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Melanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Welcome. In this panel discussion today, we’re examining how peroral endoscopic myotomy POEM has emerged as a viable alternative that can be performed in an incisionless endoscopic fashion. My guests are Dr. Jayleen Grams. She’s an Associate Professor and a minimally invasive foregut surgeon and Dr. Kondal Kyanam. He’s a gastroenterologist and they are both at UAB Medicine. Doctors thank you for joining me today. Dr. Grams, I’d like to start with you. Explain a little bit about achalasia and spastic esophageal disorders not responding to medical therapies.

Jayleen Grams, MD (Guest): Well achalasia is a primary esophageal dysmotility disorder and like other disorders, it may be a secondary disorder that is not intrinsic to the esophagus itself. And in achalasia, patients have difficulty swallowing. They have dysphagia or inability to push food down their esophagus into their stomach. We don’t know exactly what causes achalasia, but as you mentioned; there are three types of achalasia, type I, type II and type III. Type III is spastic achalasia. The other type, type I is aperistalsis and type II is pan-pressurization.

And surgery can be a primary modality of treatment for achalasia. Dr. Kyanam can probably mention the endoscopic or other gastroenterology procedures, better endoscopic procedures like dilation and Botox, but we are consulted when people need a Heller myotomy of the traditional surgical therapy for achalasia.

Kondal Kyanam, MD (Guest): And I’d like to add achalasia is basically like Dr. Grams was talking about, a disorder of what we call motility. So, it’s either empiric motility either decreased or absent so the esophagus is not propelling food into the stomach and this is unfortunately also combined with the failure of the lower sphincter to relax so the patient is not able to propel food number one and this food can get kind of stuck in the esophagus because the sphincter that protects to esophagus from the stomach doesn’t relax. And very often this results in a sensation of not being able to swallow, it is a chronic problem and then eventually gets to the attention of either a gastroenterologist or a surgeon and often we do what’s called endoscopy to evaluate the achalasia and to characterize it and then we do other tests called manometry which is measurement of pressure in the muscle layer and valve to try to figure out exactly what kind it is. So, these are all steps we would usually do before we figure out what’s the best treatment option for it.

Host: Dr. Kyanam, how has this previously been treated? And Dr. Grams mentioned the Heller myotomy. Tell us a little bit about the history of POEM and Heller myotomy and what’s different now. Why the needs?

Dr. Kyanam: So, achalasia has been traditionally quite a difficult condition to treat. Whenever we think of treatment options, we have to think of two different things and what’s the problem that we are treating and also what kind of patient has that problem. So, you have a wide variety of patients. You have young ones who are otherwise healthy and then you have older patients who have multiple medical problems like potentially a heart issue and lung issues which kind of dictate or guide us towards what treatment we can do for that.

So, the traditional treatments include like Dr. Grams mentioned, the Heller myotomy which is a surgery, but any surgical procedure obviously are concerns for cardiac issues and lung issues and the overall health of the patient. It is something we take into mind because the risks of surgery increase when they have issue with their heart or lungs. So, there are some options that we used to use. Endoscopically, one of those is an injection into the lower valve to relax it and another one is stretching it with a balloon to rupture the muscle and to stretch that area.

Both of these are effective, but they are really not long-term. They are not effective in every patient we perform it in, and the percentages of success are low and not really acceptable in this day and age. But we still continue to use these in select situations. So, this brought about the idea to some endoscopists or advanced endoscopists are people who train to perform endoscopy at a very high level of accomplishment to try to get things done that would otherwise be done surgically.

So, we came up with this thought of trying to expose the muscle fibers in the wall of the esophagus to cut them. This is what we do with the Heller myotomy, but innovators figured out that you could do this from the inside too. So, you cut the esophagus, make what we call a tunnel in the wall of the esophagus, expose the muscle layers and then carefully cut these muscle layers all the way to the extent that we think is necessary, essentially doing what we would do in the surgery but really not performing the surgery by making an incision. And then this tunnel is made through a smaller opening and once we think we have achieved what we need to separate the muscle layers, we then close the small incision in the esophagus and then come out from the mouth. So, essentially, we’ve done what was done through a Heller myotomy, but we’ve accomplished it through a small opening in the esophagus using an endoscope.

And when they first figured this out and carefully did this in the first few patients, they found that they were able to achieve very good success rates with very few complications thereby expanding this procedure to a large number of patients and potentially avoiding the complexity of an open surgery or laparoscopic surgery. And this innovation then got accepted in various different patient populations and countries. We figured out how much training would be required for this to be done, what kind of set ups were required and what to expect among the many, many countries including the United States. And it usually is done in large academic centers where we have the skills and the back up required to do this and that’s how POEM came into being.

And then once they figured out that this could be used for achalasia, they also figured out that this might be something that’s effective for other types of esophageal motility disorders using the same principles of exposing the muscles and cutting them to give relief to the symptoms that the patient has.

Dr. Grams: I would like to add in addition to what Dr. Kyanam said is that really POEM was kind of this evolution. As surgeons, we used to start doing these Heller myotomies through the chest and then as technology things advanced with laparoscopy, that is minimally invasive surgery in the abdominal cavity, we started being able to do these Heller myotomies with an abdominal approach. But it was still transabdominal, that is making these incisions on the abdominal wall. And basically, what a Heller myotomy is, cutting the muscle from outside the esophagus versus POEM which is endoluminal or from within the inside of the esophagus. And I always tell patients, there’s nothing we can do to make the esophagus work again. So, really the goal is to cut the lower esophageal sphincter and cut the muscle up on the esophagus and down on the stomach so the esophagus can drain better by gravity. And that’s what we are doing with the Heller myotomy.

The other part of the Heller myotomy is usually also doing a partial fundoplication or a partial wrap. That’s because swallowing problems or dysphagia and reflux can be opposite sides of the same coin where anything you do to help the esophagus drain better by gravity, may promote things coming back out of the stomach into the esophagus.

The other thing I wanted to mention is the person who pioneered POEM is Dr. Inoue in Japan and he did his first case in 2008 and then it rapidly spread from there. But I do think we should shout out Dr. Inoue because he really was the pioneer of this procedure and the first one to perform it.

And then the last thing I wanted to add was that one difference is that with the POEM because it’s all endoluminal and endoscopic right now; we don’t do any kind of concomitant anti-reflux or partial wrap or anything like that, although I think Dr. Inoue may be working on that now.

Host: Dr. Grams tell us what’s involved in patient selection criteria. Who is a good candidate for this procedure and why might you choose POEM over the Heller myotomy. Compare and contrast a little for us.

Dr. Grams: Patient selection for both POEM and Heller myotomy would really be the same in terms of someone who is fit to undergo an operation, someone who has been determined to have achalasia and someone who is symptomatic and needs treatment, just to simplify things. I usually offer either procedure to patients. For some patients who have severe morbid obesity, where visualization in the abdominal cavity might be difficult; might be better for POEM.

Other things would be if a patient has had multiple previous operations and we would expect something that we call a hostile abdomen that is a very difficult abdomen to get into safely, requiring a lot of adhesiolysis to get to the area of concern. Some people are doing POEM now for redo myotomies. So, people who have had a previous Heller myotomy going back into these patients can be very challenging and if you do an endoscopic myotomy; potentially can go into a plane that no one has been before and complete the myotomy.

The last big category would be type III achalasia. All types of achalasia have varying responses to Heller myotomy and POEM and it seems that type III achalasia or spastic achalasia may be best suited for a POEM over Heller myotomy.

Host: And Dr. Kyanam, are there some concerns as she was mentioning if they’ve undergone pervious endoscopic procedures? Tell us a little bit about the learning curve since this is relatively new and what you might consider as contraindications.

Dr. Kyanam: Sure. The learning curve is being worked on still but there is some evidence that suggests that first 20-30 cases should be mentored with someone who is experienced and then when you hit about number 50, is when we see that most people are able to perform it in an efficient and smooth fashion and quick time and have the least number of complications.

So, it is something that requires advanced endoscopy training so you would have a gastroenterologist who has done three years of training or a surgeon who has done a surgery and also a specialty called GI surgery and for gastroenterologists, they also generally do an extra year of fellowship called advanced endoscopy fellowship. So, you do get a lot of endoscopic skill training during these training years but there is almost always a specialized training for POEM that we achieve by going to various live animal courses and to other courses where we see experts who are already performing these procedures and they walk us through the various steps and then we get our hands on animal models and then live animal models and to produce the procedure.

They found that this system of a gradational training has been quite effective in getting people to where they can perform POEM effectively and that’s kind of the accepted way to do it now.

Criteria are still being established in granular detail. But we have a general approach on what we can do to achieve competence in performing POEM.

Host: Dr. Grams, how have your outcomes been?

Dr. Grams: So, far we are very early in our experience and so, I think the last two patients I did have been doing great. I’ve seen them both in follow up and they are very happy and have had relief of their dysphagia and neither of them required any pain medication while they were in the hospital. One of them had driven down to the beach already the Saturday after she had her operation on Thursday. So, they are doing very well. Thank you for asking.

Host: Well thank you both for telling us all about that. So, Dr. Kyanam, first last word to you. Give us a future perspective of POEM. Tell us some promising new therapies or where do you see this going in the future?

Dr. Kyanam: So, I think POEM is a revolutionary new procedure, that has just been available in the past decade and maybe for the past five or seven years, really extensively in America. I’m very excited about the future options the patients have with this procedure. It’s always important to note that choice in important. Obviously, a Heller myotomy is a very well established procedure that’s had great success over many, many years and thousands of patients.

So, I think that is always going to be something that’s available as an option for treatment of achalasia but this new innovative alternative, which is less invasive, is nonsurgical, happens through a small incision inside the esophagus obviously has a lot of appeal and has shown so far, to have very promising results that are comparable to what we’ve been doing so far. And the other exciting aspect of it is that it is somewhat more flexible. Like Dr. Grams was pointing out, we can do it in patients who had other procedures that have failed in providing them relief. We are now also able to expand this to some other indications other than achalasia where we have hypermotility disorders meaning a very vigorous contraction of the esophagus and we see early results that this is effective for that condition too.

But I do think this is a highly specialized procedure that needs to be done by a very well-trained physician and I do think this is going to be restricted to universities and will always be done in somewhat of a multidisciplinary fashion where we have a discussion about the patient even before we do the procedure about all the results and tests we do and we decide what options are best for them as a group and individual physicians then will want to help the patient. But we always have each other as a team member on standby to get this accomplished for our patients.

Dr. Grams: I would also like to add that I think in general, if you look back decades, we’ve moved from open operations to laparoscopic operations or minimally invasive approaches either with the laparoscope or with the robot. And over the next decades we are going to see things get even more minimally invasive that is more endoscopic procedures for other indications as well. And so, I think this is really a natural evolution in the treatment of achalasia to go from big open operations to the minimally invasive laparoscopic approach and now in an endoscopic approach.

Host: Then Dr. Grams, as we wrap up, please tell other physicians what you’d like them to know about achalasia, POEM, and when you feel it’s important to refer, how this can help them to be reassured with this new procedure. That this is the right option for their patients.

Dr. Grams: I think the number one thing I would like to tell referring physicians is if you have a patient who has swallowing problems and you suspect achalasia; they need to be referred to a tertiary care center. Achalasia happens in one in a 100,000 patients so it is not something that happens commonly. The second thing with achalasia is it’s really important to distinguish it from pseudoachalasia. We see patients who are referred to us for achalasia but on further evaluation, they actually have pseudoachalasia, specifically a mass or esophageal cancer that is causing a picture that looks like achalasia and a Heller myotomy or a POEM would not be the treatment for esophageal adenocarcinoma.

And so if you have a patient you suspect of having achalasia, I would refer them to a tertiary or quaternary care center. In terms of differentiating between a POEM or a Heller myotomy, I agree with Dr. Kyanam completely that this needs to be done in a multidisciplinary way with gastroenterologists. We have a conference where we meet with gastroenterologists, radiologists, thoracic surgeons, and of course us with GI surgery and we talk about these patients and what potentially would be the best intervention for them.

For some patients, they can be offer either procedure but for some patients, one or the other or neither may be the best option for them. And that really needs to be determined with a multidisciplinary team as well as with the input from the patient.

Host: Wow, what a fascinating topic. What an interesting procedure and we look forward to seeing what the future holds for people with these types of esophageal disorders. Thank you both for joining us.

A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, head on over to our website at www.uabmedicine.org/physician for more information and to get connected with one of our providers. This is Melanie Cole.