gears a little bit. Dr. Gawale and I are going to maybe share with you a little bit more about what happens after the POEM procedure and what we are facing when we see these patients in clinic. We both see a lot of patients who have had previous procedures and we follow them along, you know, in that long-term solution or long-term care. And I think the goal of my cases are to really actually get into the nitty-gritty of what I'm saying to patients when they're sitting in front of me, either, you know, three months out, six months out, years out, and give you some tools for how you might approach things, at least to set it up if you're not going to follow them all along, or at least know what they might encounter to help manage those expectations. Okay. So, we'll first start with a 50-year-old female who had an EGJ outflow obstruction with hypercontractile features. This is the preoperative manometry, the endoscopy showing a tight LES, and then the endoflip to the right showing a very sustained occluding contraction that's lasting about 30 seconds, actually fitting nicely, complementing the high-resolution manometry. Patient underwent a POEM procedure with a long myotomy, recovered well from the procedure, but still struggling with solids, like not really, you know, was on liquids before, only got to like, you know, a little bit of a soft diet, but not really doing well with the soft diet, and was not really able to eat or drink what we were expecting based on the diet recommendations. So, we did, sorry, that went out of order. We did, at that point, what would you do, knowing that she had some trouble at that point? Take a look. Take a look, okay. We can take a look, and then, and we'll take a look. So, she had mild candidiasis, and on her endoflip showed complete absent contractility. Everything was open. There was no stricture. So, now, what would you do? Manage expectations. Manage expectations. You're on a liquid diet for the rest of your life, but thanks for letting me do that POEM procedure. Treat, candidate, and then reassess. Treat, candidate, and reassess. Okay, let's say we treated the candidate, and she's still sort of the same. My thing here is, you need to figure out whether they are truly having dysphagia or having food aversion. A lot of times, these patients have a bad experience with some solid, and they don't go back to that solid, but then when you ask them, they have never tried the solid again. They've just stayed on liquids, and you ask them, why don't you? I had problems before. So, I haven't encountered patients like that. That's food aversion. It is not ongoing dysphagia, and the only way you can sort that out is to talk to the patient. I think that's what Mani's getting at. Figure out what their issue is. Yeah, I think there is a lot of understanding of what they're actually doing, you know. Is it, are they scared to eat, or are they scarfing down things, and then it gets stuck, and then they get scared, and then they stop? Or are they doing what they're supposed to be doing? And so, in addition to treating the candidate, there are things that we can talk about. One is just manage expectations, reassurance, everything is fine. You could, you know, these are things that, you know, I think that you wouldn't do reflux testing or prokinetic testing. So, these, I would focus on diet and lifestyle counseling, and figure out what it is that they are doing by asking them every step of the way of what they're actually introducing into their mouth, and how they're doing it. Now, the short way of doing diet and lifestyle counseling, which you should be doing when you're talking to your patients after poem, and even, maybe even start before the poem, is talking about what a soft diet looks like that they can easily step down to if they need to, periodically. Talking about maybe tough meats and breads are always going to be trouble for some patients. Some patients are going to be able to tolerate a steak, and some patients may never get to that steak level of things without a lot of modifications. And just throw that out there then, so that way they're not upset later. Or let them know you're going to need to have it with a lot of gravy, and it has to be really moist. Drinking water. Water is their friend. And then still letting them know that, you know, the dynamics of everything are such that if they lie down after eating, there's nothing stopping it from coming up. So, they really need to avoid eating three hours prior to bedtime, sleep with their head elevated. And that's, to me, the minimum. But let's say we did that for her, and she's still having trouble. I actually would really tease it apart for them in ways they understand. And I actually sit there and talk to them until they get it. Whether it's drawing it out, giving them analogies, giving them things that are working for them. I explained to them their esophagus is not normal. It wasn't normal before. It's not normal now. But it's no longer working against you because you've now relieved the obstruction. But it's also not working for you. And so, I have to explain to them that they have to be the one doing some of the job of their esophagus in a normal esophagus. So, they have to babysit the esophagus. They have to be the gatekeeper of their esophagus. And they have to clean up after the esophagus. Because it's not doing that work. It's just a, you know, a floppy tube for their purposes. So, sometimes I actually use, you know, big analogies. I like to use my hands and draw and dance in front of my patients, I guess. But I explain to them, you know, those long balloons with the balloon artist? You imagine taking one balloon, and you cut off the top of that balloon, and that is your esophagus. Okay? And then I say, what did you eat? Well, I had a burger and it didn't go down. I'm like, well, if you stick a burger in that balloon, it's not going to go down. Right? But if you put a little bit of water in it, and then you put a well-chewed bite, and then you put some more water, and you watch, well, it go down. And then you babysit it down, all the way down your esophagus. All of a sudden, you see this light bulb go off in their head. Oh, that's why I can't eat. And then they try it. And all of a sudden, they're eating their burger again. And they're happy. So, you have to explain it to their patients in a way that understands. You can't just tell them, oh, well, we did the procedure and you're done. That's life. You have to sort of give them the tools to make the modifications, to make it successful for them. And that's something you can start to do even before the poem procedure, but certainly right afterwards. The other thing is the gatekeeper. Okay. If you put a bunch of kids up at the top of that water slide, without water, and say, go for it, what's going to happen? A big jumbled mess up at the top. But if you first run water down, you put the adult at the top and let one kid go down. Then the net, a little bit of water, that first kid is almost out. Then let the second kid go down. You slow down everything, make sure there's sufficient water between every bite. You can get all the kids down the water slide. And it's amazing how many people stopped drinking before and during meals. And they just are trying to eat food. And they don't realize how much water is their friend. And so, I try and explain to them that slowing down and alternating consistencies and drinking water is really important. And that actually gets a lot of people through this just expected dysphagia in the setting of absent contractility after a myotomy. And that is something that you should be well-versed in, in making sure you carry your patients through that. The other thing is I tell them that their esophagus is not cleaning up after itself. There's probably no secondary peristalsis that's cleaning up after their esophagus. And they probably are still going to have poor clearance because we didn't make their body of their esophagus normal with the poem. All we did was relieve their obstruction. So, I imagine taking that food and I tell them, if you throw that food against the wall, it just slides on down, that's there to create stasis and residue and yeast setup. So, I tell them that it's a good idea to maybe figure out a way to make sure you clean up after your esophagus. So, we can do that with warm water flushes. I tell them usually like a half a cup of room water temperature, lukewarm temperature, just to sort of clean out their esophagus. In patients that might need a little bit more, I sometimes recommend papaya enzyme or pineapple juice. So, I focus a lot on these three things. I can't tell you how many times I use that water slide analogy, the balloon analogy, and cleaning up after the wall. And if you don't like those analogies, these are other things you can say that are more boring, but they work too. Modify with moistening and lubricating additions. Drink water before, during, and after meals. Drink water after every few bites. Alternate your consistencies. Consider warm water flushes after eating, and in some cases, even considering a papaya enzyme or pineapple juice. Prakash, do you have any other tips or tricks for this one? Suck on mints between meals, because that increases saliva flow. I tell them to chew gum sometimes. That also increases saliva flow. So, it's lubricating before the fact, lubricating before meals. I tell them to eat bolt upright, and if they feel something is stuck, stand up. Next, lift arms above the head. So, these are little anatomic maneuvers that straightens the esophagus and allows food to drop down. If somebody who's doing well, generally, says, all of a sudden, I've developed this problem last week, they probably have a little morsel down there that is obstructing, but not completely obstructing that they come to the ER. That person, I will endoscope. So, you sometimes have these patients say, I did great, then all of a sudden, last week, I developed this problem, and my achalasia is back, and you tell them, no, your achalasia is not back. It can't come back. We just need to make sure that there is nothing holding up, and it's usually that spaghetti-type consistency or some vegetable that is incompletely chewed, and when you go down, you'll see it sitting right above the LES. You push it through, and you're done. And sometimes, I tell them, in terms of chewing their food, I tell them to give them a visual. You want to chew your food as well enough to get through one of those big, fat bubble straws, because if you chew it well enough to get through that, it probably should go down your post-myotomy G-junction, but if you don't, and you're just going to inhale the wing, and it's just going to sit there, and that piece of meat might just block the opening, and so I try and give them very specific instructions and goals for chewing, timing, and everything like that. So, moving on, this is a 70-year-old who had jackhammer esophagus, status post a long myotomy in 2018. We included the LES in the myotomy. I know that was a discussion point from before, but this is the preoperative high-resolution manometry as well as the preoperative workup, including a workup for reflux, which was negative based on Bravo, and this is the endoscopic view of the lower esophageal sphincter and gastroesophageal junction, and then did well, and the post-POEM EGDs looked good, but then over the past year, started to feel like he had to step down to a soft, bland diet, and heartburn symptoms continued despite taking omeprazole once daily. This is this more recent endoscopy showing mild candida esophagitis, reflux esophagitis close to the gastroesophageal junction, and absent contractility on the endoflip. So, what are your thoughts? You've kind of treated like a jackhammer physiology for like a scleroderma or absent peristalsis esophagus, so you have those consequences, candida, reflux esophagitis. If it's grade C, you kind of already know it's pathologic reflux, so maybe if they're not controlled on PPI, consider an antireflux procedure potentially, a TIF maybe even in this scenario. Yeah, I think it's great to sort of be able to explain to the patient it's not just reflux, but they're also dealing with that absent contractility and poor clearance, make sure that they understand that. I think also, you know, think about it, this is now a few years out, he probably was really good the first couple years, and he's like, you know, I started getting a little lax, started trying to eat like my friends eat, I started trying to eat like my wife eats, and I realized I had to go back to eating like I know how I eat. You know, I think that it's great because, you know, we obviously do want to do the double dose PPIs, but we're going to, I just want to throw it out there that I like to focus on the other things like diet, lifestyle really well before I just jump to that antireflux procedure, because a lot of these patients actually can maintain, but it might be not just with PPI therapy alone, because they actually have an anatomic issue of why things are coming up. But if they have achieved control before, before rushing to a fundoplication, I do like to focus a little bit on the other things and taking that time to do so before committing them to an anatomical irreversible procedure. And these patients really focus on that overall volume preparing for the night and going down. I tell people all this, everyone gets attention on the top things, the acid control and the trigger foods, but there's three bottom boxes I like to focus on with them. And I actually have a handout that I give everyone to focus on it. And again, the top boxes, those are easy, people always do them, but it's the bottom boxes that, and I think Prakash went over a lot of this yesterday, sort of the adjuncts, but they go a long way. And a lot of patients can achieve control just by eating an earlier, lighter dinner, smaller amounts, and then adding an alginate product. The alginate products, unfortunately, you have to order online, but they are easy to get. There's Gaviscon Advanced, there's Reflux Gourmet, which comes in vanilla, caramel, and chocolate mint. And then there's esophageal guardian, which is a berry flavored tablet. That one's a little bit more robust, but works really well. All of them can be ordered online. And I really try and get them to do all of those things because usually there's somewhere, especially if they got some good control, we can get them back again. It's just a few reminders. So just before you jump to an anti-reflux procedure, just remember all the boxes, especially the bottom ones. I want to make a comment. That weight part is very important when you're going past the first two or three years. And a lot of these patients have taken it easy, they've eaten better, they've gained. You saw in Dr. Inouye's presentation, the guy had gained 40 pounds, 20 kilograms. That's a huge amount of weight to gain. So when the patient's sitting in the office, I particularly look at their weight gain pattern. If they carry their weight in their belly, if they're a belly kind of obesity, that creates a negative dynamic for reflux. The pathway for least resistance is going to be up, it's the same for sleep patients. Pathway of least resistance is going to be up. That's the person who needs to eat multiple small meals. That's the person who needs to make lunch their biggest meal, and not dinner. You know, and that's the person who needs to, you know, if anybody needs to get on Weight Watcher or count calories, it's that person. And you can try to tell them to get to somewhere between where they weigh now and where they weighed at the time of the poem, so 50% or so decline over several months. Easier said than done, but if they were doing well before and now they've gained weight, some loss of some of that weight is important. And you can't underestimate the effect of constipation here, okay? If they're significantly constipated, they're going to strain. I'm sure you've seen that, Bonnie. You treat their constipation, all of a sudden they feel great. Yeah, and you know, also getting that sense of the timing, because if they have a lot of nocturnal regurgitation and early morning symptoms, first things first is just have them really step back their dinner. I can't tell you how much it makes a difference for those patients who are especially those nocturnal regurgitators, just to move to an earlier, lighter dinner and sleep with their head elevated. And they usually are pretty happy, you know, as soon as they know where their threshold is. So again, I know that we have a lot of times PPIs and anti-reflux procedures in our algorithm, but please, please, please don't shortchange the patient with some simple, easy, you know, tricks and tips that they can use just because we didn't tell them of that. And so I know these procedures and medicines are there, but the counseling often takes longer. But it's well worth it. So, and I do think the top two boxes get way too much attention and the bottom boxes don't get nearly enough. So please remember all the boxes of my reflux optimization boxes here. Okay, so speaking of weight, we're gonna move into that concept. So this is a 37 year old with achalasia type two who is tolerating an only liquid diet. So ice creams, shakes, like smoothies, like, you know, all those sweet, yummy things, right? All went slid right on down and that's how she lived, but she still lost about 30 pounds. And she was diagnosed and underwent a myotomy. Her baseline weight might've been around 150. She lost weight down to 120 after the myotomy. She was able to eat again. It took her a while to get on a liquid diet. She actually was one that had food aversion. So we were encouraging her to go ahead and eat, go ahead and try and eat other things. It's time, go ahead. And so then she ate and boom, gained 50 pounds. And she was really, she overshot. So like, I think we had tried to really liberalize her diet and then she did, and then she gained weight. And then what happened was we started documenting that all her doctors started getting on her case about the weight gain. And then she got upset and got body image issues and depressed. And then all of a sudden I'm dealing with counseling sessions and we got psychological support and weight management support and try to turn her in the different direction. Talk about a swinging pendulum that we were going back, not just weight, but diet and emotions and psychological well-being. This is all something that maybe we really could have done a little better job up at the front. I think we were chasing our tails in terms of some of the maladaptive behavior she had at the beginning. So it was really hard to get us on that right track because we were overshooting. But really discussing the ideal weight. So we, even before the poem, we talk about weight management and then that first visit afterwards, we talk about weight management. And the one year visit, we talk about weight management. So we are really wanting to make sure that we set them up for success and not just open up their obstruction, but give them a whole host of new problems, including all the complications of obesity, as well as setting them up for reflux when you add that high pressure, abdominal pressure zone on top of their open LES. So this is something that I find very impressive in terms of how often it can be a problem. And we actually, I spend as much time on weight management as I do on reflux counseling, honestly, in my post-myotomy patients. And then this one is a 28-year-old type two achalasia who had both chest pain and dysphagia. His preoperative endoscopy shows those frothy secretions and retained liquid, a tight LES, and then a significant amount of pressurization pattern on the preoperative high-resolution manometry. Underwent a Heller myotomy, better at one year, but still some dysphagia and still some chest pain in the mid-chest. An esophagram demonstrated narrowing at the GE junction, but severe esophageal dysmotility throughout. The one-year EGD revealed retained secretions and frequent contractions throughout the esophagus, and a 20-millimeter balloon dilation done at the gastroesophageal junction to break up any scar tissue or subtle stricture didn't really relieve his symptoms. So then with the, we went back with an endoflip. So this is a nice way of really looking at the post-myotomy dynamics of what's going on. And we had a distensibility index of four. The diameter was a little on the low side of 11.5, but that's also in the setting of a Heller and a Doerr fundoplication. And then you can see this myotomy effect that you can see in the mid-part where the blue is above the red zone. Okay, there we go. So this is the GE junction complex here. And then here we have, we can see the myotomy effects, so the low-pressure area. But then we see these areas of contractions that are disordered right above that myotomy effect. Any thoughts? This is a blown-out myotomy waiting to happen. It's a blown-out myotomy waiting to happen, yeah. So this is an interesting case. It's interesting, because type two, you're supposed to be able to just treat with anything. They're supposed to get better. But I have found that type two can harbor a little bit of surprise every now and then, especially when you have those strong panesophageal pressurization patterns. Or I think Dr. Pandolfino showed examples of some suggestion of a spasm that sits in that pressurization pattern. Then you start to worry about some element of spasm, and maybe they aren't really type two. Maybe they are type three, and that pressurization pattern is just so strong in the manometry that we're not either seeing it or we didn't capture it well. And so then you start to wonder. And so in this case, there was some preservation of contractile activity concerning for spasm above the myotomy effect, and then he does have that obstructive factor of a door fundoplication. So what would you do if that's what your concern was? I suppose the question to Dr. Gawale is, would this be a good indication to try some sort of sildenafil before considering a myotomy or even calcium channel blocker, or would you really try to cut that area? So here you have to work with what you have. You cannot go back, right? You cannot go back. This is the reason why for type two, you gotta go with a short procedure or go with a pneumatic dilation. This was a man, right, young man? A man, pneumatic is not great, young man. You can't really tear the muscle open enough for the patient to feel great. So this is where that short myotomy may be reasonable if you feel that there is no spastic element in the soft shield body, right? So what you see in type two, that PN esophageal pressurization, you're seeing interbolus pressure, right? In the presence of high interbolus pressure, esophageal peristalsis is suppressed. So you won't see intact esophageal peristalsis in that setting. And so it is well known that when you relieve pressure down below and do a manometry a few months later in type two achilles, you may see normal esophageal body peristalsis. Now, your job before doing anything is to figure out if this type two-like pattern is indeed somebody with normal peristalsis, normal underlying peristalsis, or somebody with spasm in the esophageal body. One of the ways to bring that out is to do these challenges, or to look at the manometry in between swallows. And sometimes you'll see this long, spontaneous, big contraction sitting in between your scheduled swallows in your manometry. That patient needs a long palm. You'll end up with something like this, and then you need to do a completion palm, right? You need to do a completion palm. On the other hand, the person who has peristalsis coming back, but obstruction down below from the door, you need a pneumatic. But if you have a pattern like this, you probably need to do both, otherwise you're risking a bone. And just to make sure, we did do, which is, how are we distinguishing also that it's not an incomplete myotomy? I mean, this was a heller, so an incomplete myotomy at the junction. The best way, the best way is to use flips. So if this was an incomplete myotomy, your DI would be like two, or 2.2. It wouldn't be four. It wouldn't be four. At the level of the LES. The evidence suggests that if it is truly an incomplete myotomy, which is not very common, by the way, with the true myotomies, because they're supposed to go well into the stomach, right? If there is a true incomplete myotomy, another palm is the answer. The response is best with another palm rather than anything else. But you really have to individualize to what the patient's pattern is. But most of these are an obstructive element from scar or from the door. And that's why we did the balloon dilation, too, as part of it, just to take that out of the equation. But the DI of four made me think that that's not the, at least the driver or the main thing of what's going on, or the only thing that's going on. But just to make sure, I think it's always important to measure twice or do challenge trials or do something to make sure, before you commit the patient to another irreversible procedure. So we did do a Botox trial of both the spastic segment and the LES. You could argue that you didn't have to do the LES to see if it was just the spastic segment, but we were gonna take the LES anyway. So I just wanted to recreate what would happen if we were to go back and take that patient for a completion myotomy. Would that patient do better? And after the Botox trial, he did great for nine months, symptom-free for nine months, both in terms of dysphagia and chest pain. And then when his symptoms came back, then it was easy to say, you know what? Your symptoms entirely resolved. When we did that intervention, let's recreate that intervention, but make it more definitive. And so then we counseled him on a completion myotomy and the spasm had started to come, or that contractile activity started to come back. So we went from that proximal area right above the myotomy effect all the way down, including the LESG junction complex, and he's doing fantastic two years out. I think this case is particularly interesting because there is this question of the spasm that could be hidden. I think I'm curious to see how we learn more about it. I think endoflip might give us a little bit more information. I have to say, I did start wanting to do endoflips on all my type twos, maybe because I've seen too many of these to be able to look them in the eye and say any intervention works for you as a type two anymore. So I've backed off on that saying myself just because of my personal experience. And then I think this case also shows that residual spasm above the myotomy effect. It's really nice when you have that 16 centimeter, 322 balloon, it does not show up on the eight centimeter balloon. You can't see it on the eight centimeter balloon. You have to have the 16 centimeter balloon to show it. And we used a Botox trial to recreate and challenge the patient in the way that we were hypothesizing what was going on before we committed the patient to an irreversible treatment, but then went on to choose that definitive treatment. So not to belabor a point, but the fact that you, I'm kind of just questioning if we know enough about the DIs in post-myotomy patients to really understand if it's absolute, like I don't think we can treat it as a naive patient endoclip because in this case, you did take the LES again. So there could have been an incomplete, I mean, with the Heller, it's more about how high up are they going compared to how far down into the stomach. So I think that we still do need some more information about, and we should be looking more at like a change in DI, like what were the baseline DI before we don't know in this patient? Before we didn't have the pre-endoflip, but what we did do during the procedure though is do a pre and a post-endoflip during the poem, which is our standard practice. I would say that, and we look for what we're happy with afterwards. I think that in the case of a fundoplication, it's post-myotomy, I don't know that we have the perfect thresholds yet. And so we do have to learn a little bit more, but I would say given the lack of any even transient response to a balloon dilation in this patient, that sort of led me to wonder if there was more going on. And I do think that the balloon dilation, even though a TTS, 20 millimeter balloon dilation is not gonna fix anything. I feel like it gives me a lot of valuable information, even if it transiently changes symptoms for a couple of days or weeks, because then I get a little bit more information about if there's a little dysfunction at the LES or GE junction. So I use it as almost like a diagnostic part of my workup, both pre and post. Prakash, do you have any other? Yeah, I will tell you that the earliest use of FLIP, earliest use of FLIP was in the post-achelasia treatment population, and it performed beautifully, because that was the first indication for FLIP, because IRP doesn't function very well in that. So it's either FLIP or a esophagogram, right? So if your DI is above three, your muscle is never an issue. It is never an issue. But then you could argue, why take the LES on the second time around? You don't need the LES in the second time around. You take the door down. That's what you need to do. You need to take the door down. We left the door, but. We left the door and took the LES. We left the door and took the LES, because we were there. Yeah, so that would be my, if there is an obstruction there, you need to take the door down. But you can have fibrotic elements there from where the initial cut was made, regardless of what that cut was. And so sometimes I will do a ESO FLIP, because that's to 30, right? You're not going higher. And if you have a nice indentation, because your diameter is 11, you can bring that up to 20, 25, and that'll open up the scarring. It won't take down the door. You'll need a 35 RIGIFLEX to take the door down. But I wouldn't do that. I would say in this patient, if he had a transient improvement with the TTS balloon dilation, the next step I would have done was probably an ESO FLIP. So that's how I would have used a 20 millimeter balloon dilation response in this case. If he was like, oh, I was better for two weeks, and then it came back, then the next thing I would have done would be an ESO FLIP. So I think a lot of this is doing something, finding out what the response is, and then tailoring your next step. And it's not just one size fits all or one path for every patient. Great. And now I'll turn it over to Prakash.

Peroral Endoscopic Myotomy

esophageal outflow obstruction

achalasia

long-term care

diet and lifestyle counseling

reflux esophagitis

weight management