Update Course Rewind: Peroral endoscopic Myotomy (POEM) for Achalasia

Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello Pediatric Surgery Family. I'm Cecilia Hina, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held this past August. Today, we are talking about the poem procedure for achalasia. And for that, we have Dr. Michael Petrosian and Dr. Timothy Kane, two pediatric surgeons from Children's National Hospital. So let's uh let's just talk a little bit about poem uh because I think that for many this is a new concept, certainly a new technique. Yeah, so um I I was interested in this in the late late 2000 and really came out with the first uh uh human case in 2010. Mike was a fellow of mine finished in 2013. said we're going to start doing this. So we went to Lee Swanson in Portland, took a course, learned how to do it and that we're going to bring this back to children's. Took us two years to get the equipment. So we really did our first case in 2015. So per oral endoscopic myotomy or poem for short, is a minimally invasive endoscopic procedure used to treat achalasia that consists in esophageal selective circular myotomy of the anterior lower esophageal sphincter. But even though it's been a long time since it has been described, it has a long learning curve. Let's hear Dr. Timothy Kane. And the first two or three cases we we basically struggled and but we always had the the component that if we can't do this poem, we're going to do a Heller. But it's it's a steep learning curve. There's a lot of equipment. It's hard because it's a volume thing. So if you're not doing a lot of them, it's just doesn't doesn't build that fast. So it's hard to get your skills up. Tim, what do you think the learning curve is? So, the learning curve essentially is about 20 and mastery is about 60. So to tell us why uh you feel this is the best way to go or what are the advantages of poem over the laparoscopic uh esophageal myotomy? Yeah, I think you have you have 360 degrees of options to do a myotomy. Whereas with a Heller, you're kind of more anterior, so you got maybe 180. Um you don't you get the Vegas there that you got to worry about. Um in a reop for a Heller, you you have all those issues. So you can do a redo poem after a Heller or poem and you can use it choose a different side uh to do your dissection once you're getting the clean spot. So you don't burn any bridges. You don't dissect the hiatis, so you're not worried about reflux. So, to repeat the main benefits of poem, it has a larger surface to perform the myotomy. You don't have to worry about the vagus nerve. It has less issues and scarring for reoperations, and due to not dissecting the hiatis, it has less reflux rates. Now, let's look at their data. We've done 73. We need for reintervention, these kids about 15%. Uh reintervention means needing a balloon dilatation before a year at postop. And we've done five redues and interestingly, those five redues, three of them were kids with type three. And again, this is our our breakdown of the kids. 11% were type three, which is kind of high compared to most in the literature. Majority are 62% are type two. How many surgeons in the room who has tried this, the poem? Anybody other than these two guys? Okay, Cecilia. I have a question. Sorry. Seems like I'm everywhere. We can see that we have like a lot of surgeons here, only you two do the poem. How do you think that you can teach or show other pediatric surgeons how to do this procedure and how to get used to it so that we can spread this among everyone? Exactly how we learned. There has to be a course, which we're planning to do. is a long time in coming. So it's important to do that and spread the word around because so I don't think a course is going to do it. That What do you suggest? So, I've been to a course. I still don't feel like I am I can just go start doing it. I think I need a GI who's ready to do it with me or another partner. I need to have, you know, more than just go do a laparoscopic hernia. It's it's a much more involved thing. It's like bariatrics. You disagree? No, I agree. I agree. It's it's rare. So I mean, just look at the uh amount of Pete surgeons that do thorascopic TFs still hitting at 10%, right? It's low. So, I used to think we're going to train everybody, we're all going to do it. I I think it's worthwhile trying to figure out how do we actually next step is, yes, we've done it. Now, how do we start showing scale up? Well, I also think though that that there has to be uh just a demonstrable improvement over the current technique, which is the laparoscopic esophageal myotomy, which most pediatric surgeons feel comfortable doing. I I do agree with you. However, I think as a surgeons, we do have to be comfortable doing these procedures. Great. So let's summarize. Poem procedure stands for per oral endoscopic myotomy, and it is a great procedure for treating achalasia. Its advantages are that you have a larger surface to perform the myotomy, you don't have to worry about the vagus nerve. It has less issues and scarring for reoperations, and it has less reflux rates. The main disadvantage is that it has a steep learning curve and requires a specialized equipment, which surgeons don't usually use. Its results are comparable with laparoscopic Hellomyotomy. And the good news is that these experts are preparing a course so we can spread the knowledge even more. Thank you for watching. 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