I'm here with Dr. John Panolfino and Dr. Aziz Adham. We are going to be showing you all a case of a patient coming to us six months after POEM. So this is a post POEM assessment with endothelium. The patient we have today with us is a 23 year old who was diagnosed with type 1 amnesia in the summer of 2022. His baseline Eckhart score at that time was nine, including 20 pounds of weight loss. This is his baseline esophogram. You can see here dilatation of the esophageal body as well as a more classic bird beak pattern pre-POEM. His baseline endoflip is seen here. So we'll be able to directly compare his pre and post POEM endoflip. You can see an absent contractile response with a very tight EGJ, what we would consider a reduced EGJ opening parameter with a max diameter of nine millimeters and a distensibility index of less than one, 0.7. His baseline venometry pre-POEM also confirmed a diagnosis of achalasia with no contractility and an IRP, median IRP well above 30. This is a representative swallow with an IRP of 50. He underwent a POEM about six months ago. The POEM was done with a three centimeter esophageal myotomy with an additional one centimeter myotomy extended into the gastrocardia. Endoflip was done intraprocedurally and immediately post myotomy, he achieved a DI of 8.7 at the 60 cc fill volume and a D of maximum diameter of 17 millimeters at the 70 cc fill volume. At six months, he has this esophogram that was obtained last week while there's still some retention, we do see what we refer to as recoil of the esophageal body here. He reports an ECKARD score of zero at one month post POEM. And today as part of our standard motility assessment, all our achalasia patients, they complete patient reported surveys. And he also again reports an ECKARD score of zero. So we will now proceed to the upper endoscopy with Dr. Adam and Dr. John Pandolfino. Thank you. So thank you for everyone for joining. So we have six months into the future from Moen's case. Like Dominic mentioned, this patient's six months post POEM. So here you can see the GE junctions and there's no erosive esophagitis at all. We're here at 44 centimeters from the incisors. This patient was enrolled in our randomized control trial with a short versus long myotomy. He was randomized with a short myotomy. So in those patients, he was performed a fairly short tunnel. This is at 38 centimeters from the incisors. You can see the clip granulation tissue there. But overall, the esophagus is uniquely nice. The GE juncture is widely taped here, really no significant resistance at all. Do a little retroflexion. See that they are still grabbing the scope. So John, do you want to talk about how we pass the endoflip catheter and kind of the markings we used? And today we're going to use a 16 centimeter balloon. So how we position it adequately. Yeah, so pretty simply, we mark the distance to the squamous columnar junction, EGJ, which is some tape, very easy. We typically place this with the scope removed, just a little bit easier on the throat. And then once we're there, we just position it. We do a quick fill, 40 mLs, just to document that we're in the high pressure zone. And then we just start the exam. Usually pretty quick. Should take less than five minutes from start to finish. I use a little bit of lube, not too much, but just enough along the hood for the placement. And as I mentioned, there are a couple instances where when you're dealing with naive patients, when they have a very dilated esophagus, then in those instances, we do wind up putting the scope down probably about 10 to 20% of the time when we do these exams. So I guess I'll place it now. And I'm gonna do this with the endoscope in place. So when we do these during the actual poem procedure, you wanna be very careful and visualize the catheter going down because there are instances where the catheter could enter the actual tunnel. And you, of course, don't wanna be distending the balloon at that time. Good, Forty. And John, since this patient has type 1 achalasia, could you talk a little bit about that choice of 16 versus eight in terms of a balloon length? Yeah, I think it's important to think about when you're doing this. So typically we do this before we get the manometry in our workups when patients are coming in for dysphagia. So in those instances, it's a no brainer. It's 16 centimeters. We don't really have a good idea of what the diagnosis is. Now, in the context of someone who's already been treated, then in those particular instances, you could get away with an eight centimeter or a 16 centimeter. However, as you'll see in my talk later today and then the review of the manometry, there are many patients, you can go up to 50. There are many patients actually that have spasm after you treat them. Even if they have type 1. And the reason for that sometimes is if you have a really effective treatment, you will close the lumen and now you will see these occluding contractions. All right. So now we're inflating the balloon. It's about 50. We're already at a diameter of around nine with a distensibility index of around three and a half, four. All right. Ready for 60. Now we're going up to 60. We'll make our definitive measurements for our follow-up. Do you spend a certain amount of time at each volume or is it really just getting towards 60? That's the important issue here. I mean, I think as long as you spend about 30 seconds at each volume, you should get a pretty good measurement. Once again, it's a little different than when you're doing the exam for dysphagia, de novo, and a patient who has no diagnosis yet. In those instances, you may do it a little bit longer. But here, I think we're just really trying to get a really clean measurement of the distensibility index and the maximal diameter and also an idea of what the pressure is. I think it's one of the things that people forget is they actually don't look at the pressures. And I think that's an important part of this because when you look at people, they may have a very nice distensibility index and a maximal diameter at 70 mLs, but if that requires a pressure of 30 or 40 millimeters per mercury and they have a dilated esophagus, they're never gonna generate that pressure. So those are people that may have a nice normal distensibility index but are actually not doing so well in terms of retention. So now we're going up to 70. We've got a really nice maximal diameter above 12 already. And this patient is doing quite well here. We've got diameters now of 13, 14, and the distensibility index, once again, is holding up. And one of the paradoxes of FLIP is sometimes you see that when you go to 60 to 70, you actually get a drop in the distensibility index, once again, because there's not a great change in the diameter, but there's a more profound change in the pressure. And that's something that we typically see in achalasia. Jed, talk about the waist of the balloon. Yeah. You know, with how many sensors do you want immediately below the GE junction and how have you positioned this? So the, you know, obviously the sensors that are sitting in the stomach provide you with no information. So you really don't need to have seven or eight sensors down there. Really what we try to shoot for is two to three sensors in the stomach and then the high pressure zone localized. And what's really cool here is that what you're seeing very briefly, some little contractions, sporadic contractions, that may be just at the aspect of where the tunnel was started. And we see sometimes these effects where the, either the tunnel started or the proximal extent of the myotomy, where you may see some of these contractions. So even though this person was a type one, when we saw them post-treatment, you saw that the esophagram showed recoil and decompression. In fact, probably one of the most important predictors of how people are doing is that decompression. Is the esophageal body decompressed? Are they able to feel like they can eat with less pressure generation and less stretch of the wall? And that's actually a very important biomechanical endpoint that we look at. So with those patients that have discordance between diameter and distensibility, how do you deal with that? Let's say you're getting distensibility index that's lower than you want, but diameter is 17. Yeah, well, I mean, once again, they're directly related. So seeing major discordance is rare, right? And if you do see something like that, you have to think that the pressure sensor may be wrong. That's why we always zero it both before and then afterwards we check another zero. So it's very important to do that because these are very delicate pressure sensor. There's only one that you have. So if that's inaccurate, that can really affect your values there. So when you see a major discordance that doesn't make sense based on what you're seeing and what the body looks like, that's important. Because remember, you're looking at the entire pattern. So I can see whether something is at maximal diameter and you can also see the pressure undulations on the pressure tracing. So taking into account all of those factors, it's pretty easy to figure out why you might see that discordance. I think the thing that most people get in trouble with is actually when there's very low diameters and the pressure hasn't actually risen yet because the bag hasn't filled. And that's an instance where people may sit there and have a very low pressure reading, but there's no communication between the gastric side and the esophageal side. For a pulse problem. Sorry, on that topic then, do you, is there a balloon volume that you focus on with each of the catheters, the 322, for example, the 16 centimeter catheter, or do you focus more on the higher volume? Does it depend on the pressure? Yeah, I use 60 mLs for the 16 centimeter and 40 mLs for the eight centimeter. And it's just, that's where we've gotten the most consistent recordings in all of our studies that we've done in normal controls, non-obstructive dysphagia patients, and then achalasia patients. And I think that gives us a pretty good, standardized volume to compare things across studies, across centers, and then, obviously you want to keep it pretty reproducible within the patient. The other thing that we typically do in a lot of these patients that I think is helpful is that I'll actually pull the balloon back at 60 just to get an idea of what the bag pressure is in the esophageal body. Because remember, this is plumbing. The thing that's driving emptying is the esophageal pressure, right? That esophageal pressure has to be greater than the resistance at the EGJ and also greater than the intragastric pressure. So when we pull this back now, the sensor is actually in the esophageal body. There's no portion of this that's within a sphincter. You can see that now that pressure signal is starting to flatten. And once again, it's around 10 to 13. So you can see that if this patient swallowed this 60 mL bolus, they're only generating around 15 millimeters per mercury in their esophagus. So in order for them to empty, that sphincter pressure has to be lower than that. So it's also a very nice way to get a gauge for what the propulsive effect is of the esophageal body. And you can even see here, you can even see some nice little antegrade contractions that are occurring here. And what's really cool is that you can see that those are rate 12 per minute as opposed to six per minute, which is normal. That is pretty consistent with what you see in achalasia because you have that reduction of the latency gradient. All right, you can deflate. So you know- So how much- Go ahead. I was gonna ask you, how much of your interpretation is live and how much of it is postdoc? I mean, we always do both. So we do a live, we record it in the endoscopy notes, but then we also go back and make definitive measurements. Sometimes when you're sitting here and on the live feed, it's easy to kind of make some spot judgments, but most of the time, I will tell you, there's probably about 90% concordance between what we see live and what we actually see when we do our official reports. And now you can see as the balloon is deflating, you're starting to see a little bit more of that contractile activity, because once again, the pressure and the extension of the balloon is not affecting the diameter there. So John, what's- I'm trying to see the upper sphincter. What's the downside here of just taking it out before you actually deflate it, given how soft and flexible this- Oh, I usually take it out when it's 30 or 40 mLs. I'm just kind of showing you the upper sphincter and the vascular effect here. But yeah, so it's 24 right now. You can just pull it out. So yeah, if you want to, for time's sake, I never wait till it empties completely. I usually pull it out. The only caveat to that is if you're doing an EOE patient who has a significant proximal stenosis, you want to be a little careful because that can become very distended. And that is the singular time I've only seen any minute trauma from a flip bag being pulled out. John, can you make any kind of assessment on reflux risk based on your distensibility, or is this the patient that you're going to be putting a Bravo capsule in? Also, it's- Yeah, it's a good question. I don't think, you know, it's very important to realize, you know, we talk about DI and maximal diameter, but you need to put that into the context of what's going on in the body, right? This is all, remember, a relaxed sphincter is not open. It only opens when it's driven open by the intraballs pressure that is generated by the body. So, you know, when you look at that, a distensible index of 2.2 can be completely normal if someone has beautiful, vigorous racks, right? And you see this all the time where patients are normal, they've had a normal manometry, their DI's are a little bit low because those racks can generate a very high pressure and you're in a contained system. Similarly, when you see these patients who are very dilated, you know, they, even though their DI may be within the normal range, they may have some retention because they cannot generate significant intervals pressure. Now, in terms of trying to figure out the sweet spot for GERD, you know, there really isn't one. I've seen people, you know, who have DI's of 10, who have absolutely no reflux. I see people who have a DI of 3.5 who have reflux. I think what we really need to do is we really need to develop more of an idea of this relationship between the pressure and what diameter they get. Remember, liquid reflux only requires a very small diameter, right? So when you belch, the esophagus doesn't dilate to, you know, 10, 12 millimeters, the EGJ. There's a very small opening where air and liquid come through. So that's really where that process occurs. So if you look at the pressure that opens the actual EGJ, if that pressure is extremely low, I think that's a better marker of whether or not someone has, nope, keep going. He's going to continue the exam. We're going to get some biopsies for a research study. But if you look at that pressure, I think that's probably the way to go. Yeah, thank you for the excellent demonstration and a good discussion after. Thank you again, Northwestern team.

POEM assessment

type 1 achalasia

esophageal myotomy

esophagram

endoflip procedure