When do you start patients on PPIs after a POM or a HELM? Phil? I wait for symptoms. I like to scope them at three to six months, just to know what I'm up against. So if I were asked by Amrita, should I do it after a POM right away? I would say no, but I wouldn't quarrel if people did it. Okay. Amrita? I keep patients on PPI for actually up to three months post-POM to help with healing and if there's initial changes of reflux, just with the release of the myotomy, and then bring them back, scope them, and see if there's any evidence of esophagitis and failing PPI. And then we go towards knowing whether we need to deal with post-myotomy reflux or not. Okay. Cool. I'll rephrase the question, but in what instances does chest pain likely resolve after a POM or after a myotomy? When do you, if someone comes in with chest pain and has a certain configuration of a kalasia, when do you say, hey, it's likely that your chest pain is going to resolve or do you say chest pain is irrelevant, not going to change with POM? Amrita? I'd say in most situations, I found that patients report that it resolves. If it's a predominant symptom that they have, then I do a longer myotomy thinking to affect, you know, do more of a myotomy within the body of the esophagus, but it's not a, I don't have a great percentage for you, but I do find that most patients have resolution of that symptom. In majority, the chest pain will resolve if you have treated, done a long myotomy in those who have coxscrew esophagus or a hypercontractile or type three esophagus, achalasia. And these patients, after doing a long myotomy, the chest pain resolves in quite a majority of the percentage. It's interesting you mentioned that. The published data on long myotomies for thoracoscopic myotomies for chest pain is actually not very good. So it'll be interesting to see what the long-term data is for POMs in that situation. Yeah, the classic teaching is that chest pain doesn't respond very well to treatment, whatever the treatment may be. But I agree that you do see it improve quite a bit. And I think the distinction is what's causing the chest pain. If it's truly these spasmodic contractions and not a function of outflow obstruction, then it may not respond to treatment. But if it is in some way being driven by outflow obstruction, then it will be. Peter, if I could just ask you the question on PD, I mean, you very nicely compared the European and the other German trial. So what's your approach? I mean, how should pneumatic dilation be done? Do you start with 30 and then bring the patient back and do a 35 millimeter dilation? That's the way I've always done it. That's the way I've always done it. I never do two successive dilations in one session. And I'll never start with a 35. My personal perforation rate for 30 years is zero. Okay. And then a 35, do you go to a 40 if there is no response or do you end at 35? End at 35. Okay. Phil? I start with a 30, go to a 35 if I need to. I agree completely with Peter. That's based on good experience and actually reasonable data. 30 gives you a little window and my perforation rate is one since 1986. Okay. Probably, who knows? That was with a tumor. Phil and Peter, in Amrita's first or second case, would you have considered pneumatic dilation in either of those patients? Both of them. Yeah. I wouldn't have without offering them a big upside, but certainly would have considered it. Pneumatic dilation more successful in 70-year-olds than 20-year-olds? You know, I don't make too much of age data with treating achalasia. To me, the more relevant predictor of outcome is the degree of esophageal dilatation that you're faced with upfront. The more dilated it is, the less likely you're going to have a good treatment outcome. It's not impossible. I mean, just the other day, actually, Dusty Carlson gave me a case. He says, this person wants a pneumatic dilation, but look how dilated this esophagus is. It's never going to help them. So I said, I'll do it. I did it and it worked great. One last question from me. If you have a patient after all these procedures and if you have a recurrent dysphagia and you find failed peristalsis in the esophagus or a blown out myotomy, so how do you treat it? Well, I'd be interested in what anybody else says about a blown out myotomy, but depending on how blown out it is, they're on a short track for an esophagectomy. Agreed. I mean, nobody likes to do it. And then in Amrita's second case, I would have tried not to do a balloon because I wouldn't have thought it worked. But if the patient said no poem, no surgery, no nothing, I would try it just like Peter did and with Dusty's case and hope you get some benefit. Reg, we'll have you, let you have the final word on esophagectomy here. What are your thoughts on that? The non-surgeons chiming in, which is always a bad sign. It needs to be an end stage esophagus, but there are certainly times when it ought to be done. And I think sometimes it gets ignored in terms of the amount of dilation to the point where the esophagus gets dilated up to the cervical esophagus, and then it becomes a very technically challenged issue. So I think there's a point at which we start to cross over in terms of the proximal extent of the dilation where I start to push people towards that as opposed to just saying, esophagectomies are in the best of hands, a pretty good operation, but it's pretty hard to find best of hands surgeons to be honest in that realm. So I, and I send my patients out three states away if they need an esophagectomy for this, because I need a really good surgeon for it. Great. Reg, with that, we are five minutes over time, and that's just because of the great discussion we've been having and some excellent cases by Amrita. So again, on behalf of Reg and myself, I'd like to thank our panelists, Amrita, excellent cases, Phil, Peter, and Amit, again, excellent and very valuable input.

proton pump inhibitors

peroral endoscopic myotomy

Heller myotomy

reflux

recurrent dysphagia