Hello everyone. So Aziz and Amrita, thank you so much for inviting me to this great course. Dr. Ernest Heller performed the Hellermyotomy more than 100 years ago. In the era of laparoscopic surgery, Dr. Simi performed the laparoscopic Hellermyotomy, that was 1991. So recently, Jay Pashulich, he reported the concept of submucosal endoscopic esophageal myotomy using POSIM model. And Dr. Chris Gastaut and Dr. Kazuki Sumiyama, they reported the usefulness of submucosal tunneling using POSIM model. So we reported the POIM procedure in 2010. So please note the date of the procedure. This is the world's first case of POIM. So in the anterior myotomy, we are placing a mycosotomy. And in the submucosal tunnel, we perform the selective myotomy of the inner circular muscle. So totally same procedure to now. So after completion of a earliest myotomy, we close the mucosal entry using clips. And the esophageal gastric junction is open right after procedure. So this is a volume swallow before and after POIM procedure. This is a memorable shot. So we followed this patient for eight years. And his ECERT score dramatically improved right after procedure and keeping it eight years. So this patient said that his satisfaction is 100%. And he can eat well and gain weight 20 kilograms. And no girl symptoms. This is an endoscopic view. He has no girl. So far in our hospital, we performed more than 2,000 case series of POIM. This is a report at the time of 500 to the American Coverage of Surgeons. This is a comparative emergency center study of POIM versus pneumatic dilation. The result is POIM is a 92% success and pneumatic dilation is only 5%. And pneumatic dilation is only 54%. So POIM has better results. This is the most important LCT. It's a POIM versus laparoscopic helamyotomy. So a red bar demonstrates the POIM results. So POIM results is superior a little bit than helamyotomy. So this is a follow-up data from our hospital. So more than 10 years passed since the patient receives a POIM. And most of them are keeping good results. Next, I'd like to talk about the myotomy length. So like a CICAGO type 1 or type 2, we can place the LES myotomy, focusing just onto LES. Then we can keep a good volume floor. In the case of a vigorous sacral is here, so we have to extend the myotomy length. So LES plus is after your body. So this is a myotomy length based upon the version 3 CICAGO classification, but it looks complicated. We can summarize. So CICAGO type 1 and type 2, we can place LES myotomy. So type 3, we have to place a body plus LES. And the other diffuse spasms or jacamary sarpagus, if the opening of LES is good, we can preserve it. So Dr. Kalidas and Dr. Pandolfino, they also reported the POIM is particularly useful in the type 3. Of course, we can apply type 1 and type 2. So POIM for spastic motility disorders. So this is a case of a diffuse esophageal spasm. So you can see lots of spasms of the esophageal body. So we place a long myotomy. Then the volume can pass through very smoothly. So in this case, we are trying to preserve the lower esophageal sphincter. So this is the case. So esophageal body, so you can see a lot of abnormal contractions. So, we confirmed using the double scope, the position of the submucosal tunnel already leads to the esophagogastric junction. Then, at the time of myotomy, so we are trying to preserve the very distal end, so two or three centimeter, very thin muscle layer, that is LES. And the proximal side, so we place, this is the proximal end of the lower esophageal sphincter. We place a very long myotomy of the esophageal body. So in this case, one year after point procedure, our symptom score is dramatically improved to zero. Next, I'd like to talk about intraoperative bleeding. So esophagus, we have less risk of bleeding, but in the stomach, so anatomically, the esophagogastric junction is supplied from the branch of a left gastric artery. So sometimes we encounter this kind of a large vessel. So incidence of a significant bleeding is a 0.4%, so not so high, but you have to be very careful. So just in case you encounter a severe bleeding in the submucosal tunnel and lose your sight at the time, so coming back to the natural lumen and press the esophageal wall, esophageal mucosal using the lateral wall of the distal attachment, and wait 10 minutes, and then coming back to your submucosal tunnel. So the bleeding, most of the case, controlled well. You can see a clot. So this is the most significant bleeding in our series, so please watch. So we do not recommend doing this procedure, hook and cut. So potential risk of making an injury to the vessel, please note. Like this. So right after cutting artery, we lost the visual sight once again. So we cannot see the tip of the knife, so very dangerous procedure. So very end of the gastric myotomy, so we cut the artery. So right after procedure. So fortunately in this case, we need a transfusion, but the very end, so the patient pressure is a little bit down to 6 mmHg. At the time, we can see a bleeding point. So we coagulate this vessel using coagulating forceps. So yes, it's a tough moment. So fortunately, we can control the bleeding using coagulating forceps. But we are preparing for the conversion surgery, but we could successfully control the bleeding. So this is another case, but like this way, we can see perforating artery at the level of the stomach. So you have to be very careful not to cut this kind of a large vessel. So as a technique of a gastric might be recommended. So a splay onto the muscle layer surface that can expose the surface of the big artery. So without cutting it. So I recommend the splay coagulation more than the gastric side. I'd like to mention a little bit about the terminal acalacia, how to treat it. So we recommend to try POEM first, and if necessary, second POEM. And the last choice is esophagectomy. Very advanced acalacia patient, so dilated esophagus is packed with the food. So in this case, we perform the POEM procedure, and this is three months after POEM procedure. The patient has a little bit grade A, AB, GERD, but it doesn't matter. So one year after POEM procedure, this patient's symptom score dramatically improved, so he can eat well, smoothly, without any trouble, no midnight cough, no more aspiration pneumonia, it's a 10 kilogram gain weight. Next I'd like to talk a bit about the chest pain of acalacia. Can we control the chest pain? That's a big question. So Fukuda sensei arranged the Japan National Survey, and his results were reported at GIE, and 70% of the case responded, and the partial response is 30%, so totally 90% has some response. So chest pain, most of the case, well controlled by POEM. Next I'd like to talk about the post-POEM GERD. POEM has a good success rate in any hospital, but the potential risk is post-POEM GERD. So like this way, a 50% case has a pH abnormality, and our symptomatic GERD is a 20%. So this is our Merck Center Prospective Study in Japan. So grade C and D erosive esophagitis is 5.6%. So that's a problem. So how to avoid the post-POEM GERD? The recommended procedure is a double-scope method. So Dr. Kevin Grimm, he organized the RCT, so three-year follow-up, and the gastric myelotomy ranks significantly affect the rate of the severe GERD. So we have to keep the gastric myelotomy ranks less than 2 centimeters. In order to control the gastric myelotomy ranks 1 to 2 centimeters, we use a technique of a double-scope. It's first reported by a Portuguese doctor. So this is the endoscopic view. Intra-gastric monitoring scope demonstrates the submucosal endoscopy already reached to the gastric caldia. Then we can accurately calculate how far toward the gastric side is the submucosal endoscopy reached. So 1 to 2 centimeter myelotomy to gastric side is the best. So everybody knows the carotid muscle creates a hiss angle. In order to avoid cutting of the oblique muscle, carotid oblique muscle, it's better to dissect in the lesser curved side. So Dr. Tanaka, he reported in a posterior myelotomy, we can see two penetrating vessels. So first one is on the level of the esophageal gastric junction. The second one is 2 centimeters apart, the gastric side, 2 centimeters. So we can dissect in between the first one and the second one. Or we can dissect until the second perforating artery. In a posterior myelotomy, we can recognize the edge of the carotid muscle at the left side of the image. In the center, you can see a perforating artery. So we are going to the right side of the perforating artery. And the double scope method is also useful to identify the direction of the gastric myelotomy. Now we can recognize submucosal endoscopy going in the line of the lesser curve. For better understanding of the anatomy, so this is a case of a gastric caldia ESD. And then color string fiber is exposed already. And the yellow line area is the lesser curve of the stomach. So in this area, there is no color string muscle. So it's better to control the gastric myelotomy direction to the lesser curve of the stomach. Just in case if you don't have the second tower of endoscope at that time, so this technique is also useful. So inject the ICZ to the gastric caldia submucosal of our injection. Then we can identify the green coloration during the submucosal dissection. So next, I'd like to introduce a POEM plus F procedure. So in a surgical myelotomy, we place the dual anti-reflux procedure. So the POEM plus fundoplication is a technique to do the dual fundoplication similar procedure using the flexible endoscopy alone. So we do the first case in 2017. So far we did this procedure in 43 cases. So this is a live demonstration in the ESDGE days before the corona pandemic. So now we are doing like this. We approach anterior submucosal tunnel to the gastric side and get in abdominal cavity and then place the anterior suture of the stomach and then make anterior partial fundoplication. So this is a case. In the anterior submucosal tunnel, the very end of the gastric side, so now we are dissecting the peritoneum endoscopically. So behind, you can see a backside of the liver, okay? So now we open up the abdominal peritoneum well widely and then, okay. getting abdominal cavity and keep a little flex. Now we're placing the gastric anterior wall suture using needle forceps for endoscopy. So we catch the big, we have a big bite of the gastric anterior wall. This is an image endoscopy image of the intra-gastric monitoring. So a needle is coming in the stomach, lumen, and then going out. So this is a proximal suture. So in a semicircular tunnel, now we place the suture on to the diaphragmatic course in the semicircular tunnel. We normally place two stitches. Then we can create the fundoplication, partial fundoplication like this. So this endoscopy image is very similar to our after donor fundoplication. So, so far we did this procedure in 43 cases. So technical success rate is 100% and this is a pH data. So POEM plus fundoplication group has a good result. But, so fundoplication, if we want to do, if we do the fundoplication, it takes more than one hour additionally. So we don't think it's a routine basis. So of course most of the cases, the POEM alone, that's enough to control the cariesia and also without reflux disease. So our recommendation at this moment is a POEM alone in a posterior wall. And then just in case, if the patient becomes a severe GERD, so that may happen 0.3% if you control the gastric myotomy range 1 to 2 cm. So in such a case, we place a paroral endoscopic fundoplication alone. So for example, six months after the first POEM procedure. Next, I'd like to talk a little bit about the extension of the POEM procedure. So we have several procedures. So POET is the same to start procedure. And also a gastric POEM for gastroparesis. And the TENKA POEM for paroral endoscopic septotomy. And the diverticulum POEM as well. So this is a POET, what we call POET, and the totally same to start procedure. So we reported the same year. The report of our clinical data. So we recommend a less than 4 cm tumor is the best indication of this procedure. Next is the gastric POEM for gastroparesis. So the first case of a G-POEM was done in 2013 at the Johns Hopkins together with Moen Kashav and Dr. Stavros and Stavropoulos. Dr. Moen Kashav reported many clinical data and then the results is satisfactory. So TENKA POEM. So lots of reports, but I think the paroral endoscopic septotomy POET is the best procedure in our experience. So this is a case. So TENKA, this is accurately the Kilian Jameson. So you can see a deposit of the contrast media after swallowing. So in this case, endoscopically, we can see a septum like this. So we place a mucosal incision at the top of the septum. And then, so after endoscopic visual control, we are placing the myotomy. Then, so we perform the myotomy deep enough, at least 2 cm. So because we have to dissect the clinical pharyngeal. Then after completion of the cricopharyngeal myotomy, we are closing the mucosal defect using our regular clips. So like that. So several months after procedure, the septum going down. So the body swallows a few months after procedure, so no deposit of the contrast media to the diaphragm. Okay, so this is the 14 years history of the POEM procedure and its offshoots. So thank you very much for your kind attention. Thank you.

peroral endoscopic myotomy

POEM procedure

Hellermyotomy

laparoscopic version

submucosal endoscopic esophageal myotomy

POSIM model