ASGE Peroral Endoscopic Myotomy (POEM) Pearls to Practice: LIVE and Virtual

Video Transcription
Video Summary
In this video, Prakash Geowally from Washington University in St. Louis discusses the complications that can occur after treating esophageal motor disorders such as achalasia. He explains how to identify and manage these complications.<br /><br />Geowally highlights common symptoms that patients may experience, such as dysphagia, regurgitation, chest pain, heartburn, and weight change. He emphasizes that it is crucial to differentiate between perceptive symptoms (what the patient feels), transit symptoms (symptoms that affect the movement of food), and supraesophageal symptoms (belching and weight change).<br /><br />Geowally discusses the association between late-stage achalasia and esophageal hyposensitivity. He mentions that some patients with achalasia may experience idiopathic chest pain, which can be managed with neuromodulators such as gabapentin or amitriptyline. He also notes that patients with spastic achalasias may have true esophageal visceral hypersensitivity.<br /><br />The speaker compares the effectiveness of different treatments for achalasia, including pneumatic dilation, peroral endoscopic myotomy (POEM), and laparoscopic Heller myotomy, in relieving symptoms and managing esophagitis. He explains that patients with reflux symptoms may require additional testing, such as wireless pH monitoring or catheter-based pH monitoring, based on the type of symptom they present.<br /><br />Geowally discusses the management of reflux symptoms, including the use of antacids, agents with alginate, and proton pump inhibitors (PPIs). He also mentions alternative pharmacotherapies, such as penoprazole, and highlights the importance of optimizing PPI dosing and considering the patient's psychological state in managing reflux symptoms.<br /><br />The speaker also addresses transit symptoms and recommends starting the evaluation with endoscopy to identify strictures, mucosal inflammation, or other structural issues. He discusses the use of imaging techniques like timed barium esophagram and flip studies to further evaluate transit issues. Geowally also mentions the possibility of performing additional treatments, such as repeated POEM or pneumatic dilation, in cases of incomplete myotomy or stricture.<br /><br />Finally, the speaker discusses blown out myotomies, massive esophageal dilation, and the potential complications associated with achalasia, including esophageal cancer. He concludes by cautioning against overdoing POEM and emphasizes the importance of differentiating between reactive contractions and native esophageal patterns when treating chest pain in achalasia patients.
Asset Subtitle
Gyawali
Keywords
achalasia
esophageal motor disorders
complications
symptoms
treatments
reflux symptoms
transit issues