, I did a great job. And I think, again, it's sometimes hard to discern. So, you know, when you see this after your dilation, what are you going to do? Would you stop and do nothing? Would you get an esophagram on this patient pending any symptoms? Would you attempt to close it, or would you keep dilating at this point? So, John? I would not keep dilating. Okay. Dilate and run, no. I don't think there's a, you know, and to your earlier point, I don't see the rush. I like the idea of bringing them back soon to get a sense of is this thing closing down and what pace is it going with? But, you know, I think that they're able to maintain, you know, their nutritional status and there's not a rush. So at this point, I think that image would sort of give me a little bit of an increase in my pulse rate. So I would probably obtain an esophagram before advancing their diet. I think also, so a lot of times I do these procedures in a fluoroscopy room, depending on the degree of symptoms. So in this case, I did just throw some contrast down just to ensure there was no obvious leak. But I think if you have any concern, I would get an esophagram because you want to know if there is a perforation or leak up front. The earlier, the better. But I think also, even if you wanted to close that, it would probably be pretty difficult because it was so fibrotic. So your options might be a little bit more limited. But I did stop dilating at that point. That was plenty. I'm not going into the peritoneum like Dr. Kashav. Not intentionally. It's not going forward. But, you know, I guess, so what's the follow up now, Michael? Should we still bring them back in two weeks and just check it again? Yeah, I would bring them back two to four weeks. I would keep doing this. Oftentimes, so there are different phenotypes of these patients. When you dilate them, bring them back, that diameter, you gauge based on what you were able to do. If the endoscope goes in freely and the diameter seems to be better, that's a good sign. That means next time you can extend that further out. However, if it's closed all the way back down, then you may have to decrease the interval. So you can sort of judge based on that. I think it's also important to consider this patient got neoadjuvant therapy. So it's not only risk of poor blood supply, but the radiation, which, of course, could be ongoing. And regardless of how well you control other factors, there's still a risk for subsequent closure later on. So I agree with Keith. Perfect. So again, your therapy is going to be tailored to what the etiology of the stricture is. And then I think the key for these tough strictures is just repetitive dilations and go from there. Thank you. OK, thanks very much, Uzma. We have a couple of minutes here. So while John's pulling up his case, there are a couple of rapid fire questions. OK, no long drawn out answers. On EGD, you see an inflammatory versus something suspicion for neoplasia. Do you take a biopsy? Do you do an EMR? Or do you do nothing? I tend to do EMR pretty frequently, more for histology. It's almost like, for me, just a bigger biopsy. Right. So I have a low threshold. If you've consented the patient. I always consent up front for that. Depending on what I'm going to find. OK. Thomas, anything different? What kind of patient is that? A Barrett doing surveillance? It's an EGD you're doing for dyspepsia. And you see a lesion, which you think, yes, right? I mean, it's not for therapy. I mean, that's how most of the incident lesions are found. You're doing it for some other indication. You go in. There is a suspicious area. You're not sure whether it's inflammatory or is it cancer. What do you do? Again, where? You're asking too many questions, Thomas. Just answer. Well, I guess his point is right, though. Because if you think it's cancer, should you be attacking this right now? Or should you just take a biopsy, discuss with the patient? Depends on the case. This is too surgical. In doubt, take everything out. It's too fast. It's too rapid. Right. OK. I would biopsy. You would biopsy, I think, which is good. I'm going to go back to biopsy. Should we use a transparent cap for all upper endoscopies or only in select cases? Select cases. OK. People agree. OK. And we saw those clips that Horst put after the Z poem. Will that interfere in any way with the patient's symptoms? Will we give them a global sensation now or some other symptoms or no? Yes. That's a question from the audience. Mostly no. The issue here is will the remaining diverticulum be a problem? Yes. And also you can pick clips that have shorter stems, especially when you're that high up. OK. We've kept Dr. Cohen waiting too long, so please, John. How long do we have for? We have a few minutes. OK. Great, great. Because with our Barrett's inspection time, we have a little thing. So the case I'm going to show requires a little bit of just a little slide to go over what the anatomy is in the squamous esophagus, the blood vessels coursing perpendicular, calling these interpapillary loops. And you'll see normal ones look like a little dot under near focus, and if they get horizontal and thick, that is a worrisome feature. This is not the esophagus. This is the anus, but something more familiar. We see it in every day we do a colonoscopy. These are normal, and you have over here on the lower right, you have AIN3 in an asymptomatic screening colonoscopy, so something we can see. So here is a video that has always impressed me from Professor Inouye, showing, again, the inspection time, the slow inspection time like Pratik talked about, and looking for small areas of discoloration, and here is a one-millimeter flat, completely flat cancer. So with that, we'll go into our other concept. We've talked about different techniques. We're going to see this in a second. This is for Barrett's, residual Barrett's, an injection of a very thin, one-quarter the diameter of the fluid that you get in a scleral needle, limiting and creating a heat sink of fluid and limiting the burning to 500 microns. So the case I have is a woman who had stage IV ovarian cancer and wasn't a great operative candidate or even a candidate for resections, like we saw earlier today, and who had developed after her various chemotherapy. Thirty seconds. Okay, just take this here and ask the panel what they would do. You see here a focal area demarcation with abnormal IPCLs. This is a recurrent squamous cancer. And so I guess I'll ask the panel, if you take resection off the table, what would you do to sort of try and treat this lesion? Would you leave it alone? Would you freeze it? Would you use radiofrequency ablation or perhaps this hybrid APC? But you took resection off the table, why? Well, she was a person who had stage IV ovarian cancer and was sort of frail, and we didn't want her to potentially undergo a major complication. Yeah, you could argue do nothing at this point? Yes. Or, I mean, I think potentially RFA. Typically we would ESD, squamous dysplasia lesions. Unlike with Barrett's with adenocarcinoma, you definitely have increased potential for vascular spread, so ESD would have been a choice. Okay, as this case is playing, guys, we have to end on time. We have a 15-minute break now. The esophageal session ends. I'd just like to thank all the panelists, the speakers, and specifically the live crew and, of course, our crew in the back for a great start to the postgraduate course. Thank you all very much. Thank you.

esophageal disorders

dysphagia

achalasia

treatment options

pneumatic dilation

heller myotomy

POEM