This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and SuTab. Hi, I'm Krishna Guram. I'm the Assistant Professor of Medicine at Icahn School of Medicine at Mount Sinai, Director of Endoscopy at Elmhurst Hospital in Queens, New York. Today, we're going to discuss about stage 3 sigmoid type achalasia type 1 and the POEM procedure we do. I have no conflicts of interest. Achalasia occurs in 1 in 200,000 patients and a prevalence of 1 in 10,000. Although not as common, because of the advent of POEM procedure, it's being referred to the advanced endoscopies more often. Type 1 achalasia has a two-year clinical success, postponed by 83%. In stage 3 sigmoid achalasia, or end stage, the outcomes can be even worse, and for the longest time, esophagectomy was recommended. But over the last 20 years, laparoscopic hellers and POEM have gained significant traction. A study was conducted looking at POEM procedure for sigmoid type of achalasia versus straight type of achalasia. 16 patients were included in the sigmoid esophagus, and it showed a significant improvement in the ACCERT score, as well as the angulation of the esophagus, demonstrating that POEM can be utilized before going to heller myotomy or esophagectomy, as there's been good outcomes. The 68-year-old female with afib and xerolatone hypothyroidism, who has been suffering from dysphagia for 10 years, presented again with a partial food infection and dysphagia. Her ACCERT score was 6, with highest being in chest pain and weight loss. A CT scan was subsequently performed, demonstrating debris in the esophagus and mural thickening. EGD was performed, and large amounts of food and debris was suctioned, with significant dilation of the esophagus. A high-resolution manometry was performed, demonstrating an IRP of 28.6, when normal is less than 11, with 100% of swallows being apariscalptic. This was consistent with type 1 achalasia. A bariomesophagram was performed, and the black arrow demonstrates the height of the column of the contrast, and the white is the area of the bird's beak appearance. This imaging is very classical for the bird's beak appearance, and the blue area is where we start the incision for the poem procedure. We demonstrate a case of type 1 achalasia with grade 3 sequent esophagus, undergoing a poem procedure. Since the patient did undergo a bariomesophagram recently, there was still significant retention of barium throughout the esophagus. Excessive fluid was used to irrigate and suction the barium from the esophagus. Our fluid is mixed with 80 milligrams of gentamicin, as in the old notes procedures, to decrease the infectivity risk. As we start at the GE junction and come back, you can see the significant bogginess of the esophagus, due to retention of fluid for a long time. The tortuosity of the esophagus and significant dilated esophagus, which is more than six centimeters in size when fully distended. The GE junction is also very tight, as you can see from achalasia, and we used water and sufflation to slowly maneuver the area to get past the GE junction and to pop into the stomach. We injected about six centimeters above the GE junction and started using the Irby hybrid knife to start the incision. Once the initial incision is done, we try to get our cap into the center and try to lift the submucosal area, as it is easy to get into the muscle layer in this area, especially with fibrosis. We're injecting as we're cutting through the area to open up the submucosal tunnel. Once we get into the tunnel, we put a pink tape on our scope and mark it in the direction where we want to go to prevent us from spiraling in the esophagus. If we feel like we are spiraling, we use that line to get back into a straight trajectory. Once we get into the submucosal layer, we try to tunnel. We inject the submucosal layer and cut it into the left and right side to make it a wide tunnel. It is important to know the orientation of the anterior or posterior pulm is being done, keeping the muscle layer oriented in that direction. In this situation, it's a posterior pulm, and at 5 to 6 o'clock is the muscle, and the mucosa is at 12 to 11 o'clock. Kind of dissect out carefully to prevent any mucosodomies. Once we get into the GE junction area, there's a significant narrowing that occurs. You have to be very careful not to cause mucosodomies. We have to slowly inject, and if bleeding does occur, we need to coagulate in the same area to prevent other mucosodomies or perforations. Once the coagulation and the bleeding has stopped, we continue to proceed forward with injection, dissection, injection, dissection. Once we pass the GE junction, there's a significant opening up of this narrowed area, and that tells us we're in the gastric portion of the submucosal layer and tunnel. We usually use normal saline irrigation for better visualization of the area, but even though it's better than water, the coagulation and cutting is still not as good as when it's dry cut. We usually dissect about 3 to 4 centimeters in the gastric sides to have at least 2 centimeters of myotomy. When we do see blood vessels, we do soft coagulation to truly coagulate the vessel to prevent it from bleeding. This is a great example of an artery being coagulated and no bleeding present. When we start doing dissection, we usually start from the distal end and work ourselves more proximal. We initially inject and try to coagulate and cut afterwards the muscle. This helps in separating out the circular muscles versus the long-toed muscles. Here's our practice to do a full thickness resection right at the GE junction and try to do more circular muscles as we get more proximal. Even after you coagulate end cuts, sometimes bleeding can occur, and if it does occur, recommend that you coagulate right in that position without moving. Sometimes a coagulation can stop the bleeding without any further therapy. Once the dissection is done, usually two centimeters in the gastric area and three centimeters in the esophageal area, you come out into the esophageal lumen and slowly proceed to the GE junction. Once we get to the GE junction, we notice that it's very simple to push into the stomach. That tells us we did a good complete myotomy. We then come back to the incision area and close this up with either sutures or clips. One month post-poem, patient had an ECHR score of 0 and was put on 5 pounds. A barium esophagram shows significant opening of the bird's beak, almost like a duck's beak now. It's important to remember even in stage 3 sigmoid akalasia, there's good clinical response and success with poem procedures. Avoid doing poem at least a few days after barium esophagram, otherwise, it takes a long time to clean up the esophagus. Recommend marking on the scope at the start of a tunneling to prevent spiraling in the esophagus. Do a short tunnel on myotomy even in sigmoid esophagus rather than a long tunnel as there's increased chance of spiraling and more time to finish a procedure. With the advent of poem, even in sigmoid akalasia, it is extremely rare to send for any surgical therapy.

Dr. Krishna Guram

POEM procedure

achalasia

endoscopy advancements

sigmoid achalasia