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Per Oral Endoscopic Surgery at Penn GI

 

Fig 1 Esophograph
Barium esophagram in achalasia. Note esophageal dilatation and stenosis of the cardiac region of the esophagus with delayed evacuation of the barium meal.
Gregory G. Ginsberg, MD, FACS, recently performed the 1500th Peroral Endoscopic Myotomy (POEM) procedure at Penn Medicine to treat esophageal achalasia.

A Professor of Surgery at the Perelman School of Medicine and Director of Endoscopic Services at Penn Medicine, Dr. Ginsberg is the former President of the American Society for Gastrointestinal Endoscopy, an organization that in May 2019 awarded him its top honor, the Rudolf V. Schindler Award, in recognition of monumental achievement in endoscopy.

What is Achalasia?

Achalasia is an uncommon, idiopathic motility disorder that manifests as absent or aberrant peristalsis and incomplete relaxation of the lower esophageal sphincter (LES). Peristalsis is characterized by irregular, unsynchronized contractions of the esophageal muscles that propel the food bolus forward toward the stomach. Achalasia is caused by damage to the motor nerves of the esophagus.

“Achalasia results not only in difficulty with swallowing, but prolonged retention of content in the esophagus,” Dr. Ginsberg explained in a recent interview. Achalasia patients, he continued, often experience chest pain and regurgitation after meals—symptoms that lead to a hesitancy to eat. “These patients also experience profound weight loss and anxiety about the cause of their distress.”

While achalasia is considered rare, Dr. Ginsberg notes, “A large number of patients are referred to Penn for achalasia because we have long been a center of expertise for esophageal disorders.”

How is Achalasia Diagnosed?

Diagnosis of achalasia is generally based on a barium swallow esophagram to examine the structures of upper gastrointestinal tract, and by esophageal manometry to measure the rhythmic muscle contractions in the esophagus while swallowing, including the coordination and force exerted by the esophagus muscles, and how well the lower esophageal sphincter relaxes or opens during a swallow.

Achalasia Treatment

The standard surgical approach to achalasia is laparoscopic multi-port Heller myotomy (LHM), a modification of an open surgicasl procedure first performed more than 100 years ago.

Alternatives to surgery for the treatment of achalasia include balloon dilation to expand the constricted sphincter and injections of botulinum directly into the esophagus to relax spastic muscle contractions. Both treatments are effective in the short term, but may require repeated administration to improve the symptoms of achalasia.

LHM involves cutting the muscles of the LES to open the valve and permit food and liquids to pass into the stomach. The Heller procedure is often combined with fundoplication, a standard surgical method for treating gastro-esophageal reflux disease (GERD) in which the fundus is gathered, wrapped and sutured around the lower end of the esophagus and the lower esophageal sphincter, which increases the pressure at the lower end of the esophagus, and thereby reducing acid reflux.

Although generally safe, LHM has a longer operative time and greater pain scores and postsurgical narcotic use by comparison to more recent innovations in surgery, including Per Oral Endoscopic Myotomy, or POEM.

What is Peroral Endoscopic Myotomy (POEM)?

POEM was developed in Japan more than a decade ago by Haruhiro Inoue, MD, PhD, and first brought to Philadelphia by Dr. Ginsberg, who trained personally with Dr Inoue. Dr. Ginsberg now leads a team of surgeons qualified to perform POEM and other advanced endoscopic procedures at Penn Medicine.

Describing POEM as a minimally invasive therapy that marries the best of endoscopic advanced techniques and minimally invasive operative interventions to treat what is a very challenging medical condition, Dr. Ginsberg calls POEM an example of collaboration across various disciplines to achieve the desired goal of improving patient outcomes and improving patient value and quality.

How is POEM Performed?

Fig 2. Esophageal achlasia

POEM is initiated by creating a 2 cm entry site into the mid-esophageal wall with an endoscopic cutting tool that is then used to create a tunnel in the submucosal space extending immediately beyond the esophagogastric junction to the lesser curve of the gastric cardia.

Next, an inner circular muscle myotomy is performed by grasping and dividing the fibers. Following the myotomy, the endoscopic cutting tool is withdrawn from the submucosal tunnel and the endoscope reinserted into the lumen to inspect the mucosa, ensure mucosal integrity and confirm easy passage through the LES consistent with an adequate myotomy. The mucosal entry site is then closed with endoscopic clips.

Following POEM, Dr. Ginsberg said, patients are observed for 24 hours in-hospital, during which time they have an esophagram to confirm safe and effective passage of ingested content through the LES. Patients are then discharged home. Patients generally resume a normal diet by postoperative day five.

As of 2019, long-term outcomes for POEM have yet to be established.

“It’s important to note that there is no cure for achalasia,” Dr Ginsberg concludes. “Our objective with POEM is to improve swallowing function for these patients and avoid greater future complications as safely and effectively as we can.”

 

Who is a Candidate for POEM?

The indications for POEM at Penn GI Include:

  • long-standing sigmoid-shaped esophagus
  • previously failed endoscopic treatment or surgical myotomy
  • spastic esophageal motility disorders

POEM for Zenker Diverticulum

Dr. Ginsberg and Monica Samouy, MD, MS, are now performing investigational per oral endoscopic myotomy (POEM) for Zenker diverticulum at Penn Medicine.

Zenker diverticulum (ZD) is an acquired anatomic defect that manifests as herniation of the mucosa and submucosa at the posterior pharyngeal wall between the horizontal and oblique fibers of the cricopharyngeus muscle. Individuals with ZD are at increased risk of aspiration and aspiration pneumonia when food trapped in the false lumen is regurgitated. Potential contributors to ZD etiology include motility disorders, intrabolus pressures during swallowing and abnormalities of upper esophageal sphincter (UES) function. Symptoms include dysphagia (the primary indication for surgery), malnutrition, halitosis, cough and choking sensation.

“Z-POEM is ideal for patients who are deemed inappropriate for open surgery or who cannot have other endoscopic procedures,” says Dr. Samouy. “Many of these patients are frail or elderly, and so at greater risk for aspiration.”

The Z-POEM procedure is performed for diverticula up to three cm in diameter. Following endotracheal intubation, the muscular ridge separating the true esophageal lumen from the Zenker lumen is isolated. An electrosurgical knife is then used to incrementally and carefully dissect the muscle to the base of the diverticulum.

“Cutting through the cricopharyngeus muscle removes the tension so that the diverticula can slacken and flatten out, returning the pharyngeal wall to its normal state,” says Dr. Ginsberg. Care is taken during Z-POEM to avoid injury to the lumen (with its consequent risk of mediastinitis) and the prominent laryngeal and hypoglossal nerves. Once the procedure is complete, the entry site is closed with clips. Patients remain in the hospital overnight and are released the next day following an esophagram to ensure absence of leakage.

“Generally, there are no complications and complete resolution of symptoms within three months,” says Dr. Samouy.

At this time, Erica Thaler, MD, of the Division of Otorhinolaryngology-Head and Neck Surgery is performing per oral surgery for Zenker diverticulum using a stapling technique to close the diverticula. A rigid endoscopic approach, the stapling technique is ideal for patients with larger oropharyngeal openings who do not have cervical spondylosis, lordosis or other conditions precluding hyperextension of the neck. Michael Kochman, MD, of the Gastroenterology Division, frequently collaborates to guide this therapy with a flexible endoscope.

Referring for POEM at Penn

Those seeking consultation to determine where their patient is a candidate for POEM should first contact the GI Department’s Esophageal and Swallowing Disorders Program, where comprehensive evaluations and treatment options for esophageal and swallowing disorders are available.

Penn is a resource for health practitioners in the area and beyond, and patients can benefit from the latest technological advancements in condition diagnosis and treatment and through the Program.

Additional Resources from Penn Medicine on POEM and the Penn Gastroendoscopy Program

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