970 POEM+F – IDENTIFYING AND UNDERSTANDING THE TECHNICAL NUANCES AND CHALLENGES WHILE PERFORMING A PROCEDURE IN EVOLUTION

Abstract

Peroral endoscopic myotomy (POEM) is an accepted treatment modality for achalasia cardia (AC). Post POEM gastroesophageal reflux (GER) has emerged as a frequent adverse event. POEM + endoscopic fundoplication (POEM+F) has been described as a novel NOTES procedure thatcombines endoscopic fundoplication along with POEM. POEM+F is an evolving procedure. This video case series demonstrates technical nuances of POEM+F. 20 consecutive patients with EGD and high resolution esophageal manometry proven type II AC underwent POEM+F over 10-month period (Feb. to Nov. 2019).POEM+F performed after obtaining informed consent. All procedures performed under general anesthesia by single operator. Standard anterior POEM performed using gastroscope with distal transparent attachment. Procedure modified from original with intent to simplify it. After completing full-thickness myotomy across gastroesophageal junction (GEJ), 5.7mm ultra-slim gastroscope introduced alongside gastroscope into gastric fundus. Using double endoscope transillumination, serosa overlying the myotomy divided to enter peritoneum. Scope angled upwards & leftwards to reach gastric fundus; fundus grasped & withdrawn into tunnel to simulate wrap. Procedure continuously monitored by ultra-slim gastroscope.Spot on fundic serosa marked. Gastroscope reintroduced into peritoneal cavity carrying 3cm endoloop grasped in a reconstrainable clip. Endoloop fixed to fundus and proximally to end of myotomy & peritoneal opening. Endoloop tightened, loop tail trimmed and mucosal incision closed. Following modifications from original – [1] double endoscope trans-illumination to identify peritoneal entry; [2] Decompressing gastric lumen to facilitate grasping of fundus; [3] re-constrainable clip to grasp fundus; [4] Marking location on fundus for fixing endoloop; [5] Use of detachable endoloop to reduce friction within esophagus and tunnel; [6] Avoiding perigastric fat while fixing loop and clips on fundus; [7] Abdominal paracentesis to reduce capnoperitoneum. Follow up EGD performed at one-month. Total N = 20 (11 males, mean age – 40.9 years [18 – 67]). Mean total procedure time = 77.5min (Range 55 – 145). Mean procedure time for additional fundoplication = 42.5min (Range 30 – 105). Fundal wrap was intact in all patients at follow up EGD after 1 month. No immediate or delayed adverse events encountered. All patients resumed oral diet after 24 hours and discharged within 48 hours. POEM+F is a safe and feasible procedure. Modifications in technique described in video may help to simplify the procedure.Efficacy of POEM+F for prevention of post POEM GER needs further evaluation by larger studies with longer term follow-up.