Gastrointestinal Endoscopy (Author Interview Series - Video)
Sep 24, 2026 · 0 min · 8 segments
Drs Muhammad Ali Butt and Sultan Mahmood discuss their article, "Outcomes of peroral endoscopic myotomy in patients with cirrhosis: a multicenter experience" from the October issue.
POEM is now a well-established treatment of achalasia and other esophageal motility disorders.
But when a, when a patient also has cirrhosis, there's often an immediate hesitation, sometimes a reflexive no.
Uh, portal hypertension, coagulopathy, esophageal varices, these are all real considerations when you're creating a submucosal tunnel and cutting the muscles.
The worry has always been that you could trigger a variceal bleeding or hepatic decompensation.
But here's the problem: cirrhotic patients are not protected from developing achalasia or esophageal motility disorders.
And when they do develop them, clinicians often, um, default to Botox, a very short-term palliative measure which does not provide definitive treatment.
And, uh, and the reason is that the definitive treatment like myotomy is felt to be too risky.
Um, so to start building that evidence base, we conducted a multicenter retrospective study across six high-volume US tertiary care centers and enrolled patients between twenty twenty and twenty twenty-four.
These were complex patients with mean age of sixty-seven and a half year, over forty-five percent with Child's few class B cirrhosis, and two-thirds had experienced prior hepatic decompensation, including ascites, varices, and encephalopathy.
Procedures were performed by experienced operators with standard POEM techniques.
Um, Dr. Mehmood, anything you'd add about how patients were approached or selected at your center?
There was a deliberate pre-procedural evaluation assessing the variceal burden, optimizing the coagulopathy, involving the hepatology team when needed.
In some cases, uh, esophageal band ligation or even tips placement were performed beforehand before proceeding with the intervention.
That multidisciplinary front-end work is essential in getting good outcomes in these patients.
POEM is now a well-established treatment of achalasia and other esophageal motility disorders.
But when a, when a patient also has cirrhosis, there's often an immediate hesitation, sometimes a reflexive no.
Uh, portal hypertension, coagulopathy, esophageal varices, these are all real considerations when you're creating a submucosal tunnel and cutting the muscles.
The worry has always been that you could trigger a variceal bleeding or hepatic decompensation.
But here's the problem: cirrhotic patients are not protected from developing achalasia or esophageal motility disorders.
And when they do develop them, clinicians often, um, default to Botox, a very short-term palliative measure which does not provide definitive treatment.
And, uh, and the reason is that the definitive treatment like myotomy is felt to be too risky.
Um, so to start building that evidence base, we conducted a multicenter retrospective study across six high-volume US tertiary care centers and enrolled patients between twenty twenty and twenty twenty-four.
These were complex patients with mean age of sixty-seven and a half year, over forty-five percent with Child's few class B cirrhosis, and two-thirds had experienced prior hepatic decompensation, including ascites, varices, and encephalopathy.
Procedures were performed by experienced operators with standard POEM techniques.
Um, Dr. Mehmood, anything you'd add about how patients were approached or selected at your center?
There was a deliberate pre-procedural evaluation assessing the variceal burden, optimizing the coagulopathy, involving the hepatology team when needed.
In some cases, uh, esophageal band ligation or even tips placement were performed beforehand before proceeding with the intervention.
That multidisciplinary front-end work is essential in getting good outcomes in these patients.
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