BSG CSSC Service Development Prize 2022 highly commended submission by Prof Anjan Dhar.

Names of team involved: Jamie Barbour(1), YKS Viswanath(2), Catherine Sykes(3), Grace Fairlamb(3), Adrian Davidson(3) and Anjan Dhar(4)

Departments of Gastroenterology, Surgery and Oesophageal Physiology, Gateshead Hospital NHS Foundation Trust(1), James Cook University Hospital(2) and County Durham & Darlington NHS Foundation Trust(3),(4)

The driver for service development

The Northern Region was one of the regions that did not have access to a regional physiology service for achalasia, a condition which has historically been managed by Upper GI Surgeons by laparoscopic Heller’s myotomy. With the emergence of Per-Oral Endoscopic myotomy (POEM) as an advanced, minimally invasive and successful endoscopic treatment option, we felt the need to develop a regional, safe and effective service to introduce POEM into our region in 2019.

The development of the Northern Region Achalasia Group

The idea for creating a regional Achalasia and POEM service was developed by 2 consultant gastroenterologists (JB and AD) together with an experienced laparoscopic upper GI Surgeon (YKSV) in early 2019. We also engaged with our Regional Oesophageal Physiologists (CS, GF and Ad D), to set up a monthly MDT meeting to discuss the physiology of all achalasia patients referred to us for a POEM procedure. A patient information leaflet was created for all patients who had this condition. A standardised protocol for assessment including Eckhardt Score, a timed barium swallow and high resolution manometry was developed. Following MDT decision for treatment, the patient was offered the choice of either a laparoscopic Heller’s myotomy or POEM. The POEM procedure was delivered at James Cook Surgical Theatres, together with the support of anaesthetic and nursing colleagues. Patients were given endoscopic oesophageal myotomy under general anaesthesia, using submucosal dissection, and kept overnight in hospital after the procedure, followed by early recovery and discharge the next day.

Our team consists of patient representatives, regional physiologists, specialist nurses, endoscopy nurses, regional endoscopists, expert national endoscopy trainers, and access to international POEM experts for specialist opinion. The team is spread across multiple Trusts but works together to provide an innovative patient-centred, safe and effective regional service.

Training in POEM and Proctoring by national experts

Skill set before training

The three endoscopists brought different skill sets to the team before any training was undertaken. YKSV was the surgical expert and was familiar with the appearance of the oesophageal muscle during myotomy. AD was expert in physiology and interventional endoscopy such as stents and clips. JAB had the most experience in ESD providing a tertiary lower GI ESD service for the region. All 3 operators were inexperienced in using the TTJ knife- relatively unique to POEMs procedure or endoscopic myotomy. The operators moved up the learning curve steadily and supported each other as they did so.

Courses, model work, observation of experts and ad hoc hands-on training

We attended POEM specific courses with hands on practise on synthetic models. We individually also attended lists with experts in Leeds, London and Nottingham to become familiar with the different aspects of the procedure. We were able to get ad hoc hands-on experience during some of these visits.

Dedicated hands-on training lists with expert supervision in Middlesborough

From Sept 2019 onwards we received direct supervision from a small group of experts who came up to Middlesbrough to perform POEM procedure on patients from the Northern region selected by our Achalasia MDT. Prof Matt Banks, Dr Bu Hayee, Mr James Catton and Dr Noor Muhammed have supported these lists.

Learning points identified on the learning curve

Preparation

It took multiple procedures for the team to start feeling that we knew our roles and responsibilities. Teamwork is vital for all procedures no less for POEM. Getting the right kit ready in the right position and team members able to support the procedure was vital.

Tip control and Co-ordination of the movement of the knife and the diathermy peddle

Endoscopic Submucosal Dissection requires very fine tip control and this is not usually required in routine upper endoscopy. Using the knife and cutting in the right plane depended on excellent tip control and co-ordination with the diathermy foot peddle. This slowly developed over time.

Keeping orientated during the procedure

Dissecting down a tunnel in the oesophagus was unfamiliar to all 3 operators. It is vital to remain aware of where the muscles side is and where the mucosal side is. As a myotomy is going to be made anyway the plane of dissection needs to keep close to the muscle. Drifting towards the mucosa is easy and our supervisors were frequently keeping us in the safe zone. With time we started recognising the subtle differences appearance of the muscle and mucosa and needed less prompting.

Fatigue, overload and Endoscopic Non-Technical Skills (ENTS)

We started by taking turns during the procedure. One started with the incision and entry and partial dissection, then another took over to complete the dissection and start the myotomy. This meant that we did not become fatigued with the effort of prolonged concentration. Learning a new technique that is challenging is like driving a car with little experience. It exhausts you and risks complications. Our supervisors were able to keep each session within their control and they took over when necessary without significant complication.

Our Journey between 2019-2022, and during the pandemic

Learning a challenging technique requires expert supervision, optimal learning environment and practise. A critical mass of experience is required to start developing muscle memory and to be able to delegate some tasks to the sub-conscious part of the brain. Our journey to independence was always going to be slow given the frequency of offering the procedure in the initial few years.

We started in Sept 2019 and had 2 further sessions in December 2019 and March 2020. We restarted in Oct 2020 then stopped until May 2021. We have since continued with regular lists every 2-3 months. Our journey to bring POEM to the North East has been a very satisfying and humbling experience involving interactions with Physiologists, industry partners as well as deep reflection, willingness to accept failure, re-learn techniques from experts and from each other, and finally supporting each other in every case for a high quality outcome for the patient. We had to pause the POEM programme during COVID-19, and resumed in the second wave as endoscopy recover started.

Our success story and Outcomes so far

Despite the constraints of COVID-19, we have managed to carry out the POEM procedure in 14 patients, with good success and no significant complications. This compares to only 6 patients who chose to have a Heller’s myotomy. Going forward, we plan to do 15-20 patients each year independently, with minimal remote supervision. 3 patients have has post-POEM high resolution manometry with a further 3 patients waiting for the test.

We have also engaged with local clinicians to offer to service to all patients and all three endoscopists are able to see referred in patients in clinic to discuss the procedures with them and get their agreement to participate.