All right, so next up is Joe Triggs from the University of Pennsylvania, talking about post-pollen management. All right, I want to thank everyone, thank the virtual learners and people here, and Dr. Adam and Dr. Sethi for inviting me. I was a fellow of Aziz at one point, so any of my deficits you can blame on him as well, just to mention. So, no disclosures, unfortunately. Post-pollen care, so I kind of, when I got this talk, it was management of post-pollen. And you know, there's not a lot out there on, you know, how to manage after pollen, so I thought about what my order set is in Epic, and how I take care of these patients immediately. And so some of that's in here, some long-term stuff, but a lot of it's sort of the acute right after you do a pollen, how are you going to take care of these people, really the nuts and bolts of like, what do you do? So you know, one thing you learn as an intern in medicine is to start with, as soon as the patient's admitted, thinking about when are they going to leave the hospital. Dispo is very important, obviously, right? Now all joking aside, you know, when we do, after you've completed a pollen, you know, the question is, you know, what do you have to do? Well, what we know, especially early, there was a very fear of, you know, mediastinitis and complications, perforation, leak. And so all of these patients are originally admitted. You know, the short answer now is that the patients actually can be discharged the same day. It really depends on the procedure, how that procedure went, and the patient themselves. When I look at my patients, anyone who's not like ASA 1, 2, I'm probably just going to admit them ultimately, because what I don't want to do is send them home and have it be a problem. Because a lot of my patients, and I'm sure this is true of the other providers here, is they have to travel to see me. You know, they don't live next to my hospital. Sometimes they come three, four hours away to come, or, you know, sometimes it's closer, but oftentimes it's to travel. And I don't want to send someone out and say, go to your local hospital where no one does pollen, or no one does these things, and, you know, let's see how you do over the next 24 hours if there's a problem. I, you know, I consider it like if I did this procedure, I own this, I want to take care of it. So, you know, I actually admit more patients for 23-hour OBS than some, I think, but it is because I think a lot of my patients end up traveling. But this is a study, David Carlock and his group, 103 patients, you know, they were able to discharge safely, 62% of them. Only two of those actually ended up needing any kind of follow-up imaging. And the ones that they admitted, it was mostly for pain. And we'll talk about pain. I would say most of the patients do wake up with some pain. It was, you know, I can remember when I was a fellow first, you know, realizing this and calling, I think it was Aziz probably, and saying, hey, your patient has a lot of epigastric pain. And he's like, yeah, that's what happens. So they do end up having some pain, and we'll talk about that in a little bit. But this is the algorithm sort of that was put together in this paper. If chest pain requiring opiates admitted, any kind of fever admitted, any adverse event during the procedure itself admit, medical comorbidities, that's what I was sort of speaking to before, ASA3 or above, admit, sometimes even just elderly patients. I mean, I've done palm on patients over 85 years old. And I usually admit those patients because their reserve is very small, obviously. And so I err on the side of admission. You know, this is 30%. In this study, at least 30% were admitted just for pain control. That pain, and we'll talk about it later, does resolve pretty quickly. But usually they do have pain. And then same day discharge, this is one diet. And we're going to talk about diet a little bit later. But this was 72 hours of clear, 72 hours of full liquids, twice daily PPI, and broad spectrum antibiotics for seven days, which we'll review as well. This was touched on as well. Just, you know, when you're thinking about post-POEM care, you know, you got to think about adverse events. What are those adverse events? How can I plan for them and plan? And how can those plans hopefully prevent them from happening? But this was a study, this was 1,800 patients, a 12 center international study. There was the adverse event rate was 7.5%, which is relatively, I mean, good for this pretty invasive procedure. And only 0.5 were marked as serious with no deaths in this series. You know, and the one thing, and it was brought up before on imaging, you know, we don't consider pneumo or capnoperitoneum, you know, an actual adverse event, unless you actually need to do a needle decompression or it's actually symptomatic to that level. And so the adverse event is any symptomatic event related to any seizure of the POEM requiring temporary stoppage of the procedure or further action to resolve or treat symptoms, prevented the completion or prolonged hospital stay or need for a repeat procedure. So that doesn't include, as I said, capnoperitoneum or the like. And you saw Dr. Adam show you a technique for decompression, and I'll talk about it here in a little bit too. But this was, you know, what are the adverse events that actually happen? You know, inadvertent mucosotomy. I find that this happens more in redos or patients that have had a Heller. It can be more difficult. Typically, it can be closed with endoclips, rarely need suturing or over the scope clipping. I don't think I've ever needed probably more. Yeah, I mean, you know, you can't end up putting in a stent if you really needed to. You know, in this series, there was one that required surgery. Needle decompression for capnoperitoneum, esophageal leaks typically can be treated again with endoclips or stents. You know, and then the adverse events after 48 hours, empyema, pneumonia, delayed tunnel bleed. I mean, these can be more serious. You know, anytime that early when things aren't noticed early, that's when it can be a problem. So you really want to do take care of bleeding initially. As soon as you see it, you know, cauterize every vessel and make sure you're inspecting that mucosa for mucosotomies, inadvertent mucosotomies so that you can close it immediately. In this study, you know, we heard a little bit about some of the factors associated with adverse events. This is sigmoid esophagus, less than 20 procedures for the provider. And some others that I'm not sure are really related, but triangle tip knife or energy use other than spray coag. So what do you do for symptomatic capnoperitoneum? And we saw Aziz take care of this. You really decompress it. And so if you're not comfortable doing this, you can't. I don't think you can do the do a poem. And it's really easy because if you've been a medicine resident and you've done, you know, TAP to CITES, you know, it's not all that different, but you really do have to be comfortable with this. This will happen. And so it's an iatrogenic communication between submucosal space and the peritoneum. You know, I actually have a, you know, it's because we have a lot of CRNAs, a lot of anesthesia residents that rotate through. And I talk to them about it before the procedure. I say, hey, look, this is a real possibility. If you start seeing peak pressures going up or you start seeing entitled CO2 going up, you know, let me know because that it's meaningful. And sometimes these patients can decompensate and become unstable. So you really need to be aware and know that these things are happening. You know, one of the things you look at the belly and make sure you've examined the patient before you started and you look at the belly, oh, it's very distended. Well, sometimes you actually just come out of the tunnel, deflate their stomach. They're actually much softer and you can say, okay, well, everything's fine. We can proceed. It's just that they, you've like over insufflated their stomach, actually. But when you do want to decompress, come out, suction down the stomach, you know, you can in the upper quadrant, you can, I typically try to go maybe on the left side, surgeons, there's a Palmer's point, which is like a two centimeters below the left mid clavicular line. That's where they put in trocars. Initially, it's a fairly safe space here. The patients are distended. It's not as much of a risk, but you can use that area. Usually use like a 14 gauge angiocath or a varus needle and decompress. And then I do the same thing that Dr. Adam showed, which is just take the plunger out and let it bubble up. And I leave that in for the rest of the procedure until I'm finished, because if you've already have a capnoperitoneum, that hole is going to stay open and you're going to keep insufflating and it's going to be a problem. Do patients need an esophagram or imaging after a poem? The short answer is no, but it depends again on the procedure and the patient. Don't ignore prolonged or severe symptoms. You don't have to get an esophagram oftentimes. And you look at these studies and we saw one earlier with that Dr. Dragunov had published where CT esophagram, everyone has findings. This is a study that was done at Penn. 72% of patients had pneumoperitoneum. I mean, that's a lot. And it's part of the reason that I was saying that I don't want my patients necessarily to go to any hospital. And if you go to any hospital that's not familiar with these, and someone shows up and they have retroperitoneal gas or pneumoperitoneum, and they might be getting an XLAT for all you know. So you really want to try to avoid those types of things. And so you can look, but oftentimes it doesn't mean that you have to do anything necessarily. I remember I was called at like three in the morning for someone who had severe pain, gotten an esophagram, got a CT scan. Ultimately, it was just some subcutaneous air that was causing pain. You know, the CT and everything looked like she had a huge amount of sub-Q air, but we ended up doing nothing and just monitoring her for an extra day in the hospital and it was all fine. There's another study looking at the same sort of thing, 170 patients between 2014 and 2018. And, you know, large numbers of patients have significant findings on their imaging. And so the question is, is do you really need to do anything? And the answer is, you don't necessarily, you don't do anything about these things. And so do you really need to get this imaging? Not necessarily. Similar things have been looked at. There was a series on pneumatic dilation. You need esophagram afterwards. Dr. Gary Falk, who's my partner at Penn, he still gets, he does get an esophagram, but he does get an esophagram afterwards. I trained with John Pendolfino. We stopped getting esophagrams and I don't do it on my pneumatic dilations anymore either. So in a similar fashion, I would say. Do patients need a course of antibiotics after a poem? So short answer is no. Single prophylactic dose is usually fine. You know, I give 500 of Levaquin to all these patients. It's a 24 hour dosing and just give one dose and that's it. You can give Cefazolin as well. This was a study that looked at, a randomized study that looked at this question. One prophylactic dose or a week, or I think a dose and then a dose afterwards. And then several days after that. And what they looked at, and this is a lot of information you don't necessarily have to look at, but group A was just the single dose. Group B was the secondary dose. And I don't know if I can. Yeah, so there's really no change in these inflammatory markers, white blood cell count, or the interleukins or TNF. No change, really. When you looked at blood cultures in these different, in these patients, there was rare, but positive blood cultures in both the people that had a single dose versus those with a short course of antibiotics. That was not statistically significant. So my practice is a single dose. And I think that that's probably what most people do at this point. So is Polam safe on patients who take antiplatelet and anticoagulation therapy? The short answer is yes, but they're at higher risk for major bleeding. Other meds other than aspirin should probably be stopped. And so the question of like post-Polam management here is when do you restart these medications and can this be, how do you manage that? This was a study that looked at 3,000 patients, 126 of them, it was a case controlled study, 126 of them were anticoagulation and 126 matched controls. Major bleeding in that was, you know, 5.6% in patients who were on anticoagulation or antiplatelet therapy, most of which were on antiplatelet versus 0.8% in the patients that were not on anticoagulative therapy. What's really interesting, you know, when I looked at this data a little bit closer, it's actually really delayed bleeding that's the problem. So, you know, this is the list of patients. It's day 10, day 19, day 5, day 12, day 6, day 12. That's when these delayed bleedings are happening in these patients. And how can we avoid that? You probably, you know, just be careful when you're doing your tunneling. Make sure you're really looking at all these vessels, you know, and cauterizing, you know, and I agree with what Dr. Dragunov said. I train fellows in PALM. And so I'm probably quicker to say, let's get out the co-ag grasper, you know, because that's part of a training, you know, as well as how to use that. You know, you don't need to look, you can do, I can do a PALM by myself in under 45 minutes. I don't need to be, you don't need to do that when you're first starting. You know, I probably, I was, I certainly wasn't doing that when I first started. So, you know, being, being, making, making sure you're cauterizing the vessels that need to be cauterized is important. There was some signal of maybe vitamin K antagonists, you know, having higher risk of bleeding subsequently. And maybe that's because of the less tight control. I don't know, but it's such a small number. I really wouldn't want to say much about it. But it does look like it's at least delayed bleeding is the issue. The other thing is, is that, you know, what is your guidance on when to restart these medications? Well, you know, there's two, you know, the ASGE has guidelines and the ESGE has guidelines as well. I'd refer you to those documents. And then Doug Rex also wrote this review after the ESGE guidelines came out and really, you know, it's for antiplatelet therapies hold, you know, this, this was seven days. I usually do five, five days, honestly, for high risk, high risk procedures, which this is high risk procedures with patients that are low risk for thromboembolism. You know, you can stop their warfarin five days before as well. Recheck an INR, DOACs two to three days, high risk, high risk for thromboembolism. Then you're talking about bridge therapy that all gets more complicated and poem. And, and so you really need to have a discussion, talk to the cardiologist or whoever's prescribing these medications of how important they are. You know, I have had patients who've had recent stenting, recent cardiac stenting. And what do you do with those patients? I mean, it's all individualized. Oftentimes I try to temporize them. I'll say, let's get you through your cardiac event. I can both, you know, try to Botox you or just, you know, do a standard balloon dilation, get you through the next six months when we can actually stop your medications and do a more definitive therapy if that's really what you want. How do we manage post-operative pain? So this is what I said, this is what I was talking about before. These patients, they wake up and not everyone. I have noticed that, you know, if you do have capnoparatine or some sub-Q error, those are the patients that are gonna have more pain, even if it's not so symptomatic that you need to treat it. But I think that that's the error probably that causes a lot of that. There isn't real data on how to treat this. There's some data on the timeline of it. Now, we'll talk about that in a second. But my standard order set is like 0.4 of Dilaudid, like Q15 minutes initially. They usually don't need a lot of doses. I give Tylenol now. I used to discharge everyone with opiates. I discharge no one with opiates now, unless it's, you know, unless they absolutely need it. I try to talk them down that they don't need them. I actually started giving Tordol as well. I don't know, that's probably not broadly used necessarily, I don't know if anyone else uses it. We can ask other faculty. I looked at the literature, and you look at like plastic surgery literature, there's really not that much increased risk of, there's no increased risk of bleeding in a lot of the literature and some of the meta-analyses that I reviewed. I find that it does help these patients. So if they don't have kidneys issues, if they're not really old, and I think they can tolerate it, I'll give them Tordol probably during, while they're still sedated during the procedure. But I don't know if others are doing that. It's not really described. My pain regimen, this is what I said. So yeah, Tordol, IV Dilaudid, and Piotrinal, rarely do I give them other meds to go home with. And you can see immediately post-POLOM, patients do have, report higher pain scores. And then that goes down pretty rapidly. This is another study that looked at it. This is the same study looking at same day discharge, excuse me. And you can see it pretty rapidly, their need for morphine equivalents decreased. So they wake up in pain, but 24 hours later, they're usually fine. What diet do patients follow? Or do I prescribe after a POLOM? There's no good data on this either. Everyone has a different answer. If you Google post-POLOM diet, I know that you can find the University of Michigan one that's out there. I don't know. I think Ryan Laws at Mayo now. I don't know who's doing, maybe it's Ali. I'm not sure who's doing POLOM there, but you can find Dr. Kehala's diet online. You can follow, there's like a bunch of them you can actually find online that people have posted on their websites of this is your diet afterwards. But there's no great data. Most diets are two to seven days of liquids and anywhere from two to three weeks of soft foods. A lot of this is kind of borrowed and adapted and shifted from surgical literature. The diet that I do seems to work for my patients is two days of clear, two days of full liquids, two days of soft foods and advances tolerated afterwards. Since I'm in Philly, I do tell all my patients not to have a cheesesteak immediately afterwards. That is something I do tell them. But I'm not sure how much there's gonna be other talk about counseling of patients and so forth. I meet every one of these patients in clinic and I review all of the options for treatment of achalasia. And one of the main things I stress to them is this is a treatment, not a cure. I can make you swallow better, I think, but I cannot make you swallow like you did when you were 10, 15 or however, before they had achalasia, I can't do that. This is a treatment, it's not a cure for this disease. And so I tell them that they're not gonna be able to go have whatever they want, whenever they want, as much as they want, it's better. I would say of all the things that I do endoscopically, this is the one thing where my patients come back and tell me you changed my life more than any other thing. And so it's really gratifying. And maybe some of that upfront counseling of I'm not gonna cure you, but this is a treatment helps at least set expectations. But it is satisfying when, makes you feel good about your job when the patients come back and tell you that. What about acid suppression after POLLEN, what do you recommend? So no real data on this either. I would say, we looked at some of this, we looked at this, one of the other presenters showed this. This is from the New England Journal, a POLLEN versus lap-heller study. And what you can see is, if you look at, this is at two years, if you look at mean acid exposure time, it's the same. And then the percentage of patients that were above 4.5% is the same. And no patient, and then the percentage of patients with high grade esophagitis is the same. I mean, it's not that different. Low grade esophagitis, I don't make much of it. You can treat that with a PPI typically. So acid, I think, as we heard earlier, there's maybe much to do about nothing here. But what do I do? Because I do, I want my patients to feel well, certainly. So what I do is I actually give them IV PPI during the procedure, or right after the procedure, really. I discharge them on twice daily PPI. And then I tell them to stop that after a month. Really, I'm hoping that that's promoting healing. And if there is a bleed, hopefully it can stabilize clots. Stop PPI, if they don't feel well when they stop it, I say add back once a day, or add, if that doesn't work, okay, go back to twice a day. But try to minimize, the lowest effective dosing is what I try to do after a month. And then I usually repeat endoscopy in three to six months, preferably off PPI to see if there is acid, if there is esophagitis, if they're off, because symptoms and physiology, or esophagitis don't always correlate. Patients can say, I feel great, you go down there and it's like high grade esophagitis. And you can have patients tell you they're having the worst reflux of their life, and you go down there and everything looks beautiful. And so symptoms are not a perfect correlate. You know, I don't know how much we'll talk about this at this course either, but TIF post-poem, you know, there are series that have looked at this. I think I have another slide on it. So TIF is, you know, transoral incisionless fundoplication. It's a great treatment for reflux. I think that there is a role for this post-poem. What I will say is that I don't think upfront TIF is probably the right answer. It's, you know, risk costs without maybe any necessarily benefit for a large portion of the patients. You know, and if they can tolerate, you know, if they're fine on a once daily PPI, or they don't need anything, I mean, how can you argue that you should just be doing upfront TIF for everyone? And so I don't recommend it. You know, in this study, this is a case series that they looked at it, and most people get better if they had a poem. Most people are getting better afterwards. If they had a poem and they have symptomatic reflux, they get better after TIF usually. Recommended follow-up after poem. You know, who knows what the right answer is? That's what I'll first say. I can tell you what I do. I can tell you what, you know, John Pendolpino does. You know, when I was at Northwestern, we did, we had a natural history of achalasia study. And so every year, every patient after poem gets everything. They get a manometry, they get an esophagram, they get a flip, they get, you know, pH studies. And a lot of that is great. It's great data, can publish a lot of papers that way. I'm not sure that all of that is absolutely necessary for the care of patients in sort of standard care. You know, but what do we know about, you know, these patients long-term? Well, we know that maybe about a third of them were gonna have reflux. And we know that long-term, there may be some recurrences of symptoms and there may be some recurrence of disease. And so maybe if we reach 90 to 95% efficacy upfront, that efficacy may wane over time at some level. You know, studies, this was four years, maybe even up to 10 years, you're still pretty high, but it's not everyone. And I really searched for this cartoon figure that I remember from when I was a fellow that I saw. It was a woman with achalasia and she was, you know, had very symptomatic. The next picture, she's fine and her esophagus is dilating. And then the third picture is her of a sigmoid esophagus and she's wasted looking and cachectic. And this happens post-palm as well. So that's sort of the natural history of achalasia or the belief of natural history of achalasia that's left untreated is that, you know, you can accommodate and your stomach, your esophagus will become like a stomach. And you may feel fine for a long period of time, but there will reach a point where you potentially, your esophagus is sigmoid, you're having symptoms where you're filling up. And so, you know, what I don't want to do is that to happen in patients who are under my care and already have gotten a poem. And if I can prevent that, that's what I do. And so what I do is every year, I do kind of a check-in with my patients. It doesn't have to be an office visit. Usually it's either an, I sort of alternate esophagram and EGD. And so it's, you can get an esophagram one year, the next year you have an EGD, but we sort of touch base at least once a year saying, how are you doing? What are your symptoms? Maybe I take an Eckert score and, you know, check in, make sure their esophagus isn't dilating and things are still going fine. Because what I really don't want to do is end up, you know, and I've seen this before. Someone gets treatment, they come back 15 years later and they need an esophagectomy. And that's not what I want to happen to my patients. I think that's all I have here. So feel free to contact me if you have any questions. I don't know if we're taking questions now or what the scenario is here. Yes. Tunnel bleeds, the delayed bleeding. So they have bleeding in the tunnel and they present with over GI bleeding. So you go in there and scope it. What do you find? I mean, you have bleeding in a tunnel, what happens? This is very rare, I would say. It does happen. I've only seen it once. And what happened is you see a huge hematoma. There was actually, it fissualized essentially, like auto fissualizes the bleed into the stomach. It was my partner's patient. He tried to open the tunnel back up, took the clips off, tried to go in. It had already, this is three, four days later, it had already completely like sealed, couldn't do that. You could potentially put a stent in to try to tamponade. Fortunately, this one fissualized and sort of auto coagulated, but you could potentially have to go to IR. You could potentially have to make a new track, try to get back in there, try to suck out clot if you can. I think a stent, as I said, to tamponade, these are sort of your options. The last thing I would say is go to surgery and get an esophagectomy or something like that, but I don't think it'll ever really get to that point. So mostly, really, not much can be done. I mean, the bleeding is in the tunnel. There's really not a really good way to access the tunnel again, and you're hoping that this is gonna stop and you have not to intervene. Yeah, well, I mean, also, if they're on anticoagulation, you can hold that, reverse them. I don't know, Aziz, if you have any other thoughts. So the most important thing I would say is after you complete your myotomy and everything, before you do your closure, go back into the tunnel and take a look because oftentimes you will see some bleeding there. So you wanna make sure you coagulate that, give it a few minutes, make sure there's no further bleeding because I think those missed vessels is often what you'll encounter. Now, when you do get bleeding, oftentimes, this will kind of self-tamponade, right, that it's in within this tunnel. The tunnel entry fibrosis within a couple of days, and you won't really even be able to get in. So the best management, I would say, typically, it's gonna be conservative management, admit them, transfusion, something like that. If it gets really severe, it would be very rare, and then you may have to get at least a surgeon on board, get IR, interventional radiology, potentially, on board, that sort of thing. But for the most part, it's conservative management. Make sure there's no bleeding at the end, before you place your clips. Yeah. Is there any role for any of the topical hemostatic? I would probably avoid that because you're exposing the mediastinum often, right? Even if you're preserving the longitudinal fibers, you'll see the mediastinum exposed. We don't know how this functions, you know, so. Yeah, and the other thing, I mean, the only one that's commercially available is HemoSpray, I think, and if you've used it, it's a whiteout. So you're done at that point anyway. So I agree, I have not used it, would not use it. I would try a lot of different things before I would ever come to that. For mucosal injuries during the procedure, do you try to just salvage the procedure still, or does it depend on the severity of the injury, or? Yeah, so I, it depends on how bad it is. I typically just continue and clip it at the end, and then, you know, look at it, say, okay, I'm happy. I've had it so I couldn't, you know, doing a redo of a Heller, I couldn't even find it. I had to pass a wire out, the mucosotomy, and then find it, and then sort of clip on the wire to close it, and, you know, and I was like, okay, well, it's hard to get the wire out, so I guess I clipped it closed. I mean, you know, it can be difficult, but I typically just continue my procedure. I have aborted before when the mucosa, and this happens from chronic stasis, is so friable that it's just falling apart, and that's not necessarily a mucosotomy. That's just unstable tissue that you can't even tunnel in. I don't know if you've ever experienced, where literally it's just like the mucosa just falling apart. I've treated that, actually, the one patient I can think of, I treated them with Botox, sort of temporized them, kept them on clears only, had their esophagus calmed down. I brought them back, and I was actually able to complete the procedure, but it was just so much inflammation from chronic stasis, because it was a sigmoid esophagus, that I wasn't able to essentially tunnel initially. Kind of on a similar thing is, you know, I'm familiar with like two days of clear liquids, or three days of clear liquids. Do you guys ever ask, treat preemptively with antifungal therapy, in case you run into Canada, or? I don't empirically do that. I think one of the surgeons at Northwestern maybe does that. I like to scope all my patients beforehand myself, even the outside referrals that I've had scopes before. I like to see what I'm getting into, honestly. And so if they have Canada, I will treat it. I have had a patient that had severe candidiasis, like thick layered, and I kept them on therapy until I did my procedure, like three plus weeks later, just because I wanted it, and it was perfect by the time I got there. But I do not empirically treat them, everyone up front. So you scope them up front, way ahead of your poem? I usually do. You know, I wanna see an esophagam. I wanna see the EGD. I have to see the manometry myself. You know, I tell all my patients that I'm like a carpenter. I like to measure twice and cut once. Once you start cutting, you can't uncut. And so, you know, be mindful and thoughtful. All right, thank you very much. Thank you.

post-POEM management

peroral endoscopic myotomy

discharge planning

acute pain management

diet after pollen

acid suppression

bleeding management