It's going to be endoscopic luminal cases. And we have three presenters, Philip Gee, who's coming from MD Anderson, and Dennis Yang from Florida, a Center for Interventional Endoscopy, and Amitabh Chak from Cleveland, from CASE. So if you guys want to come up, whatever order you've decided. So again, the way this works is we're just showing video. And ask questions, raise your hand, yell out, whatever you want to do. And let's just make this interactive. You guys are awake, right? Coffee? Do you need more? Yeah? No? We're awake. I guess I'll be first, since my slides popped up. So welcome, everybody. I'm Dennis Yang from Advent Health Orlando. And thanks, Ashley, for the introduction and the ASG. So just like Ashley said, please, the whole point is to make this interactive, to get feedback from you guys, and ask questions at any time. So let's see. How do I move the slides? OK, there we go. So just a little overview, since we're going to talk about poem, I figure I show this slide regarding the steps of poem procedure. So the procedure is an endoscopic procedure in which we make a mucosal incision in order to gain access to the submucosal space in the esophagus. Once we do this, we can dissect along the esophagus into the cardiac. The whole point of the procedure is to gain access to the muscle in order to do a myotomy for the management of esophageal motility disorders, such as achalasia. So with this in mind, let's start with our first case. We have a 74-year-old man with a 30-year-old history of progressive dysphagia. On endoscopy, the physician says there's a tortuous esophagus with a hypertensive lower esophageal sphincter. And if you can see from these CT images, he has a quite dilated esophagus filled with fluid. Anybody wants to comment on the shape of the esophagus? Yeah, so it's a sigmoid-shaped esophagus, right? So we know this has been going on for a while. The patient got a high-resolution manometry that showed elevated IRP, panesophageal pressurization, aparistalsis, incomplete bolus clearance, and the diagnosis was type 2 echalasia, and the patient is referred for a POM procedure. And this is what we see during the procedure. So again, you see a very dilated esophagus. There's fluid pulling. A lot of times, so this is the area I want you to pay attention to. So this is what I'm seeing when I first do the procedure. Any comments on that? Any thoughts about that? Huh? I heard something back there. So what do you see here? Is there anything abnormal? Is there anything that throws you off? What do you see? You get once. All right, so we see a stricture, right? So there's a clear stricture here at the LES. This is not mentioned by the referred physician in his endoscopy report, and so it's not mentioned anywhere. So obviously, this is not a patient. We know that there is esophageal dysmotility, but this is not a patient that you want to go right now and do a POM procedure, right? They have a concomitant problem, which is this esophageal stricture. We brought him in. We dilated him several times. It was quite refractory. I ended up, so a few years ago, we reported a study looking at the efficacy of, and this is off-label, of course, of axial stem for the management of esophageal strictures. In this particular case, I thought it would be helpful just because it was a very finite, short stricture. It actually worked pretty well. Those are the images of that patient. You can see on the far right how that stricture resolved. My thought was to treat the stricture first, see how his esophageal symptoms do. If there's still persistent dysphagia, LES obstruction, in spite of stricture management, then we can talk about POM. Yes? Did you biopsy or EUS the stricture? I did not EUS the stricture. Why would Philip ask that? To look for secondary causes, right? The patient did have esophageal biopsies. Those were normal, but we did not EUS. He did have the CT scan as well. Can I ask another question? With this concept of putting stents in, this off-label use, is there any long-term data on that? It looked good. You're happy. It is very tempting to put stents in thinking, if I just keep it open a really long time, will it work? We face this more with post-leak strictures and how to manage those, which are the hardest things ever. The question is, the stents make you feel good for a bit, but what's the long-term data on that? That's a great point. We often look at stents as the ultimate solution for the management of esophageal strictures. Unfortunately, the data is not that great. A lot of these strictures still tend to recur, especially long-term. That data for that study demonstrated was relatively short-term follow-up. Again, most of the time, these patients with short-term follow-up, they do fairly well. I generally don't look at stenting as my first option. This patient underwent dilation, I believe, four times. I was bringing them fairly frequently and just was not getting somewhere. I wanted to get a response just to see if his dysphagia improved with resolution of the stricture. Yes. Jennifer, yeah. This is a really nice case. I just wonder, if you had needed to do a poem after this, would the presence of the stricture or the multiple dilations or the presence of a stent had made that a more technically challenging procedure? I wouldn't have done it immediately after. If you saw from the initial procedure, even passing the scope, the mucosa just ripped because you're dilating that stricture. That's not a point where I would have considered doing the poem. I wanted to just leave it for a while, see how he does. If he still has symptoms, we'll reevaluate if the stricture resolved. If it resolved, I would be then checking to see if there's still a hypertensive LES. At that time, we can consider it. Now, having said that, this patient has a sigmoid esophagus. Even if they have outflow obstruction secondary to akalasia, their response rate is going to be significantly lower with poem or any type of myotomy. These are all things I discuss up front with the patient and make them aware. How long would you keep the stent in and what are the indicators that it's time to take the stent? Do you keep it weeks? Probably everybody does it a little bit different. I'm not talking about this type of stent. I'm talking generally a fully covered esophageal stent. I generally leave it anywhere between four to six weeks. I don't like to leave a whole lot longer than six weeks to start worrying about tissue overgrowth, but it'd be interesting to see if anybody does it differently, brings them earlier or later, but that's generally six weeks. True. My question is just for the LAMs because of the tissue engrossment, because I've seen a case actually in our situation that- Yeah. Sure. Remember. Yeah. Sorry. It was like a pyloric benign intrinsic stenosis of pylorus was placed at that outside. After, I think, six weeks, tissue embedded and we couldn't take it out, the patient ended up needing surgery. Of course, the dilation, the stent didn't help the structure as well. Right. Sure. Sure. Remember, pylorus, esophagus, a little bit different anatomical location and obviously duration of stent may be defined by that as well, but I don't want you to focus on the LAMs portion of that because that's, again, there's extremely limited data. I've heard of bad outcomes with LAM stents for esophageal strictures, including eroding into the aorta. This is not something we're trying to promote, it's just a particular point. Yeah. Let's stop. Yeah. That's not the focus of- The putting in of the stent is always the easy part, then you send it to your colleagues to take it out. That's the key. The take-home message of the case is mainly you want to rule out other causes of dysphagia. This patient was referred for POM procedure and they have achalasia, but there was a concomitant stricture and that's what needed to be managed before considering for POM. Yeah. I'll be the devil's advocate. Is it achalasia or is it EGJ outlet obstruction? Right. So- How do you tell? That's a great question. Whether it's achalasia or is that a secondary dilation from a stricture that's caused dilation and tortuosity- Right. So if you look at his- Is it type four, which is not going to respond to POM? And those are, I think we don't have obviously all the answers for that, but he's got this sigmoid shape esophagus. So this has been going on for a while. He's, as per the patient, he's undergone endoscopies before and was never detected to have any issues from that. So that tends to, I suspect that tends to fit a little bit more towards achalasia and perhaps in the setting of retention esophagitis, he may have developed a stricture. But again, those are all important things to tease out. So I'll quickly go over case two. This is a 79-year-old man with achalasia type three, had undergone helamyotomy with door fundoplication, had recurrence of symptoms just a year later. Those are his manometric findings and his esophogram. So I just wanted to use this case to basically show some portions of the procedure. One of the things you'll notice in a lot of these patients with achalasia is that when you're doing the endoscopy, they have this appearance of the esophagus and you see almost like a blanching of the mucosa of how tight this esophagus LES is. So again, when we do the PONE procedure, you can do either anterior approach or posterior approach tunnel. You probably have heard this before. There's no great data supporting that one is necessarily better than the other one. But in this particular case, we decided to go posteriorly because the patient had had a helamyotomy with a door fundoplication. When you're doing the mucosal incision to entry, this can be one of the most challenging parts in your initial training, and we'll practice this on the hands-on portion. But one of the key things is you need to dissect that submucosa around the mucosal incision. And this concept, we're going to be followed up, I'm sure, by Philip regarding ESD. Because if you don't clear that submucosa layer underneath that mucosal flap, you're not going to be able to create enough space to actually get your scope in. And then the tendency is always for beginners to keep cutting and making that incision bigger and bigger. But that's not the point, right? So if you clear that submucosa, you're going to be able to sneak the cap in, as you can see there. Once you're in the submucosal space, the first thing you want to do is start orienting yourself to where your landmarks are. And in this case, you want to dissect close to the muscle layer. Another teaching point in this part of the video, as you can see, we're encountering some vessels during our dissection, there's a penetrating vessel there. So you want to treat this, right? So you don't want to take your chance and then cause a bleeding, the blood in the tunnel, because it's a tunnel, it's going to stay there, it's going to stain your submucosa, and it's going to make subsequent portions of the procedure much more challenging. So again, once you've completed your tunnel, this was a long tunnel because this patient had type 3 akalasia, we're doing the myotomy. And as you can see there, we're just first kind of cutting that circular muscle under visualization. I tend to do a selective myotomy where I try to leave some of that longitudinal muscle initially behind. And then once you start getting to the LES and cardiac, you tend to do a full thickness myotomy just because those longitudinal muscles tend to split either way. And then, of course, the last portion of the procedure, which is perhaps one of the most important parts, is adequate closure of that initial mucosal incision. And I tell all the fellows that are trying with me is that that first clip is going to be setting the tone for your closure. So if you grab it and are able to kind of bring both sides of that mucosal incision equally together, it's going to allow and facilitate subsequent closure much easier. Always do under direct visualization, always oppose a clip where the middle of the clip is lining up with that incision so you know that when you close it, it's going to adequately grab both sides. So again, the purpose of this case was just to, again, discuss that there's three types of akalasia, right? So that's where the importance of manometry comes into play because it may help us tailor the type of procedure these patients need. Type 1, there's absent peristalsis. Type 2, that panesophageal pressurization. Type 3, that spastic type of contractions. There's data looking at POM. Recently this study looking at POM versus pneumatic dilation with patients after laparoscopic helomyotomy. As you can see, POM still seems to be a better, perhaps, long-term option for these patients. But response rate is significantly lower when compared to treatment-naive patients. This may have something to do with the underlying disease and not necessarily to the fact that they already had a helomyotomy. Can I ask a question? So when you're first learning this, do you feel like you first started out, you're doing ESD? Because all the techniques you guys can see are sort of ESD techniques, right? The submucosal injection and dissection and, I mean, sort of, you know, because you watch this and, you know, for me, when I first started seeing videos, like, how do you know where you are? It seems a little scary to me. I don't know. How many of you guys are going to learn POM? Uh-oh. How many of you want to learn POM? Okay. That's good. I was going to say, that concludes the part. Yeah, right. Exactly. I can't feel like we can go home now. But, okay, for those who want to do it, you know, is it something where you started doing ESD first and you kind of mastered those skills and then you felt like, all right, I can make a hole in the esophagus and go down and cut muscle and, you know, sort of scarier things? I think that's a great question and I think there's more than one way to approach how you do theraspace endoscopy training. My bias is training in POM is easier than doing ESD. Every single case of ESD is going to be a little bit different and we don't always encounter the easiest lesion to start with. But when you train in POM, you're also going to do it in a stepwise fashion. So right now with my fellows, my fellows are doing some of that submucosal tunneling. And why? Because you're in a confined space. You kind of have an idea where your different layers are as opposed to ESD where that can significantly change based on the lesion, based on the location of the organ. So for me, a POM, and then POM is a repetitive procedure, right? You have mucosal incision, tunneling, myotomy, closure. You keep doing these four steps. Now you don't want to start on a patient with a sick motor esophagus or post-halo myotomy but on your treatment, naive patient, younger patient, those are the initial procedures that you can start doing some tunneling that generally tends to be the easier portion and then advance from there. And you're going to see that the better you get at these steps, the better you're going to be at doing ESD. But again, that's my bias because that's how I train. And I thought it was a nice step-wise approach. I'm interested to see what Philip says about that later. So there are courses to learn POM, right? Yes. And, you know, how many do you think you needed to do? I think there's probably some early data on how many. Yeah. So the ESG provides a guideline in a lot of these procedures. And they say, you know, at least for ESD they'll say you need to do 10 plus animal models and then go into proctorships and so forth. There's data that's saying learning curve can be 30 POM cases. So I think everybody's going to be a little bit different. You do want to go attend to these courses, not only from the hands-on perspective like we're going to do today, but from the cognitive aspect of things. So I think sometimes we downplay the importance of the cognitive aspect of the procedure and put emphasis on the technical part. But you really can't do the technical part without the cognitive aspect. So going to a lot of these courses, listening to people talk about procedure is going to be very helpful. Then you start doing more and more hands-ons. And eventually you're going to start doing, hopefully if you have in the program where they do POM, start doing portions of the procedure and then eventually go into proctored procedures. So just a quick question, where does collaboration with surgery come in this, like especially for fellows that are starting off or starting off a new program? Yeah, you should. I think if you're starting a program in POM, you need to have a multidisciplinary approach, right? You don't want to be doing these procedures without having your cardiothoracic surgeon on board. You know in your early phases you want to avoid complications and you want to have controlled complications. So having that support is going to be important and buying from your motility group. Eventually you'll notice that you probably don't need their help for most of the time, but from a collaborative standpoint, it's going to be important. So how much time do I have left? Yeah, you can go for it. Huh? Go for it. You want me to stop here? Is there a long piece? No, I'll just show the video. So this is just basically to show that sometimes during procedures things can happen, right? In this particular case, the patient's abdomen started getting more distended. So what would be the first thing you want to think about if you're doing these type of procedures and their abdomen gets more distended? So what? Pneumoperitoneum. So, Tom, perforation, pneumoperitoneum. But the first thing's first. You could just be putting too much air into their stomach, so you want to go in and decompress. In cases where that's not happening and pneumoperitoneum can develop, you need to know how to do some of these things. So again, the teaching point is that, you know, not only should you learn how to do these procedures, but you need to learn how to manage complications, whether it's bleeding or pneumoperitoneum. In this particular patient, if you see her belly doesn't look too distended, but when we looked at her parameters, she was developing pneumoperitoneum. I didn't want the patient to be uncomfortable after the procedure, so we insert the various needle. This type of needle has a blunt end with a spring kind of needle. Once you find the abdominal cavity and you connect it to a syringe with fluid, you'll see the bubbling there, and that just tells you that you're adequately decompressing the patient. So again, this is just to show you that you need to understand how to manage these issues. It's not just about the procedure itself. I thought you were doing a liver biopsy today. Portal pressure measurements. And then just quickly about bleeding, which hopefully Phillip will elaborate on. This is another thing that's going to happen, right? For all these procedures, perhaps these are the most important things you need to learn how to do. Number one, don't panic. You see the bleeding happening. You need to think what you're going to do. We have a big vessel that's kind of bleeding right now, so what I'm going to do is put pressure towards the bleeding point with the cap, and then we're going to start filling it up with water in order to be able to actually identify the bleeding vessel. You'll see that that's really going to permit you to locate where that bleeding is coming from, and using the quad grasper, then you can grab that vessel and see if the bleeding has ceased. In this case, it has ceased, so we know we're on the right spot, and then proceed with the cautery. The tendency for people is to start burning without actually seeing the bleeder, and what that's going to cause is more charring, more bleeding, and everybody's going to start getting a little bit more anxious. So take your time, oppose the area, find the bleeder, and then treat it.

endoscopic luminal cases

per oral endoscopic myotomy

dysphagia

training process

complications management

collaboration with surgeons