Haru Inoue, who, as we all know, is the father of poem. Haru, welcome back. He joins us from Showa University. We appreciate your being here with us live. Along with Norio, helped us start poem courses here at the ASGE. And we welcome you back and look forward to hearing about your lecture today. Yeah, thank you very much for inviting me to this wonderful, exciting course. It's my honor. OK, so I'd like to talk about the poem, 15 years. OK, this is my disclosure. I'd like to first talk about the background story. So Ernest Heller reported that Heller married me more than 100 years ago. And the 1991, so Dr. Simi, so he reported that laparoscopic Heller married me at the era of laparoscopic surgery, beginning of laparoscopic surgery. OK. Then so recently, 2007, so Jay Pastrucher, so he reported the possibility of a poem using POSI model. And Dr. Chris Gastaut and Sumiyama Sensei, both of them reported the safetiness of mucosal throat valve. So 2010, so we reported the poem procedure. So sorry, so please note the date of the procedure. September 8, 2008. So back to the future. So place a mucosal incision onto the mucosal surface. And then get in a, so we have already created the submucosal tunnel. Now I'm performing the inner circular myotomy. This is a selective myotomy. This is totally equal to the current procedure. So of course, we select the first case. It's a relatively easy case. Anyway, complete the myotomy. And then after that, close the mucosal entry using clips. And the esophageal-gastric junction is a well-opened, right after procedure. So this is a volume swallow before and after procedure, so smooth passage. This is a memorable shot. That's a type of number three, case number three. So the patient is 39 years old. And they got a score that the right after procedure dramatically improved. And eight years later, we followed this patient. And it keeps the same good results. And this is an actual photo with the world's first poem patient. 80 years and eight months after procedure. So patient satisfaction is 100%. She can eat well and gain weight at 20 kilograms and no good symptoms. And this is the endoscopy image, 80 years after first poem. So he has no good. So far in our hospital, 2,600 patients received the poem procedure. So we reported our first 500 experience to the Journal of the American College of Surgeons. And this is a very important paper from Paul Fokken's team. And the poem versus the pneumatic dilation. It's an international center study. And the poem, the success rate is at 92%. And the pneumatic dilation is at 54%. So poem is a better result. And this is one of the most important paper. Poem versus laparoscopic helamyotomy, a randomized controlled trial. So reported in the New England Journal of Medicine. The red bar demonstrates the poem, and the blue bar is the helamyotomy. So poem is a little bit better than the helamyotomy, but almost same results. This is another, I think, important paper. This is more than 10 years of follow-up patient series in our hospital. All the patients getting better. One patient is a parallel, but all the patients improved, even after 10 years later of the poem procedure. So I'd like to talk about myotomy range. So of course, at Chicago, type 1 or type 2, we can focus on to the LES myotomy, short myotomy, I mean. So in the case of a vigorous acaracea, Chicago type 3 or something, so we have to place a longer myotomy, including the abnormal contractions of the soft tissue body. The after procedure looks good. So this is a myotomy range based on a Chicago classification version 3, but it looks a little bit complicated. So we can summarize that the Chicago type 1, type 2, we are focusing on to the LES, short myotomy. And the type 3, we have to place a longer myotomy. And the types, in the case of a diffuse spasm and the jacama isaptus, if the LES relaxation is good, we can preserve the lower isaptus sphincter. That is a category 3. So Dr. Kauridas and Dr. Pandolfino, so they reported that the type 3 acaracea is a well-responded to the poem procedure. But of course, we can apply the poem to type 1, type 2 as well. So this is the application of a poem procedure to motility disorders. So success rate is high. And this is a case of a diffusing soft tissue spasm. So you may see abnormal contractions. And we place a longer myotomy. And after that, a very smooth passage of contrasting media. So in this case, this patient still has the LES relaxation. So we try to preserve the LES preserving. So this is the actual case. In the isaptive body, lots of abnormal contractions. OK. So in this case, we perform the double scope checkup to identify the esophageal gastric junction. In this case, we are trying to preserve the area. So like this. So we start the myotomy in the very proximal part. And then so this is a very distal end of the submucosal tunnel. So last two centimeters is the LES. So we try to preserve it. So once again, this is the LES preserved. So our proximal part, we place a very long myotomy. Like this. OK, mucosal entry is very compact. So in this case, a cut score dramatically improved. One year after procedure. So next, I would like to talk about the intraoperative reading. So esophagus, esophageal site, we have less risk of bleeding. But in the gastric site, so anatomically, there is a branch of the left gastric artery. So this side is the axial endoscopy image. Sometimes a big artery passing the gastric wall. So we have to be careful in the gastric side. So significant bleeding happened in 0.4%. So unusual, but we have to be very careful. In the case of severe bleeding, if we lost the site in the submucosal space, we come back to a natural lumen. And then, so using the lateral wall of the distal attachment, we press the bleeding point through the mucosal, together with the mucosal layer. Then, so 10 minutes later, so once again, we approach to the submucosal tunnel. Most of the case, the bleeding controls. Of course, the clot remains. But anyway, so this is the most severe bleeding I experienced last 2,000 cases. So this is the most severe bleeding. So please note. So this is a gastric marziming, Fukun cut technique. So this Fukun cut technique is a blind procedure. So potential risk of cutting injury to the large artery. So right after cutting, once again, so right after cutting the artery, we lost the site. So we can't do anything. So I'm so upset. OK, so in this case, so this is a bleeding jet. So finally, we can see it. And then using a coagulating forceps, we stop the bleeding. But in this case, at this moment, blood pressure is down to 60. So a bleeding jet is getting weak. So we can find a bleeding point. But we need transfusion to this patient. So only one transfusion among 2,000. So finally, we get the hemostasis. OK, so this is another case. But in the gastric side, even in a rectal curve, greater curve, so potentially, we may have this kind of a large artery. So everybody has to be very careful in the gastric side. The substance side is OK. So we recommend, so this is a small foot gun cut. It's OK, visual control, so it's OK. But so generally, we recommend the gastric side like this way, splay coagulation. So even when there is a large vessel, we can explore the surface of the vessel. And then we can recognize it before bleeding. Then we can make a prophylaxis coagulation. OK, so I'd like to briefly mention about the terminal arteries, how to treat terminal arteries. So I think, so try, try point first. And if necessary, second point. And the esophagectomy is the last choice. So this is a case, so esophagus is packed with a lot of food residue. And then, so it's a very advanced case. So in this case, we performed a point procedure. And then three months after point procedure, so patient had the AB, grade AB girth, but the tertiary fine. And the one year after point procedure, ECGAR score improved good. And the no more midnight cough, no more aspiration, the gain rate 10 kilograms. So some patients react to point. So before sending the patient to surgeon, so please try the point once. And the chest pain of arthrasia, we can control or not. So this is a paper accepted to GIE this year. So Dr. Fukuda reported Japanese collecting data. So roughly 70% responded to the point procedure. We can control the chest pain as well. And the partial response is 30%. So totally, almost cases have some level of a response to control their chest pain. So this is a fact. So post-formed girth, I'd like to talk about. So this is many papers that demonstrate that the reported post-formed girth happen in a 20% to 50%. So I'm going to pH the 50%, of course. But the symptomatic girth is a 20%. So this is a March Center prospective study in Japan. We have a grade C and a grade D girth in about a 6%. So number is so-so. So the treatment of this patient is a discussion. So our strategy, how to avoid the post-formed girth. So we recommend a double-scope technique. So this is the RCT reported by Dr. Kevin Grims. So in his results, so gastric myotomy, more than a 3-centimeter course, the increased severe girth. It's a moderate and severe asphagitis. So we have to control the gastric myotomy length to 1 or 2 centimeters. That is his results. So in order to control the gastric myotomy length, best method is the double-scope method. This is reported by Portuguese doctors. So we follow them. So this is an actual image. So intra-gastric pediatric scope, we keep it retroflex view and then submucosal endoscopy already reached to the stomach. And then we can evaluate the accurate position of the submucosal endoscope objectively like this. So scope diameter is one centimetre. So this is a pediatric scope, so six millimetre. Then we can control the gastric myotomy length, one to two centimetres. Like this. This is a one centimetre scope. So we recommend a guideline in JGS. So another point is it's better to preserve, it's better to preserve the oblique muscle. So that is the carotid muscle. You know that this carotid muscle creates the hiss angle. Then so it's better to go the lesser curbside in the stomach. So do not go to the yellow dot line. So Dr. Tanaka reported that two penetrating vessels is a good indicator in the submucosal space in a posterior approach. The first penetrating vessel is a level of esophagogastric junction and the second one is a two centimetre distal from esophagogastric junction. So it's a good marker. And also carotid muscle is the left side of the yellow dot. Okay? So like this way, using a double scope method, we can evaluate very good. And also we can control the submucosal endoscopy position in a lesser curve. So this is the good understanding. So this is an image of a light after ESD, not a poem. This is a light after ESD of the gastric caudae. So you can see a yellow dot and the yellow line. This area is a lesser curve and there is no carotid muscle. So greater curbside, there is a carotid muscle. So we can control the endoscope to a blue direction, blue line in a lesser curbside. But if a second power of endoscopy power is impossible to prepare at the time, so injection of indigo ICD to gastric caudae, then we can see a green colouration in a submucosal tunnel. We have already reached to the stomach. So that is another alternative. Anyway, another method is to do the poem plus fundamentation. That is really a recreation of the Heller-Doe procedure. So surgical myotomy, everybody knows surgeon plays the Doe fundamentation after Heller. So we do it using a flexible endoscope. First case was done in 2017. So far we did 43 cases. So this is a live demo at the time before COVID-19. So in the anterior submucosal tunnel, we create the distal end of the submucosal tunnel, we get the abdominal cavity and we place the suture onto the anterior wall of the stomach. And using a V-lock, we make, we place two stitches. So this is actual video. So very end of the submucosal tunnel, now we are dissecting the peritoneum. Muscle layer has already been dissected. Behind you can see a backside of the liver lobe. So now we open up, widen the peritoneal opening, carefully, carefully, slowly, slowly, a visual control. So this area, abdominal esophagus, anterior wall, so usually no large vessels. So anyway, we get in abdominal cavity, of course, a CO2 insufflation, we place an anterior suture. So this is a needle holder, we catch the anterior wall through layers. Okay, this is an intragastric endoscope monitoring, needle is coming into this gastric lumen and then out. Then this is a proximal suture on to the light curse, diaphragmatic curse in a submucosal tunnel. This side is a mucosal tube. Anyway, so we are fixing the, so then so we put the V-lock, we can create the partial fan flication nicely. So this endoscopy image is a very similar to our after door fan flication. We do this procedure 43 cases, the technical success rate is 100%. This is a pH monitoring. Poema alone group, compared to Poema alone group, fan flication group has a good control of the reflux. But, so if we perform the F fan flication endoscopically, it takes one hour and a half more in addition to the poem. So it takes a longer time. So it's not necessary to do this routinely. So our strategy is a poem case is a posterior myotomy, the poem alone, that is our standard. So 0.3% patients become the severe reflux. So in such a case, we perform the power endoscopic fan flication in the anterior wall. So this is our treatment strategy, current treatment strategy for esophageal caries here. So finally, I'd like to briefly mention about the extension of the poem procedure. So Poema actually opened the door of the submucosal endoscopy. So there are several offshoots. So star procedure poets, and the gastric poems, and the tenka poems. So that is a power endoscopic septectomy, so poets, and diverticulum poem, more like that. So star, at the same time, we reported a different journal, another journal. So we call this procedure poet. But anyway, so a less than three centimeter tumor is a good indication of this procedure. G poem is a good procedure. So our first case, together with Dr. Moen Kashyap and Dr. Stavros Stavropoulos, together with, so that was 2013. So right after completing the procedure, so Dr. Moen Kashyap reported the care precisely. And the G poem, talking about the tenka poem, so we actually doing the power endoscopic septectomy. So that is a power endoscopic septectomy. So reported by Dr. Alessandro Repicci and Dr. Roberta Masseri. So this procedure is the best, I think. So this is a before treatment. So you know, this is a case of a Kilian Jaminson. Our endoscopic study looks like this. So we put the mucosal incision, and then started to cut the muscle layer. It's the same to a poem procedure. So using a splice coagulation, we dissect the, this is a cricopharyngeal muscle we are dissecting. So at least a two centimeter dissection is carried out. Yes. So this is a connecting tissue, the left behind is a mediastinum. So behind we can see a pleura. Okay, anyway, so after cutting the muscle layer, we close the mucosal entry using clips, like this. So several months after the poets, so you can see a very nice control of the septum. Okay. So this is our 14 years journey of the introduction of the poem procedure. Thank you so much for your kind attention. Hiro, thank you. That was a fantastic lecture, really taking us through your journey. Do we have any questions? I have one question. We had a long, a bit of a discussion yesterday regarding the spastic disorders and poem. And it seems to be there's quite a bit of controversy about the issue of sparing the LES. Do you do this in all of these cases? Or what are you looking for to determine whether that's the practice? Yeah, thank you so much. It's a big discussion, I think. So we follow the results of a high resolution manometry. Of course, the relaxation of the LES, if we can confirm it. So what I mean is no outflow of extraction. So at the time, it's not necessary to cut the LES. So we try to preserve it. But based upon the results of manometry. I see. Any comments or questions from the audience? Yes, Aziz. There was a question about blown out myotomy, if they've experienced that in the Japanese cohorts. So I don't know if you heard that, Hiro. We had also a discussion about blown out myotomy. Sorry, once again. Blown out myotomy. Have you experienced this in Japan, in the Japanese experience? Once again, so I cannot. It's called blown out myotomy, where the distal end of the esophagus balloons out after myotomy, either Heller or poem. So it turns into a type of diverticulum. Oh, I cannot follow you. So what you mean is ballooning, ballooning out? Yes, when the distal portion of the esophagus after myotomy becomes weak and forms a type of diverticulum. Here it is called blown out myotomy. I understand. I understand. I understand. So you are talking about the diverticulum after a poem procedure? Yes. Okay. So theoretically, we never approach to the lateral wall. So lateral wall of the esophagus, so everybody knows it can emerge in the CT. So behind the lateral wall is a lung. So it's a negative pressure. So we have to place a myotomy anterior wall or posterior wall. Then so we have the back. So if we place a lateral myotomy, so we have a potential risk. But most important is releasing the lower esophageal sphincter. If the intra esophageal pressure is down, so by the complete dissection of the lower esophageal sphincter muscle, so I think less risk of ballooning after poem procedure. So we don't have not so many such complications we don't have. Okay. And last question with regards to the anti-reflux poem procedure. So just to clarify, plus the poem plus F. So your practice currently has switched from performing, used to perform mostly anterior poem. Now you are performing posterior to start and if reflux anterior plus poem F, is that correct? Yes. So in our first 500 patients that we did the anterior myotomy, but after that we switched to the posterior myotomy. And we routinely performed the poem in a posterior approach. And we are just in case the patient becomes the severe reflux, the less than 1% of the poem patient. In such a case, we approach anterior wall and then perform a front flication endoscopically. That is our strategy at this moment. Any questions? I think it's a beautiful example, Haru, of how in your journey you've really adopted and changed your practices based on the experience that you've developed over time and what we've seen happen. So thank you so much for sharing that with us. And we look forward to the next 15 years. Thank you so much. And welcoming you back here too as well. Okay, thank you so much. Thank you. So thank you very much.

Haru Inoue

poem procedure

peroral endoscopic myotomy

esophageal disorders

Chicago classification

bleeding control

reflux