Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me in this panel today is Dr. Kristen Wong, she's an assistant professor and foregut and bariatric surgeon; and Dr. Sergio Sanchez-Luna, he's an assistant professor, gastroenterologist, and an interventional endoscopist and they're both with UAB Medicine. They're here to highlight the program at UAB for per-oral endoscopic myotomy or POEM.

Doctors, thank you so much for joining us today. Dr. Sanchez-luna, I'd like to start with you. I'd like you to just kind of give a brief overview about achalasia and spastic esophageal disorders that don't respond to medical therapies, what the thought previously had been, why we are updating this topic.

Dr Sergio Sanchez-Luna: Hello, Melanie. Well, first of all, I'm so thankful to you for this very kind invitation. And I'm so honored as well to be here in the podcast with Kristen. So, I'm very excited to be here and just to talk a little bit about achalasia. So first of all, let's explain to our colleagues that this is a very rare disorder. It's not common, and it causes predominantly the symptoms of difficulty swallowing foods or liquids. And there is no cure for achalasia. That's important for patients and or providers to know about this, that there is no cure, but we have excellent treatments, which we will discuss in the podcast, on how we can manage those symptoms, make those symptoms better and eventually improve our patient's quality of life.

So basically, the thought process is that this a result of damage to the nerves that go into the esophagus, but also specific and we're getting a little bit into medical terms, but achalasia also leads to failure of the Lower esophageal sphincter to to relax. And this is accompanied a loss of peristalsis in the distal esophagus. So, I would say those are pretty much the landmark features of achalasia. And typically, that's what we see in clinic. And I would say, in a nutshell, that's what achalasia is, Melanie. Kristen if you would like to add anything to that?

Dr Kristen Wong: Yeah. Thanks, Sergio. And thanks, Melanie. I want to also reiterate, I appreciate the invitation for being invited. So, I would just add that achalasia is an interesting disorder because it is rare and, for that reason, it's often that these patients go undiagnosed for years. So oftentimes, patients will present with regurgitation, chest pain, weight loss, which can all be attributed to gastroesophageal reflux disease as well. So when people see these in the clinic, they automatically diagnose them with GERD. So oftentimes, they will come in having these symptoms for years already on PPIs, because that is kind of the reflex treatment for GERD. So, just to stress the importance of being on the lookout for our colleagues in the community of those cardinal symptoms, dysphagia, regurgitation, chest pain, weight loss, some people will even have recurrent aspiration pneumonia episodes from their regurgitation. So, just stressing the importance of having a high index of suspicion if you see somebody with those symptoms.

Melanie Cole (Host): Thank you both for that comprehensive overview. Then, Dr. Wong, how did you get started in ESD and POEM? Tell us a little bit about the POEM program at UAB Medicine and the surgeries you've completed so far.

Dr Kristen Wong: Sure. So, full disclosure, I started my practice in September. I recently graduated from fellowship from the University of Wisconsin. They have a great advanced endoscopy program there. And so, really what drew me to University of Alabama in Birmingham was opportunity to pair with Dr. Sergio Sanchez-Luna and develop this POEM program. So, the POEM procedure has been around, it was first performed by Dr. Inoue in Japan in 2008. Prior to that, the only surgical treatment we had for this was the laparoscopic Heller myotomy with Dor fundoplication, and that has been the gold standard. But once the POEM procedure was introduced, it's kind of taken the gastroenterology world by storm. And more and more surgical endoscopists are now doing the procedure as well. And so, we here at Alabama are trying to get this program off the ground. We do see a lot of referrals from the community for achalasia patients.

And so, we're going to go into a little bit, I think, about how we counsel these patients and how we make that decision. But Sergio and I are really working to get the word out across the state and the surrounding areas that POEM is being offered. And now, insurance also covers the POEM procedure. So, it's being recognized as a non-inferior treatment for achalasia in terms of comparison to the laparoscopic Heller myotomy. So, it's something that's been around. We have 10 years of data on it, and it's now a very accepted procedure.

Dr Sergio Sanchez-Luna: And you know, I think, Kristen, you do mention that this becomes sort of the standard of care in a lot of places. And this is no longer considered, and this is important for audience, Melanie, an experimental procedure. You know, because a lot of people, and even some insurance companies would still, although very rare you see this, would still consider this an experimental procedure. And it's no longer an experimental procedure, as Kristen was mentioning. You know, we have plenty of data, good quality data, suggesting that this is really a non-inferior treatment and that, typically, it's associated with a clinical success with greater than 90% with a very low risk of adverse event. So, I would say, this is no longer experimental. This has become sort of standard of care. And I would say this is here to stay.

Melanie Cole (Host): Well, Dr. Sanchez-Luna, then tell us what's involved in patient selection and why you might choose POEM over Heller myotomy. Compare and contrast a little bit and tell us the importance of really careful patient selection for these better outcomes.

Dr Sergio Sanchez-Luna: Before we go into offering any endoscopic procedure for the treatment of achalasia or any surgical intervention, first, we want to make sure that you're really diagnosing achalasia correctly. So, there are a lot of ways that we can evaluate a patient for achalasia. Patients typically, when they have the symptoms, the majority of them, they already had an endoscopy, typically have a barium esophagram, typically have a study called high resolution manometry, which also can classify the subtypes of achalasia because there are certain subtypes that, depending on the subtype of achalasia, patients have to undergo a multidisciplinary discussion, which we have here at UAB in regards to offer them the best treatment, just tailored to whatever subtype of achalasia they have. But I would say the order thing is we also have something called FLIP, which is also a procedure that evaluates for changes in the sensibility and volume of the lower esophageal sphincter that helped us also diagnose achalasia whenever high resolution manometry is not available, or whenever a patient cannot tolerate a high resolution manometry.

So, as Kristen was mentioning, it's very important to have an adequate diagnosis. A lot of peoples go undiagnosed for several years or decades, but it's also important, and I would emphasize this, to rule out pseudoachalasia. So, what's pseudoachalasia? It's our disorders that can present like achalasia, but they are not achalasia. And mainly, the thing we worry about the most are cancers of the gastroesophageal junction. So, certain types of cancers of that area can present as pseudoachalasia, and it's important to make sure there is a good quality, careful endoscopy in which we can document that there's indeed no evidence of a tumor or a growth, or an obstruction at that moment that maybe a cancer in that sense that this is not achalasia. We have to treat that. So that's important. But I would say, in the majority of centers, patients typically need to get an endoscopy, high resolution manometry or endoFLIP and a barium esophagram to also evaluate for parameters that are useful for us when we decide on either planning for a POEM procedure or to plan for laparoscopic Heller myotomy. You know, I'm not a surgeon, but I would defer to Kristen to see when do you decide to choose between a Heller myotomy with Dor fundoplication versus POEM. I would say in general it also involves a lot of the patient's choice. But I will pass this to you, Kristen. What are your thoughts about that?

Dr Kristen Wong: Sure. Thanks, Sergio. So, in terms of deciding who is a good candidate for which procedure, we have to talk about the outcomes. And so, all of the data we have is fairly new. Like I mentioned on the POEM procedure, we have 10 years of data. So, one study I do want to point out to our listeners is there's only one randomized controlled trial that compares POEM to laparoscopic Heller myotomy with a Dor fundoplication, and that's a New England Journal of Medicine article from 2019 where the primary outcome was clinical success as defined by a post-operative Eckardt score. So for those of you who don't know what an Eckardt score is, it's kind of our standard test for achalasia patients. It's a scoring system that the patients take based on dysphagia, regurgitation, chest pain and weight loss, so those cardinal symptoms.

So when they looked at both the POEM and the Heller, they found that 83% of people that had undergone a POEM with achalasia had clinical success, meaning an Eckardt scored less than three, and 81% had clinical success in the Heller myotomy. And those were considered similar or the same. So, the conclusion was that POEM was non-inferior to a lap Heller myotomy plus Dor in controlling symptoms at two years.

But the most important thing that I counsel my patients when they come in, is the biggest difference and the most discussed drawback that we talk about with POEM is the risk for reflux. So, that's both symptomatic reflux, so heartburn and chest pain, versus actual esophagitis or increased acid exposure in your esophagus. So, why do we care about that? Well, when we do a POEM procedure or a Heller myotomy, we are purposely breaking down one of those anatomical barriers for acid reflux. And with the POEM procedure, we don't then perform an anti-reflux procedure at the same time like we do with the Heller myotomy with the fundoplication. So, our head-to-head studies along with this randomized control trial, all show an increase in the subjective and objective measurements of GERD after a POEM, that is more significant than the Heller.

So for the most part, I counsel the patients on it's their decision, but I will tell them about the increased risk for post-POEM reflux, because approximately 20 to 30% of those patients post-POEM are taking PPIs. And so, that's something that they have to weigh for themselves. Otherwise, I also look at the contraindications to each procedure. So if they have a contraindication to a POEM, which would include prior therapy that compromises esophageal mucosal integrity, such as an endoscopic mucosal resection or an EMR or a radiofrequency ablation therapy to the mucosa for Barrett esophagus. Things like that would give me pause when offering a POEM to one of those patients. And then a Heller, so contraindications to a Heller include the inability to tolerate pneumoperitoneum during the procedure or, if they've had a previous surgery on their stomach, for example, a previous wrap or a gastric resection or something that would preclude me from doing a fundoplication, then I don't often offer a Heller because I don't think it would be advantageous.

Melanie Cole (Host): That was an excellent comprehensive assessment and overview, Dr. Wong. And thank you for telling us about the contraindications, because you got to my question before I got to it and especially if they've undergone previous endoscopic procedures. But I'd like you to tell other providers a little bit about the learning curve, since this is relatively new. What's involved in the preoperative evaluation? Talk a little bit about the procedure, the technique required, any of the barriers that you've encountered since you've begun the program and how you have overcome those.

Dr Kristen Wong: Sure. So, we can start with the actual technique for the POEM procedure. So again, it's a fully endoscopic approach. There's no incisions on the outside of the body. It involves creation of a mucosotomy around the mid-portion of the esophagus. Then, we're tunneling in the submucosal space, both on the esophageal side and onto the gastric side. Our goal is to get about eight to 10 centimeters on the esophageal side and about two to three centimeters on the gastric side. And then, we withdraw the scope and we go ahead and perform our myotomy. And people do that, either a myotomy of the circular layer muscle fibers, or both the circular and the longitudinal muscle fibers. And then, we go ahead and we close with endoscopic clips. And so, the advantage of this approach is obvious that you get a longer esophageal myotomy than you would with a Heller. And so, you also, in theory, get faster return to work and less postoperative pain because there's no incisions.

Barriers, there is a high learning curve with this procedure. And there's a lot of literature that's been published and there's a lot in terms of number of procedures performed and who is supervising them for these procedures. And so, coming in to here, I have probably done about, 20 to 30 procedures in fellowship. And since I've been here, probably performed at least 10 procedures. And I have two coming up this week. So as we build our practice here, Sergio and I, we share patients, we discuss complicated patients. And, so it's really a sharing of information. But I think that between both of us, we have the experience, probably one of the most experienced centers in the Southeast for sure.

Melanie Cole (Host): Dr. Sanchez-Luna, as we're getting ready to wrap up here, do you have some future perspective of POEM, any promising therapies? Where do you see this program going in the future? What would you like other providers to know about the program at UAB Medicine, why it's so important to refer their patients and what you hope will happen in the future with it?

Dr Sergio Sanchez-Luna: So, I would say the beauty about working at a place like UAB is just having the multidisciplinary support and the collegiality between the providers. So, for example, any procedure is not exempt from complications, so complications are likely to happen. And I think that's the beauty that when you're treated in a state-of-the-art place with state-of-the-art equipment, we're pretty much making sure that we have the best outcomes. But if for other reason, there is a complication or an adverse outcome, then we have all the available providers and technology to treat that as well. So, I would say that's the beauty about working at a place like UAB, where you literally have every piece of equipment needed, but not only equipment, but also you have colleagues that are exceptionally trained, Kristen, she's both also a surgeon and an endoscopist, so I think that's the beauty, that you also get to learn different perspectives from this disease.

So I would say, future implications, as Kristen was mentioning, I always tell my patients that reflux will likely happen after a POEM, but also we have recent data that also suggests that reflux that happens after POEM, typically, it's well managed with antireflux medications such as proton pump inhibitors or PPIs. Also overall, symptoms of heartburn, they tend to get better over time. So, I also think that the more we do this procedure, the better the outcomes are. And also, the more information we have to encourage patients to undergo a minimally invasive endoscopic option like Dr. Wong was saying, that also provides really good clinical outcomes and also, most importantly, improves their quality of life. These patients, a lot of them are pretty miserable. They've been dealing with this for years, even decades, and this significantly impacts their quality of life. They can't go out for dinner, because of the symptoms they're having. They cannot eat different options of food. So, I think overall this really has an impact on the quality of life. And I would say, I'm just so honored to contribute to the program and also offering this minimally invasive technique to them. So, I think that's the beauty about working at a place like UAB. Is there something else you would like to add, Kristen?

Dr Kristen Wong: I do want to support what you said and also state that it's just so exciting to be on the forefront of this technology. This is a relatively new procedure. And this technique is also being applied to other parts of the body. So, Dr. Sanchez-Luna and I now also offer this same submucosal tunneling and myotomy technique for patients with gastroparesis, for a pyloromyotomy. And so, we are again honored to be here at UAB, but also very excited to be with the forefront and being able to offer these minimally invasive surgeries to our patient population, so it's very exciting.

Melanie Cole (Host): Well, you both certainly are on the forefront in medicine. It's such an exciting time to be in your field. And this is such an interesting topic and an interesting procedure, and I look forward to seeing what the future holds for people with these types of esophageal disorders. So, I hope you'll both come back and update us anytime as the program moves forward. Thank you both for joining us.

And for more information about POEM or to refer a patient to UAB Medicine, you can call the MIST line at 1-800 UAB-MIST, or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.