For this, let me welcome again Phil Katz and Amit back to the panel discussion. For the case, we have one of our ASGE as well as endoscopy experts from Columbia at New York, Amrita Sethi, who's been at the forefront of advanced procedures and specifically third space endoscopy and who's been doing quite a bit of poem at her place. So Amrita, welcome and thank you for being part of this course today. And we have you, you can start sharing your screen or, you know, start presenting your case. Welcome and thank you, Amrita. Thank you Prateek and Vani for both having me for this course. So we've had a lot of discussion so far and looking forward to contributing and hearing some thoughts. So I was asked to talk a little bit about some cases of patients who had already undergone myotomy, whether they be Heller or, or poem and look a little at their symptoms and also how we would treat them. So we'll start with the first case. This is a patient who is post Heller for symptoms of dysphagia. And unfortunately, both of these cases that I will have will have come from outside centers with limited data. But basically this is a 25 year old gentleman with a history of achalasia again, subtype is not clear due to lack of records, but believe it was type two who now presents again with dysphagia and just chest pain primarily. So a little on the history, he was diagnosed with achalasia at age 11 and was treated initially with repeat pneumatic balloon dilations. And then in 2006 or at age 14, he underwent a Heller with a Dorafund application at the same time. Six years later, he developed recurrent symptoms along with vomiting and underwent an evaluation. He must have, they must have consulted Phil because they underwent a timed barium swallow that was delayed. And the thought was to repeat the Heller myotomy with a takedown of the door. And then five years later, he presented with recurrent symptoms and a description of constant reflux. His Eckhart score was seven, three dysphagia, one regurgitation, three chest pain and no weight loss. So my question to the panel is, you know, you have a 25 year old male who's undergone multiple myotomies over a significant time period and having recurrent symptoms of dysphagia and chest pain. Do we think this is recurrent achalasia, post-myotomy reflux, it's unclear if he had a, I'm sure he did have a door, but how effective that was or possibly a stricture and what are the next steps? Okay. Thanks, Amrita. Great case. Great case. Peter, if you and Phil can have your cameras on, if you're still with us, let's, you know, open this up. Reg, I see you there, Phil. You know, great talk about approach to achalasia, EG junction, outflow obstruction, really didn't get into, you know, somebody who's been treated and what's the role of these different technologies that you went over in a patient who has undergone, you know, either a Heller or a POEM, how good are these tests and would you still have these tests done in that same algorithm that you shared with us? Great question. Not quite as good an answer, but all are valuable and have to be used in conjunction with each other. Valuable evidence predominantly from Peter's group, John and Peter and Dustin Carlson, that FLIP can help here with evidence of a low distensibility index being reflective of an incomplete myotomy. I think you have to look very carefully at anatomy here, angulation of the esophagus, sigmoidization, subtle strictures. So you got to really be careful at your endoscopy and at a time swallow. I don't think there's a major role for manometry here. Be interesting to see, you know, Peter's view. Usually with a time swallow and FLIP, you can get pretty close. If you can't really tell what kind of residual contractions you have, perhaps a manometry will help to see if there's residual spasm, especially because this guy has chest pain. But this one's going to be tough. My bias is probably one of those rare people who is failed, good at kalasia treatment. And you're going to have to decide whether there's any emptying that still can be fixed or whether this is primarily a body motility problem with some element of sensitivity. Peter? Phil, how often is it to see an incomplete myotomy presenting that many years later? Well, I mean, unfortunately, Reg, this guy's had a couple. Supposedly. I mean, on paper, if we look at Tom Rice and, you know, Richter's data when they were together at the Cleveland Clinic, one would suggest that late relapse is reflux and not the myotomy failing. I don't like the term recurrent achalasia because that doesn't really make intellectual sense to me. So I think it's unusual to, I wouldn't say not find something that you still can deal with as an outlet obstruction, but a major big deal, incomplete myotomy wouldn't occur late in most of the patients that I see. Reg, since you were talking about that, Reg, can you just- Peter's on. He wants to comment. I'm sorry. I would agree with what Phil just, or Reg said actually, was that most of these are going to be reflux. After you've had two myotomies or even one myotomy for that matter, the likelihood of having it be an outflow obstruction as opposed to a reflux-related stricture or esophagitis or whatever, I think is very small. You know, in my experience, I think reflux, the second part is a twisting of the fundo or a development of a hiatal hernia. And sometimes the hiatal hernias can be very subtle and you really have to look carefully on retroflex view because endoscopy is far more sensitive than ovarian swallow and picking up a herniated fundoplication. But I think that, in my experience, has been about as common as reflux in terms of a mechanical issue causing that recurrent dysphagia. The other mechanical issue is this recently described blown out myotomy or BOM that actually we published on as well, where you get this pseudodiverticulum forming along the length of the myotomy. This can be the size of a grapefruit. So Peter, in terms of investigation at this stage, what's the next step here? We are endoscopists. Okay, Amrita, do you have any follow-up on this case? Yes, I do. Yeah, please go ahead. Yep, so the patient was sent for manometry, mildly elevated IRP, 100% failed peristalsis, and 40% panesophageal pressurization. Also sent for an esophogram, and it was timed, and it showed dilation, particularly the distal esophagus, so questioning whether that sort of pseudodiverticulum was there, but signs consistent, and I'm sorry, I don't have the esophogram images. They were done elsewhere, tapered narrowing of the lumen, and there was delayed passage of the barium after six minutes. And then on the patient underwent an endoscopy, which showed a moderately dilated esophagus, and flip was done that showed a low distensibility, one, and then an elevated pressure, elevated distension stayed consistently low. So there was the GE junction was not patent, it was showed signs typical of achalasia, and so the patient was offered treatment. It was considered to be consistent with perhaps untreated achalasia recurrent, and the patient was offered treatment, further treatment. Did you do a two centimeter dilation at that time? No, I did not. Any reason? Not offhand. I think the patient- I didn't say that because your flip never distended. If your flip had gone up to two centimeters, you say, well, that's equivalent to a two centimeter dilation, but in this case, you really haven't ruled out that this is fibrotic. Yes. No, we didn't do that. It certainly didn't have a resistance suggestive of stenosis or anything like that, but a good point and something to consider for the future. So Peter, you're not convinced that this is obstruction, or you think this is, and Reg, maybe getting to you, I mean, you were a little surprised that this is too far out after surgery. I mean, what are your thoughts on that, Reg? You know, I agree with Peter that dilation at this stage is probably, honestly, I'd probably just go to a ESO flip or a large caliber balloon in this patient, assuming that I didn't see fibrosis that looked like that. Because surgical options in this patient with two previous surgeries, I want to stay away from, if at all possible. So I'm going to do everything I can to either find out if it's reflux and treat the reflux or try a pneumatic dilation at this stage. POM would be another potential option if you felt like it was really recurrent reflux, but my guess it's either scarring or some deformation related to the fundo, scarring from reflux or deformation related to the fundo. So Peter and Reg, I mean, on endoscopy, you don't see a stricture. There is no fibrosis, at least apparent on endoscopy. So in this situation, how do you, you know, say that this is not just an incomplete myotomy versus fibrosis? How do you differentiate that? Perhaps it's a moot point. I mean, you'd still treat it the same, but since Peter, you're bringing up that issue, how do you differentiate between the two? Well, I mean, everything's been done here and it's all pointing toward it being an incomplete myotomy. But, you know, that's bizarre because this person was, I mean, this poor sphincter has been beaten to death. It had a numerous pneumatic dilations. It had two myotomies done. Easy is easy. And POM is all you have left. And then you're done. Yes, Amit. Can I come in here? In such a situation there's one investigation which we would do and that is a radial EUS because what we do is that is one of the ways to know whether there are any remnant fibers, muscle fibers remaining at the OGJ and if you do a radial EUS we can easily pick up whether there are any residual fibers remaining there and if that is the case and if you don't see fibrosis on upper geoscopy then I'm quite sure that this recurrence is because of some residual fibers then probably a repeat poem or a balloon dilation will help. And the added advantage of that is you'll do a two centimeter dilation. Fair enough. It's good to see you're stuck on the two centimeter dilation but let's move on. Amrita tell us what happened and let's go in here. So we went on to offer a poem and this is the video of that. So this is the esophagus. You'll notice it's not actually that torturous or sigmoid healthy looking mucosa. We are going posterior because the prior treatments were Heller's. The submucosa interestingly was very clear and you'll see that in a moment not suggestive of what we see in prior interventions but again this is very proximal so this is up at least 10 centimeters above the GE junction where there hasn't been intervention. However as we move more distally down towards the GE junction you'll see that it does get tight and you can see that the mucosa will start to hug the muscle fibers very closely so dissection in these situations you do have to be careful. It's almost like picking the mucosa picking the submucosa off of the muscle but down here getting close very narrow very little room to work. Sometimes you do have to actually take a few muscle fibers in order to to actually get the scope down and dissect further. I'm just going to skip ahead a little bit here probably. Again just down by the GE junction starts to get a little bit more the submucosa gets to be a little bit more fibrotic and again less room and sometimes we see when we are dealing with prior Heller's and it's the issue of the fund application that kind of causes the mucosa to oops sorry about that. Let's move on and so here is now when we go so this is doing this can I ask you and Amit to comment on the difficulty of doing a poem after you know maybe a couple of PDs or a couple of Heller's which have been done like in this situation. Can you comment on that either you or Amit? Yeah I mean it's very so here you actually see good orientation of the muscle fibers but in most situations the muscle fibers are completely disarray. You can't really find your planes that well and if the submucosa is very fibrotic then you can't see vessels which in this case was because it was hidden underneath the muscle. Sometimes you have to cuff the muscle fibers actually to expose vessels and whatnot but it does become difficult. In the other video it's actually even more difficult because it was a post poem so the submucosa itself had been manipulated quite a bit and wasn't as clear in this situation but I almost wonder looking at the orientation of these muscle fibers in this case really the extent of the Heller because it's really it wasn't in that much disarray. So I don't know Amit if you have any comments. Yes as far as Heller is concerned it usually doesn't come in the way of a posterior poem because Heller is usually done anteriorly. So when you do a posterior poem you're going in a virgin field. Pneumatic dilatation can sometimes repeated pneumatic dilatation or even botox can sometimes cause a fibrosis and that can be you know you can find difficulty to separate the mucosa from the muscle layer. But here it looks like Amrita has done a good job and you can see that there are intact muscle fibers over here. So two times surgery has been done so this patient definitely had some residual fibers there which were intact though both the times it was a surgical procedure so it was all approached anteriorly as I suppose so. So the posterior fibers were intact. And Amrita here I see you using the suturing device to close it. Is that typical? Do you use clips or you prefer to suture the mucosotomy? What's your approach? I typically use clips but the the way the incision was the way it was kind of involuting this one I wanted to make sure it was robust and I had a I was worried a little bit about positioning the clips so I decided to use the sutures in this in this case. But typically I use clips and it only takes about five clips. Reg in the situation we've been talking about doing a poem post Heller but how about the other way around after do you have cases in which you've attempted to do a myotomy after poem? What's your experience with that? Actually I haven't. I think you know I guess I'd say that I think the main thing in any repeat myotomy is having a really good sense of the completeness of the previous myotomy and ensuring that it's complete. And so my it wouldn't surprise me if in the second myotomy especially because if you don't have something like endoflip to assess the completeness of it it's tenuous going back in and trying to extend a previous myotomy. And I think most surgeons sphincters tighten a little bit doing that. So I think it's it is possible that the second myotomy provided some relief but was not complete and I think you know it looks like Amrita has given us a pretty good complete myotomy in this situation. Okay and Amrita and Amit how far down below the G-junction do you extend it? Two centimeters for me. I don't really change that for post Heller or post poem patients. You should definitely don't not to go more than three or four centimeters because that will definitely increase the chances of GERD after poem. That's one of the important aspects of poem to remember that we do not go in the stomach more than three centimeters. Okay Reg do you want to take on I mean we are coming Amrita do you have any other videos to show us as Reg looks through the Q&A chat and we have about eight minutes and we have some questions to address. Amrita any other videos to show? Yeah I can just really quickly without asking you guys questions. By the way this patient did well and follow-up record at three months is is two. Now it's early to tell whether you have recurrence of symptoms but so far doing pretty well. You got to do a repeat flip and an emptying study just to tell us how good you did. Yeah I will certainly do that. The other patient was is actually much older patient who had undergone a poem two years prior. Posterior poem had recurrence of his symptoms. He underwent manometry repeat manometry. However the NPH however it was a failed study and it was thought that perhaps the probe was coiling. So we didn't have good information from either of those and so we we took the patient to EGD and it did show you know this guy's older very dilated distal esophagus a pop at the G junction and even placing the flip was really difficult. We had to use grabbers and to manipulate it to go down and definitely noticed technical difficulty using the catheter. So we had not a lot of data on that one. We did do an esophagram though that showed a sigmoid esophagus very very dilated but findings that could be consistent with incomplete myotomy and so based on all of that we offered him an esophagram as a poem as well. This time it's you can see much older guys in his 70s hasn't been treated for most of his life and this is a I didn't speed up this video. This is normal time but this is trying with pressure to try to get through G junction and there's just so much resistance. So again very suggestive of recurrence. He and then and you see this the sort of the health the health of the mucosa is poor a lot of esophagitis very long-standing disease a lot of stasis and also corresponding to that is and this we're going anterior because the prior poem was posterior very very thick muscularis mucosa really took some time to get through that and when you do get to the submucosa it takes a lot and you do kind of sometimes think that you perforate because it takes you have to go very deep but you can see the blue of the submucosa there it's very fibrotic like a fibrosis for almost three that makes it difficult because it's hard to discern the muscle fibers from the submucosa you can't see the vessels well easy chances of bleeding and it's also very tight to get through and so if I can speed that up for you here but as you approach the GE junction again very very little space to work with normal submucosa until you get past the GE junction and open up into the cardia and then you do see that once you're there it opens well and going past through already. One of the things is that the mucosal findings do correlate sometimes with the submucosal fibrosis right and what you showed us on the EGD and the mucosa I mean there was a hundred percent chance that there would be intense submucosal fibrosis. Both to you and Amit does that ever change sort of your approach to that case that either you will wait and attempt at some other time or maybe not do it or do it at a different place within the esophagus any thoughts there? Yeah I completely agree with you Pratik. Actually I was just going to ask that question to Amrita that after seeing such a mucosa that is quite sure that you are going to encounter submucosal fibrosis. So in such a situation what we usually do or prefer is to place a nasojejunal or a nasogastric tube and just feed the patient for a few weeks with keeping a nil orally and we have found remarkable improvement in the mucosal health as well as the reduction in the submucosal fibrosis. If you do that few few weeks of waiting with NJ feeding or NJ feeding we can do a much safer and simpler POEM procedure. We did consider that I think given just logistical situations with this patient that wouldn't have been possible and I think I did contemplate going into another spot so that's another thing that we've done is close that incision and start somewhere else but we did decide to proceed and I think if you're careful and really try to work hard at establishing some degree of a window into the submucosa it can be done. I think it might be a reason that the first procedure did not succeed in terms of a complete resolution of symptoms because there was so much scar tissue it may have been difficult to really distinguish if the GE junction had been reached and gone beyond and actually cutting completely the muscles but as you could see in this in the video we did end up doing full thickness it was quite still quite thick down at the GE junction and the post passage of the scope clearly shows that there was a release and the patient's doing well and has an ECHR of two right now. Excellent. Amrita, I mean this has to be one of the most difficult POEMs with that degree of submucosal fibrosis so great job on doing that. you

achalasia

myotomies

recurrent symptoms

Poem procedure

fibrosis

complete myotomy