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Updates in Endoscopic Interventions: A Look at POEM and ESD
Abdul Aziz Aadam, MD, offers new perspectives in two endoscopic treatments for gastroenterologic conditions: peroral endoscopic myotomy (POEM) for esophageal disorders not responding to medical therapies, and endoscopic submucosal dissection (ESD), an outpatient procedure to remove deep tumors from the gastrointestinal (GI) tract. He shares how POEM was developed based on both the already established surgical principles of esophageal myotomy and the advanced techniques of ESD and how this relates to its use in practice and outcomes.
Featured Speaker:
Abdul Aziz Aadam, MD, is an interventional gastroenterologist with specialized expertise in gastrointestinal oncology as well as complex pancreas and biliary disorders. He is part of a multidisciplinary team that incorporates the latest research and state-of-the-art technology into a patient-centered, comprehensive care plan. He is active in clinical research and has been invited to present his work at several national conferences. Dr. Aadam has undergone additional training to perform advanced endoscopic procedures such as endoscopic ultrasound (EUS), ERCP and stent placement within the GI tract. He is currently leading the initiative in endoscopic submucosal dissection (ESD). ESD allows for the removal of early cancers in the GI tract using a flexible endoscope as an alternative to invasive surgery in certain situations.
Abdul Aziz Aadam, MD
Abdul Aziz Aadam, MDAbdul Aziz Aadam, MD, is an interventional gastroenterologist with specialized expertise in gastrointestinal oncology as well as complex pancreas and biliary disorders. He is part of a multidisciplinary team that incorporates the latest research and state-of-the-art technology into a patient-centered, comprehensive care plan. He is active in clinical research and has been invited to present his work at several national conferences. Dr. Aadam has undergone additional training to perform advanced endoscopic procedures such as endoscopic ultrasound (EUS), ERCP and stent placement within the GI tract. He is currently leading the initiative in endoscopic submucosal dissection (ESD). ESD allows for the removal of early cancers in the GI tract using a flexible endoscope as an alternative to invasive surgery in certain situations.
Transcription:
Updates in Endoscopic Interventions: A Look at POEM and ESD
Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole, and I invite you to listen as we provide updates in endoscopic interventions. A look at peroral endoscopic myotomy or POEM and endoscopic submucosal dissection, or ESD. Joining me is Dr. Abdul Aziz Aadam. He's a Physician and Associate Professor of Medicine and Gastroenterology and Hepatology at Northwestern Medicine. Dr. Aadam, it's a pleasure to have you join us today. Tell us how you got started in ESD and POEM. Speak a little bit about your training. Tell us a little bit about yourself.
Abdul Aziz Aadam, MD (Guest): Well, thank you very much for having me. So, it's really interesting. So, about six years ago I started to hear about these procedures that were being performed predominantly in Japan. At that time I was trying to think of where I wanted my career to go, what kind of niche specialty I could find myself in. And I actually applied for a grant through our GI society, the ASGE and I was actually awarded a grant to go to Japan, to train in these procedures. So, I went to the National Cancer Center in Tokyo, Japan where I worked with some really fantastic physicians and kind of the godfather of colorectal ESD Yutaka Saito. It was really an eye opening experience as to really the innovation and what they had done. And it was just an eye-opening experience. And I was fortunate to bring those skills back to Northwestern. And shortly upon my return, we started our ESD program and from then it just really evolved into other what we call third space endoscopy procedures where we're really going beyond just the lumen of the GI tract and really in between the layers of the GI tract. And the third space is what we call the submucosa and where you're able to get your endoscope and accessories into the middle layers of the GI tract and essentially be able to remove tumors or perform other interventions like you might in POEM just through the endoscope.
Host: That's so interesting, your travels Doctor. So, then explain a little bit about esophageal achalasia and spastic esophageal disorders that are not responding to medical therapies and other conditions that these procedures might be used for, or even that you see could be used for in the future.
Dr. Aadam: Yeah, that's a great question. So, it's really an evolution of, you know, a surgery that was introduced over a hundred years ago, the Heller myotomy and around 2008 to 2010 researchers and physicians realized that these same kind of interventions could be done and endoluminally through the GI track. So, you know, specifically for achalasia, that's how this started. Instead of performing a myotomy surgically entering the chest, we're able to do this with an endoscope by making a small incision within the esophagus, creating a tunnel in the middle layers of the esophagus, exposing that muscle layer, and then performing that myotomy, which effectively releases that obstruction at the gastroesophageal junction and allows patients to relieve their dysphagia symptoms.
And this then evolved into other conditions such as gastroparesis, you know, patients who have very poor emptying of their stomach. We similarly created an incision into the stomach. We make an endoscopic tunnel and then we perform on myotomy of the pylorus. And that's gone even further. Now we're doing these interventions for Zenker's diverticulum really in the hypopharynx, a very small area, but again, we can create a tunnel. We can expose the diverticulum perform a myotomy there. We're also doing these for other situations like cricopharyngeal bars. So, as you can see, I mean, it has really evolved into the various kind of treatments that we do that would have been done surgically. And now it's just a transition in a more minimally invasive methods.
Host: We'll then speak about patient selection, Dr. Aadam. Who's a good candidate for either one of these procedures? I guess we're kind of going back and forth with them a little bit. Tell us a little bit about patient selection criteria.
Dr. Aadam: That's really interesting and that's really the crux of what we do and paramount kind of focus here is on a multi-disciplinary group and discussion. So, here at Northwestern at the Digestive Health Center we have Gastroenterologists and Surgeons who work together. We have Motility Specialists and our Dieticians, and our Behavioral Health Specialists and it's that multidisciplinary group that really decides, you know, what the best intervention is for the patient. I certainly don't make these decisions in a vacuum. When patients are referred to me, they're also typically seeing another Motility Specialist or another physician. And as a group, we determine, you know, what's the best intervention. For certain conditions, you know like achalasia, we want to make sure that the diagnosis is rock solid. Others, like gastroparesis we want to make sure that other medical interventions have been exhausted. We just want to make sure that we tailor the correct treatment for the right patient.
Host: Such an important point. And I'm glad you told us about the multidisciplinary team that reviews and treats the patients. So, how often are these procedures performed? Tell us a little bit about the volume that you see at Northwestern.
Dr. Aadam: So, the volumes you know have been steadily increasing over the years to the point where I block off my schedule for you know, a couple of hours every week, just so we can reserve appointments for patients. So, on average, we perform, you know, about five to six of these procedures typically in a month sometimes more. So I'd say, you know, in a year we probably perform about a hundred either ESD or POEM procedures.
Host: Now tell us some technological innovations that are aiding you in these procedures.
Dr. Aadam: So, there's been so much advancement in endoscopic accessories especially things like knives. Remember these are accessories that are passed through a very small channel in an endoscope. And we have water jets and injection solutions that really expand the submucosal layer and really enable a safe tunneling procedure. Closure devices have really evolved. We're able to do endoscopic suturing. As you can imagine, these procedures do have increased risks associated. If we get into a situation where we encounter a perforation, for example, the overwhelming majority of those can be closed endoscopically. The other innovations, you know, specifically around motility disorders is endoflip. Endoflip is a procedure where we have a balloon catheter that we fill with water, and we can measure the distensability of areas like the gastroesophageal junction or the pylorus of the stomach. And we use this in real time to actually determine how much our myotomy has really been able to expand the GE junction and what kind of effect we're getting on distensibility. We're not just eyeballing this anymore. It's really, measure twice, cut once kind of phenomenon. And we're using this because we want to be able to do the right amount of cutting. We don't want to cut too little. We don't want to cut too much. So, we're trying to get it just right. So, these are the innovations that have really evolved, and these are the things that we're studying at Northwestern to see how we can really impact these procedures and innovate further.
Host: Isn't that amazing, what you're describing, the technology, the innovations? It's just really fascinating. So Northwestern Medicine really has extensive on-site expertise, technology, facilities, research. You've been talking about a bit of this. Elaborate a little, and please tell us about this learning curve, since these are relatively new and you spoke about Heller myotomy, tell us a little bit about the learning curve and what you'd like other providers to know about the expertise at Northwestern Medicine. What sets you apart for ESD and POEM?
Dr. Aadam: So there is a big learning curve. And you know proper training plays a big role in that. Proper patient selection really makes sure that, you know, you're performing these procedures on the patients who are going to benefit the most and not encounter rather difficult situations. And again, it's that multidisciplinary discussion that really kind of helps evolve this further, because it's not just about performing the procedure and it's a one and done sort of thing. There's a lot of post-procedure management. There's a lot of decision-making that goes on around early cancer, for example, how we're going to manage these patients, you know, going forward, do they need additional therapies? And that sort of thing. So, it's all done in this multidisciplinary setting. And I think that's really where our expertise collectively provides the best outcomes for the patient.
Host: And before we wrap up, tell us about any ongoing research that supporting the development of your program Doctor, and really anything you'd like to let other providers know, and when you feel it's important they refer to the specialists at Northwestern Medicine.
Dr. Aadam: So, some of our research specifically is focusing on identifying when we perform these POEM procedures. For example, what's the correct length of myotomy. Can we do these procedures with shorter myotomies so we preserve some more of the esophageal function. Other things that we're looking at are healthcare, economics around these procedures. Like you mentioned, these are new, these aren't reimbursed by third party payers readily. So, we want to establish the fact that these procedures can be done minimally invasively. They're typically done on an outpatient basis. So, there's a lot of health care economics, and we're really studying that to show its impact and try to advance these procedures forward specifically in the United States.
Host: Thank you Doctor for joining us today. What a fascinating topic. Thank you so much for sharing your expertise. To refer your patient or for more information, please visit our website@nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please also remember to subscribe, rate and review this podcast and all the other Northwestern Medicine Podcasts. I'm Melanie Cole.
Updates in Endoscopic Interventions: A Look at POEM and ESD
Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole, and I invite you to listen as we provide updates in endoscopic interventions. A look at peroral endoscopic myotomy or POEM and endoscopic submucosal dissection, or ESD. Joining me is Dr. Abdul Aziz Aadam. He's a Physician and Associate Professor of Medicine and Gastroenterology and Hepatology at Northwestern Medicine. Dr. Aadam, it's a pleasure to have you join us today. Tell us how you got started in ESD and POEM. Speak a little bit about your training. Tell us a little bit about yourself.
Abdul Aziz Aadam, MD (Guest): Well, thank you very much for having me. So, it's really interesting. So, about six years ago I started to hear about these procedures that were being performed predominantly in Japan. At that time I was trying to think of where I wanted my career to go, what kind of niche specialty I could find myself in. And I actually applied for a grant through our GI society, the ASGE and I was actually awarded a grant to go to Japan, to train in these procedures. So, I went to the National Cancer Center in Tokyo, Japan where I worked with some really fantastic physicians and kind of the godfather of colorectal ESD Yutaka Saito. It was really an eye opening experience as to really the innovation and what they had done. And it was just an eye-opening experience. And I was fortunate to bring those skills back to Northwestern. And shortly upon my return, we started our ESD program and from then it just really evolved into other what we call third space endoscopy procedures where we're really going beyond just the lumen of the GI tract and really in between the layers of the GI tract. And the third space is what we call the submucosa and where you're able to get your endoscope and accessories into the middle layers of the GI tract and essentially be able to remove tumors or perform other interventions like you might in POEM just through the endoscope.
Host: That's so interesting, your travels Doctor. So, then explain a little bit about esophageal achalasia and spastic esophageal disorders that are not responding to medical therapies and other conditions that these procedures might be used for, or even that you see could be used for in the future.
Dr. Aadam: Yeah, that's a great question. So, it's really an evolution of, you know, a surgery that was introduced over a hundred years ago, the Heller myotomy and around 2008 to 2010 researchers and physicians realized that these same kind of interventions could be done and endoluminally through the GI track. So, you know, specifically for achalasia, that's how this started. Instead of performing a myotomy surgically entering the chest, we're able to do this with an endoscope by making a small incision within the esophagus, creating a tunnel in the middle layers of the esophagus, exposing that muscle layer, and then performing that myotomy, which effectively releases that obstruction at the gastroesophageal junction and allows patients to relieve their dysphagia symptoms.
And this then evolved into other conditions such as gastroparesis, you know, patients who have very poor emptying of their stomach. We similarly created an incision into the stomach. We make an endoscopic tunnel and then we perform on myotomy of the pylorus. And that's gone even further. Now we're doing these interventions for Zenker's diverticulum really in the hypopharynx, a very small area, but again, we can create a tunnel. We can expose the diverticulum perform a myotomy there. We're also doing these for other situations like cricopharyngeal bars. So, as you can see, I mean, it has really evolved into the various kind of treatments that we do that would have been done surgically. And now it's just a transition in a more minimally invasive methods.
Host: We'll then speak about patient selection, Dr. Aadam. Who's a good candidate for either one of these procedures? I guess we're kind of going back and forth with them a little bit. Tell us a little bit about patient selection criteria.
Dr. Aadam: That's really interesting and that's really the crux of what we do and paramount kind of focus here is on a multi-disciplinary group and discussion. So, here at Northwestern at the Digestive Health Center we have Gastroenterologists and Surgeons who work together. We have Motility Specialists and our Dieticians, and our Behavioral Health Specialists and it's that multidisciplinary group that really decides, you know, what the best intervention is for the patient. I certainly don't make these decisions in a vacuum. When patients are referred to me, they're also typically seeing another Motility Specialist or another physician. And as a group, we determine, you know, what's the best intervention. For certain conditions, you know like achalasia, we want to make sure that the diagnosis is rock solid. Others, like gastroparesis we want to make sure that other medical interventions have been exhausted. We just want to make sure that we tailor the correct treatment for the right patient.
Host: Such an important point. And I'm glad you told us about the multidisciplinary team that reviews and treats the patients. So, how often are these procedures performed? Tell us a little bit about the volume that you see at Northwestern.
Dr. Aadam: So, the volumes you know have been steadily increasing over the years to the point where I block off my schedule for you know, a couple of hours every week, just so we can reserve appointments for patients. So, on average, we perform, you know, about five to six of these procedures typically in a month sometimes more. So I'd say, you know, in a year we probably perform about a hundred either ESD or POEM procedures.
Host: Now tell us some technological innovations that are aiding you in these procedures.
Dr. Aadam: So, there's been so much advancement in endoscopic accessories especially things like knives. Remember these are accessories that are passed through a very small channel in an endoscope. And we have water jets and injection solutions that really expand the submucosal layer and really enable a safe tunneling procedure. Closure devices have really evolved. We're able to do endoscopic suturing. As you can imagine, these procedures do have increased risks associated. If we get into a situation where we encounter a perforation, for example, the overwhelming majority of those can be closed endoscopically. The other innovations, you know, specifically around motility disorders is endoflip. Endoflip is a procedure where we have a balloon catheter that we fill with water, and we can measure the distensability of areas like the gastroesophageal junction or the pylorus of the stomach. And we use this in real time to actually determine how much our myotomy has really been able to expand the GE junction and what kind of effect we're getting on distensibility. We're not just eyeballing this anymore. It's really, measure twice, cut once kind of phenomenon. And we're using this because we want to be able to do the right amount of cutting. We don't want to cut too little. We don't want to cut too much. So, we're trying to get it just right. So, these are the innovations that have really evolved, and these are the things that we're studying at Northwestern to see how we can really impact these procedures and innovate further.
Host: Isn't that amazing, what you're describing, the technology, the innovations? It's just really fascinating. So Northwestern Medicine really has extensive on-site expertise, technology, facilities, research. You've been talking about a bit of this. Elaborate a little, and please tell us about this learning curve, since these are relatively new and you spoke about Heller myotomy, tell us a little bit about the learning curve and what you'd like other providers to know about the expertise at Northwestern Medicine. What sets you apart for ESD and POEM?
Dr. Aadam: So there is a big learning curve. And you know proper training plays a big role in that. Proper patient selection really makes sure that, you know, you're performing these procedures on the patients who are going to benefit the most and not encounter rather difficult situations. And again, it's that multidisciplinary discussion that really kind of helps evolve this further, because it's not just about performing the procedure and it's a one and done sort of thing. There's a lot of post-procedure management. There's a lot of decision-making that goes on around early cancer, for example, how we're going to manage these patients, you know, going forward, do they need additional therapies? And that sort of thing. So, it's all done in this multidisciplinary setting. And I think that's really where our expertise collectively provides the best outcomes for the patient.
Host: And before we wrap up, tell us about any ongoing research that supporting the development of your program Doctor, and really anything you'd like to let other providers know, and when you feel it's important they refer to the specialists at Northwestern Medicine.
Dr. Aadam: So, some of our research specifically is focusing on identifying when we perform these POEM procedures. For example, what's the correct length of myotomy. Can we do these procedures with shorter myotomies so we preserve some more of the esophageal function. Other things that we're looking at are healthcare, economics around these procedures. Like you mentioned, these are new, these aren't reimbursed by third party payers readily. So, we want to establish the fact that these procedures can be done minimally invasively. They're typically done on an outpatient basis. So, there's a lot of health care economics, and we're really studying that to show its impact and try to advance these procedures forward specifically in the United States.
Host: Thank you Doctor for joining us today. What a fascinating topic. Thank you so much for sharing your expertise. To refer your patient or for more information, please visit our website@nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please also remember to subscribe, rate and review this podcast and all the other Northwestern Medicine Podcasts. I'm Melanie Cole.