Originally Broadcast: September 29, 2022 | 8 AM - 5 PM ET
Case 1 features a Z-POEM performed on a 65 year old patient with large symptomatic Zenker diverticulum. Patient originally had no significant PMHx and presented with dysphagia to solids and pills, with significant halitosis.
Hey, good morning from Thomasville Georgia where we are live at Archbold Medical Center we have an action packed day with four cases that psaropoulos will be doing all back to back. No talk. Just endoscopy. We have a poem as anchors and two year sts one gastric and one colony. Before we begin. A big welcome to psaropoulos to Archbold Medical Center. It's a hidden gem, a quail hunting destination stone's throw away from Tallahassee Georgia. I'm sorry Tallahassee florida. We welcome you all and invite you to visit us before we begin. A big thank you and a round of applause to the staff. The sponsors and most importantly, the support of our brass were probably gullible enough and well actually willing open proactive and even excited to go along with this audacious idea of a mini Georgia life course on Stephanopoulos's second day here in Thomasville, anybody has put a course like this knows how much work it takes. And so like the acknowledged captain for the Tylers work was unstinted support without which it would not be possible. We also have our sponsors. Finally thank you to scott from broadcast met for bringing this to your bedroom or to the endoscopy room or wherever you are to suli who's traveled all the way from Long Island to help with the course. I'll be reminding you all to answer, ask questions. Send your questions using the button on the screen. And so PSaropoulos needs no introduction. Let's get started. DR Buchanan. The first fellow will be, let me say hello to. But before, so thanks a tool, a tool is a veteran moderator by person should be called Long Island live. We are transitioning to Georgia live. So a tool has been there for the last 567 years as a brave moderator for the long hours. But this course is take sully is amazing. He likes working with me so much that it's one of her best vacation activity became vacation to florida and she figured she spent three days she got bored at the beach. So I need to do some cases with and be abused adequately. So it was great stuff and as you said this is the second day scope in here but the stuff just stepped into it with no trepidation but some of them and uh you know it's amazing that the nurse manager, Katherine put all the equipment together and then scott. I mailed him two weeks ago on a weekend scott, can we do a live course? He said sure why not? So it's amazing that everything came together. Everything came together in a fantastic providential way really. And the rest of the people in the room who deserve great credit because we did a long 10 hour day yesterday to for warm up. So for me who doesn't want to be on camera. Not as of yet actually. Um and don't nursing nested this, this is gonna be the team. So we are going to do four cases start with Zippo and go hard, too difficult to use my usual day. So the poem. Then um anti reflux poem. Then we'll do track motion for a gastric cases. The program said director. But we figured maybe gastric um is also a good idea. We're still doing the erectile later on. I don't think we'll get to it live. And then we're doing a difficult colony SD manipulated twice with hot forceps and a pc in the sequence. So that would probably be the most challenging case of the day. Dr Buchanan advanced fellow also stepped in right there with me coming to Georgia. Um He's gonna be demoted from attending to fellow for a few weeks a year. Yeah so he's gonna present the cases and run the two rooms and switch between the rooms and make sure that patients are doing well. Um You know basically this is this is what we have for you today. I hope you enjoy it. I also hope people get to watch it on demand. Will have it on the website as we have done in past years. Thank you all passed the baton to Dr Buchanan. Thank you Dr Stavropoulos exciting times at Archbold in Thomasville Georgia. So four cases lined up today. We'll start with our first case. Mhm. This is a 65 year old male with no past, no significant past medical history who had presented with dysplasia. This has been ongoing for about one year now salads and pills with significant halitosis. He had an E. G. D. Performed about 20 years ago where he was told he had a banker's diverticular which at that time was not symptomatic barium Upper G. I. Study was performed As you can see huge huge 13 cm anchor diverticular. So diagnosis is a large symptomatic sinkers and the plan today is for a Z. Cone with dr. All right so do we have the end of it? Yeah. Right. So this is the bankers um as you saw it's a pretty big one for so there are many ways to do it. We can do a, well the old time approaches surgically. Were to put a um direct instrument by. Nt through a laryngoscope and do an incision with the C. 02 laser with other instruments can put a harmonic scalpel or you can put a stapler to avoid any leak leak from the incision. The problem with a stapler is there's a leading segment that doesn't staple and cut so it leaves the reeds and often you get three cancers from that. Sir Swanstrom, one of the surgeons has described taking orthopedic saw and cutting that segment off so that the stapler can get all the way to the bottom of the of the septum between the particular and the esophagus. The really old way was to go through the left side of the neck with a long incision and also do a diver tickle ectomy or suspend the diverticular with its founders high. So things don't go into the diverticular. Obviously even surgeons going in open through the neck are leery about cutting the diverticular um off because the liquor it is huge. So even then they sometimes they just suspended upside down instead of cutting it off. Now the last 25 years we've progressed to endoscopic, flexible cept autumn. So you can cut all the layers going down. The problem with that is again leak. So therefore over the past 678 years, the septa to me by tunneling developed after as an offshoot of poem for a cattle asia. So we do a little tunnel and then we cut the muscle, the crack of orange juice and then we um connect them you cause over it. The questions that arise from this procedure is if you leave the mucosa there in the sub mucosa, there's still alleged it's not it's not bolstered by muscle but there's still allege, Will that be a problem with things getting stuck in the director's room. Having done this for the last again, 67 years. This is not the issue. That's also we kind of had the hint that this may not be the issue because no matter how good the diverticular Tommy did. Even with the older techniques, the most of the diverticular is still there to catch food and other things, but this never bothers the patient. So, um we think that the main reason for this is the spasm of the sphincter the upper sphincter blocking the food from getting this obvious. You can see how it can prefer actually go to the left and the vertical. Um as opposed to the collapsed lumen of the sofa goes in the right here. So it's just a spastic sphincter which is also the cause of the diverticular. So really just cutting the sphincter over two centimeters or three sufficient. Even if you have a giant a particular like this, you don't need to go down and cut the whole septum and leaving some mucosa doesn't make a difference again because the sphincter is cut, it's it's like a collage for the hyper firing. So once you treat the sphincter, the same thing with Uncle Asia. Once you treat this finger, you rarely have to do anything with any any epic friend diverticular. That ankle asia patients have the same thing with those anchors. So that's what we're gonna do. Now the technique that multiple techniques for zippo and like you can go start in the high performance here, get in the tunnel to the septum and then do the cat. So you have a two centimeter tunnel. And then there's the ultra short tunnel technique which we have published data For bankers and also for Killian Jamieson, that particular which is an article um that is one or two cm further down. So it works great for Killian Jamieson to uh that both diverticular, the Killian Jamieson is rarer than as anchors. So this is our ultra short tunnel techniques make the tunnel. Well initially you just make an incision in the mucosa and start cutting the muscle by putting your nose in there. And that the tunnel only develops really after you cut a centimeter or two of muscle. And sometimes I don't have to get the scope in there at all. You can do the whole my ultimate just your nose um stuck in the because of incision. And what helps with that is a paper cup from food here. I'm using the Olympus trade cap which gives you better visibility to demonstrate the septum. But I'm gonna switch to the food cap to do this incision again. Because sometimes, especially if you make a small cat, all you have to do is put half the cap in and that alone allows you to do the my ah to me. So this is where you wanna go. And then we we use clips. Now the clipping is the harder part of this procedure we have found. For virus reason you can see everything is collapsed. If you try to clip here on the on the edges of the diverticular um you end up cutting too much tissue and obscuring obstructing the lumen. So it's it can be challenging. So you want to stay towards the middle, not near the edges and make a smaller hole as possible. So the clips do not have to write the edges of the septum and you know the favorite knife as it is for all our poems is the hybrid knife because of its ability to inject powerfully and make tunneling of the sub mucosa. Here would make little tunnels on the left in the sub because of the vertical. Um To protect the new cause of the diverticular from injury. That's the probably the most common injury. And we're also gonna do it in the summer because of the sovereign protector because of the So when we close there's no chance of leak. Alright, so let's put the food pickup in. So there there are that studies that try to compare the tunnel technique with clearly the endoscopic technique beats the surgical techniques. Um But the question is does the tunnel technique offer Higher safety? Um because the efficacy of the older endoscopic technique is on the 90% plus. But does the tunnel technique offer A lower risk of complications like leaks? And maybe even higher efficacy? Because even though the initial success of the olden discovered technique is 90%, in most centers. The recurrence rate in some centers is as high as 30% by two years. And you have to do it again. That the idea is that that's because these operators are not aggressive with how much they cut. So the idea is, does the tunnel make allow you to be more aggressive since there is less chance presumably of a leak. I can't say that the data are clear on that. Also. I can't even say that the data are clear on a higher efficacy data. Some studies that show lesser complications that are poorly done retrospective studies with multiple small international centers mixed with some americans and it's very difficult to um really um interpret the data so we can we can do the tunnel and look cool but it's not clear that the safety has increased dramatically with this technique which is was already you know pretty safe. So you know we need more data basically on this that are good quality data. And there were some studies that did show a higher complication rate with a Z poem the tunnel technique. So we'll see and this is in comparison to the un roofing technique. Um So technically do you find one more challenging than the other or one required more experience or a learning curve being different? Well the ultra short tunnel is much more difficult than just taking a knife and cutting all the layers like right down the middle. Um Yeah, so it takes some more scale but yeah it requires more skill but the idea is that you're safer because you're doing everything in a tunnel. So the whole question is is that true? There is some concern that this technique gets open, gets the operator to go austerely in an orientation that may not be so good um In terms of exposing um the planes of the neck posterior lee whether maybe a higher chance of linking infection. But it's all a bit speculative right now. So the first step we do here is we do a little blob to sort of mark where we're gonna enter, inject, go go. Okay, well I overdid it because initially it didn't lift. I'm not sure why. Okay now we're gonna that right there. So this is so from the middle mark, we know where the approximate middle is. I'm just gonna go right next to it. So we're gonna use the hybrid knife. It injects threw the knife using a special pump, the Air B jet that rejects that thousands of PS I pressure originally developed to do liver and brain surgery and open. So we are going to um So the entry is the initial entry in every procedure that I use this nice poem. Z poems. A poem is a puncture entry to try to do a slice entry. You are more likely to cut vessels that start bleeding with the puncture entry. You may be unlucky enough to puncture into a vessel. But the good thing about punctures is the coagulation is much easier. Like you stay right in your puncture and do some forced coagulation or or even the little touches of spray. And it works if you slice through, you don't know exactly where the vessel is. Unlike a puncture wound, just keeping the knife, that doesn't ensure that it co opts the vessel. So so initial is a good puncture that allows you to start seeing what lies on the other side and get you to the proper level before you start slicing. There we go. That's the that's the entry one incision. And now we were just enlarge it a little Exactly. So the the injection happens with the pedal. You can see here something because already on the left now common way to make your view easier because we are in very cramped quarters is the most cramped third space procedure which can make things difficult is to go underwater. Which number one, the water pressure acts as a as a force that's plays open the incision and allows visualization. Also it magnifies and then you can see in more detail what you're doing. You can see the muscle in white and because of that, particularly on the left. It also does other things if you have fat in that word standing of the lens. So there is the the muscle and I'm gonna inject there on the because of the sofa which will outline the middle, the muscle at the middle there. Now if you're underwater because of the higher refraction index, you get a little out of focus. So in this case you can use the the near focus to get back in focus now underwater or under sailing as it say, you need to use currents that cut underwater And we're using the via three here. The new or generated via has a very high the most expensive aspect of that generator is its processor which processes tissue impedance 25 million times per second which means it can instantaneously adjust the current to the tissue impedance. So if you have very low ph impedance you can lower the energy and vice versa. Which allows you not to do zipper cats. But on the other hand to cut and coagulate properly. So the the underwater current that works best. And is that and I at the highest cut interval we're trying to switch right now. And I have to say yesterday on the cases we did poem me as they didn't cut well underwater but sometimes it also depends on the about the composition of the patient and other things. So now we are on the card. I let's see if it cuts. Today is the interval maxed. The cutting duration is maxed. So the cutting duration, we can show you on the camera. So the cat can you focus, don't you see it? But on and a cat you have you can play with a cat in duration. And a cat is a mixed current that cuts and coagulates. So um when you are increased at cutting direction it means so every cycle it spends more time cutting versus coagulating. So if you want to have pure as pure cutting as possible you can increase the the cutting duration And then the interval which goes I think from 1-6 is how frequently the past has happened. Like does it the Now people that do S D. They are taught to just intermittently step on the pedals. Even if you can't have it on a interval of six, you are making your own interval by by pressing on the pedal. Intermediate li I nevertheless I like interval one so it goes very fast because often when sailing is smooth you just want to stay on the yellow pedal and cut quickly. So anyway, that's what we have. So now the question is let's use that. Yes. So then look at is working I believe and look at that and see to get into to form a tunnel really. You really need to start cutting the muscle immediately. That is the muscle. So we do an all the way to the sub because of the you can see the water pressure technique in action because I'm using my right foot is on the water pedal and suing water pressure while the left foot is on the yellow pedal cutting and I'm using a combination of dials and torque to got the muscle there. I'm extending my micro tunnel by cutting the muscle a little bit of injection on the as of a outside, a little bit of injection on the particular side and a little bit of cutting in between of the mass. So there's a little extra because I should cut here. There's the marker panel again I'm probably done five of my autumn without even getting, my. without getting my um scope in the so called tunnel. And then it's important not to split the muscles. So I'm checking and making sure where the sub because on the right it's clear that the because of the suburb is there. But on the left, I keep seeing fibers so you don't want to split the muscle and miss a part of me out there. So I'm gonna cut this your goes out there in order to make sure that I'm definitely to the left of the muscle. And then inject there. I think we are right right there. There's a vessel there, I'm gonna suck the water and use well we can use precisely. It's a it's a it's a current that uses the that processor calculates very rapidly to modulate the current appropriately between a more cat and Karen on a more coagulating card based on characteristics such an adaptable current that can help deliver the right type of modulated current. So let's make sure. So I'm making sure. See you have to make sure you don't miss any muscle. Now you always want to see a clean sub because on the right and left because if you split the muscle you will think you did a good poem. A good poem but it won't be true. So here I have isolated the muscle again, I don't know if we have any questions from the audience. No questions yet. But given that this is a 13 centimeters. And how far are you planning to go down? Well? Again, the patient's problems are from the tight sphincter. So after two or three centimeters you're not doing anything. So I will I will stop. Maybe I close to one something with her now. So so the tunnel on the other side is very well defined. Now right, I'm extending the tunnel on the sofa, ideal sub mucosa. Now let's go to the other side. Does the characteristic of the fiber of the muscle itself give you a sense of how far to keep going. Well. Initial Yeah, the initial, the muscle is thicker, thicker and then becomes thinner. And if you do a lot of poem, you start recognizing that this is a sofa deal muscle rather than the crack of foreign jews. So then you can stop at that point and so it can be tricky with the muscle trying to hide there. The main thing is not let it so you can get diverted and start cutting deep into the neck there on the left. And that's where the problems have. And that's what I was talking about the tunnel, you can end up over dissecting this side because you see the stinker is basically going around the esophagus. So it tends to stick to the more than the diverticular, so it forces your dissection to veer off to the diverticular side, That's where many of the new causal injuries happen too. So you need to stay glued to the sofa goes and I'll avoid getting diverted. That's the muscle here. So just some comments from the viewers, I think they're very excited to see you back in action. Thank you. So things are getting easier now. That's a clue that we may have cut enough muscle because now it's it's getting more and more separated from the sofa. So we are moving from the crack of juice to jail muscle. So I think I'm cleaning the sub on the sofa jail side. And then we'll go in again from there is the muscle. You see it's concave the muscles concave towards the diverticular because it's a circular muscle around the proximal esophagus. So it's around the sofa. So again wants to hug the so you have to not let it push it to the side. Now it gets really see now it gets really easy. That's your clue that you've cut enough. So now now it's staying in the middle. The muscle as opposed to being tightly around the opening of the because now I can keep going at this point. The dissection gets pretty trivial, right? Yeah. Right in the middle. You have nice because on the right it's nice having those on the left. You can keep going and going. That's why you might get you know, a bit cut happy and overdo it. But what about vasculature? Are you anticipating any abnormal vascular This procedure is relatively a vascular sometimes you saw I did calculate one intravascular vessel. But that's basically about it the rest of the time I've been on and a cat. I see now it thins out here dramatically. So I think I'm gonna stop here because this this muscle is very thin. And so you feel that the rest of the bank of the wall is mostly subcutaneous fascia and tissue without musculature. Well there's musculature. It just don't not causing obstruction. The finger up there. The spastic finger, that is the cause of the bankers in the first place is what's stopping the food. So tight finger is stopping the food and diverting into the vertical. Um But that particular itself is not usually the problem. That's why even though you do a barium after Z. Poem and there's still a big particular um there the person still feels great. The pills don't get stuck. The solid food doesn't get stuck and they regurgitate less. You figure some food is going in the diverticular. Um But because now the sprinkler is loose, you divert a lot more food down the esophagus. I mean I can't keep going indefinitely here now but we are we are I think deep enough. So let's come back. So there's the maya to me because of the is on the right. And so because of the diverticular on the left? I'm boom, that's what we did. Now let's see how the looks see it's looser than before. I know it's hard to appreciate but to lose herself this this looks tight because this is all injected sub mucosa from my my autumn. So my my bottom is probably down to here. Okay which is 20 read one before And the beginning of the was about 20 I believe. So one see what happens here even with some some current got transmitted to the mucosa and the food has sharp edges so it tends to scrape things. I use it for specific things. So this is something because housing so the beginning of the vertical um is uh 20. So we did about the four cm. My auto man which I think is adequate. That's that particular which is also faced by all the injections. So both sides are gonna do look swollen but we cut the for 3-4 cm at least. So that's that's the length of it. So cutting any more of the septum doesn't have any point really. So we're gonna now close it which is the most difficult and annoying part and dangerous part. Yeah so what clip do we want? So traditionally everybody likes the clips that don't have a big stem on them. So we are gonna think about that. I mean the initial clip may have to be a long clip to bring the edges together and then the remaining clips can be even smaller. So I think for the middle of the incision we might try to use a something like I sometimes I use the boston resolution but I like the how the arms work but hold on but it has a longer stem so we can use also the the low Kado we can try six. No, that's the 11. Don't want something with big arms. One of them is discussing them because of the opposite wall accidentally in the cliff. So again, water pressure helps you not do that like here. But I'm surprised at them because I only use precise like the single time for that vessel. That's probably what did it? I don't see and a cat causing this, you know, whitening of them because I hear and it transmitted through the sub Nikos to get there but found the proper resistance that deliver the energy. But you have robust covering the defect which is much more reliable than this epithelium like sloughing off their so we're okay, there's robust one millimeter of tight something because that they use for suturing approximately. Okay, so there you go. Okay, that is all right, rotate to the right open again. Water is essential. We don't want to cuts cuts on the other side. That that particular side you have to rotate to the left, you have to rotate, rotate departure of patients. Not too much for patients. Okay, Karos, you were like that. Do you think a tool it looks pretty good. We didn't catch the other side. I get slowly deployed. I gotta go to that. So now we've got to do the either side of this. We can use you can try to use smaller clips. Now attempt that because when we go near the walls a long arm clip is gonna bunch the wall together which will tighten the orifice to the server because that means when the patient eats and puts tension on that because of that clip can rip off at the edges. So you need something with shorter clips that will just approximate the edges and not grab Too much tissue along the Wall. So I'm gonna try the easy clip. The tiny one color coded white. It's very very small clips. The smallest clip of the easy clips. I don't know if there's anything that small in any of the other one used clips. So the easy clip comes with a catheter that you load it on manually and there's some learning of that. But it gives you a great variety of clips that are extremely inexpensive. The clips themselves, maybe $40 or so. And the catheter. Canada costs more. But You only need one catheter per case. I mean 1 1 delivery Catheter for per case and you can load as many clips as you want at $40 each, which is as you can see after I left new york. Surely got rusty. Really? How we doing success? Yeah, these clips questions. Okay. Maybe I'm not connected here. Don't wait, no, no you don't. Certainly you don't cook it outside the border, Do you know? Okay, do it again. I think that it's not Hi, how many questions are there scott? Because you shouldn't do it. Please load it. Okay, thanks sometime. Rust. Rust. The Okay, what's the question? So? Well, there's no question. In fact, it seems like there is a common perfection. Oh, okay. I didn't, I didn't pay that person. Okay. How we doing with a clip? How was good? Okay, we have a clip so we can go on either side of it. Okay, so near the walls. Will use the short arm clips. Try to avoid pinching the wall. There is a question from before whether as to whether the sailing serves as a heat sink when you're using poetry. I also have that idea. I don't have proof. Yeah. Well, I'll tell you when I use the sailing as a potential heat sink when I have a very difficult poem. Okay. Extended hold on because it's a little critical. Let me let me talk after we deployed. Okay, push it out. Yeah, go now start pulling it back. Okay, now we have to cock it very gently there. Now you can rotate it nicely. Right? So now we'll go, obviously you need the water pressure again, which is a very key technique for this And then use the cap there to push the other clip to the side now you need to you need to rotate a little to the right, 2:00, it's touching the cup. So if you see it not rotating, you tell me to go out a little rotate to the right stop. Okay. Um Alright, sometimes the sword stem is problematic, isn't it? Okay, rotate more here, the gap. Yeah, I think put it back quickly, quickly rotate to the left, left, left. Okay, come on left, left, do it. Okay. Stop my guy to the right. A little good pregnant that with their another water. No. Yeah, about right now. Okay, we've got some bubbles. Right, Okay. I think this is this is okay here. Okay. They're close. Yeah, deploy. Okay. So should we be using one, let's do the other side. Mhm. Um And this is the zippo and it's important to take the time to do the closer. Right. Is that the only really complication for this procedure is leak. So, were you then painted with the Purest at the hem a static gel? We So yesterday purist art the democratic gel. No, I mean, there's never an issue with him. A space is I mean, I don't know that anybody has gotten significant bleed from this delayed bleed. So, I wouldn't worry about that. You're talking about sealing it. Well, so it's ahem a static gel in addition. It seals as well. Or does it not? I don't think at this location with saliva coming down constantly and food. I don't think that anything will stay here for long. If I just pour it on the clips, it was a little another location. Say, I don't know, a little out of the way, but this is right in the pathway. Okay. So I'm gonna do it. I mean this clip is not easy to use but it has ideal characteristics for this application. That's why I'm doing it. Okay. Open Okay now I'm gonna cook it. I use my method of cooking. It is little taps on my chest because that and susie are not gonna over close it. So you copied the and then we're gonna rotate it to the left. Okay, nice. And now All right, a little Okay. Close and deploy. Okay. And another one. Another question. So now we need to do this wall and then maybe put one in between if necessary. And I keep people with Z poem longer than poem patients because of disclosure. I have no not great trust in it. So I keep people maybe two nights sometimes three nights. Also older people with comorbidities. He's very young for his anchors patients. The average Zanker patients in their seventies, late seventies All the way to the 90s and beyond. So, so the seeker older patients and the closure for for poem as you'll see on the next case I closed with suturing right? So it's very secure in the middle of the nothing can open that. But up here in the neck with people taking their pills and eating food and with clips that can be slopped off by you know a piece of bread. Um I feel much less secure. So we we usually I think on the average patient may wait two nights before we do a barium and proceeding with diet liquid diet. So one of the questions is about the temperature sensor which is called a lower reading. Given all the sailing injection. Does it help to use 20 point? But it's a names of hemp probe. So it's sitting right at the back of the. Yes well so does it help to use maybe slightly warm sailing when we injected? Just remind me to discuss the heat sink because I stopped because of the clips that took all my concentration. But for the I've used I don't know not so much saying I've done the ordinarily at this difficult colonies this I've used liters of sailing you. For those who use a sailing warmer Because you can get severe hypothermia. We've gone down to 93 The grease fire night. And then we have waited until the patient go to 95 to excavate them. That's what anesthesia wanted. So so yeah so you don't want to get there. So we have obviously always bear hugger warming blanket on every procedure. But then for procedures that need a lot of water pressure technique. We have a sailing warmer that want the hours used also to hit fluids up that go into the patient. I think that's a sense of if you're gonna use more than a liter or two. So Yeah. So that's a valid point. Yeah. Okay. Turn to the right. Okay. Nice. Okay. How are we doing with the rotation? Okay. Left left left the other way. Yeah. Uh reverse a little right, right left left. Come on. All right. I wish it was a little more left, but it's probably Okay. Right, okay. Where's the left arm? Oh, what happened close a little. What happened there? Clothes and gloves? No open the clip, pull back in. Can we deploy it this way? The food, the cap caught the edge of it and somehow somebody deployed it. I don't know the question is can I salvage it? No, I can't see the right arm. That's what's annoying me. I don't want to deploy in the. Okay, okay. How about that? Is this deployment gonna work? I have no idea. I'll try looks that looks good. Try try. I don't get to try not at all. I think it's just come off. Okay, clip malfunction. Yeah, these clips have a learning curve but they're invaluable for their very short little arms. So Okay, let's do it again. Sorry about this. So the heat sink. The heat sink. I used definitely on verify brought IQ poems like um two previous Heller's and a poem attempt by somebody else for example, like no sub mucosa. Trying to get through the G junction there is like solid fibrosis on those cases, even if you get through the mucosa, turns out into a purple cooked piece of mucosa and then typically in 24 hours it slaps off and you have a huge ulcer leading into your tunnel and hopefully not in the media steinem. So there when you do this end of underwater dissection, I think that water made make it less likely that you're gonna cook them because because you are very close to them because because you can't avoid it, there's a solid wall of fibrosis is connecting the muscle and mucosa. So, so the best technique is that I pure cutting underwater and you might be able to salvage them because our it's not partially cooked and necrosis later. Okay, let's try again. Put it out. Okay, done. Ah what happened? Why is this? I don't know why this is. Come on, give me a forceps. Okay, this, I'm not sure you guys are setting that clip properly. It shouldn't be going in and out when I go down so I'm not sure you're setting it properly there go down. It's not supposed to go in and out of the catheter. Like this. Set it properly open. Klaus open. Close open. Okay, take three. Let me see that clip. Okay, let's try. Okay, I get without no, how are you doing? Put it out all the way. Put it out. Okay, now start closing, stop. Okay figured. Okay, turn to the right, Okay, stop too much to the right. Good luck. I can't hold it more to the left, more to the left, so too much. That's the water. You really need to be a little to the right now. Okay, to the left, a little left left. Okay, close deploy. Okay, wait a minute, wait a minute, okay. No, okay. What happened to that farm? You have another 1? Yeah, I think it was and no water. Yeah, it's coming. It's um come off right. Is the pump on? I don't know, there's no current came off dead I think. Look at the connection back there has probably come off Stacy. Yeah, the pumps died. Must have gotten unplugged. It's probably got an unplugged. You see the wires? Where is the power cable? To the pump? Okay, the water pump died. I'm not sure what the problem is. I don't think that there's no there's no light on the pump. There should be a green light, yep. So where's the power cable? Is the power cable really its own It's a book man. He's probably died. How can the bum die that? I've never seen before. This is not a pedal problem. Half pump is that? And the gator. What is that? It's old. Yeah, sure. I need to make sure my arrows are correct. Try it now, that's the lead up. Okay. Alright, back to the torture. But these closures are often like that. If you are obsessive, compulsive about closing. That can be, you know, difficult. Okay, one more clip again. You can see how you cannot put an 11 millimeter regular clip over here. It's gonna pull the wall and close the lumen by 20%. This final clip over here, you just have to do a very short armed clip. Okay, let's do it. Yeah. Mhm. Okay, start closing, right? Yeah. Okay, to the bubbles. Okay, now let's try to rotate, rotate. Okay, stop. I'll get close. Goodbye. Uh Stop. Stop. Stop. Open. Okay. Okay, thank you. Okay, now what else do we put here? We tried to Sneak one in there. It's not gonna be easy. Not with this clip. You know what? Give me another. That is another low Kado. No, hold on. Because the streets are not catching the opposite wall there. I'm busy to see. I think it's okay. I'm not sure. What do you think? Although I thought that there was an area right there. Yeah, put another one right there. Give me this Olympus. Unless you can try to make it work. I got no place to deploy here. Okay, go out very slowly. Okay. Okay, start moving back. I'll put them back. I got to do to me. Okay. Oh, what happened there? So that last a little. Okay, It's gonna work cause your boy. Okay, open very slowly. Okay, I think that's the best we can do. That's why he's gonna get two days. Two nights before volume. Study. Okay. That's it, yep. Excellent. Good job. Alright, onto the next game to the anti reflux poem. So what about the fluid? Do you care about taking the fluid out that we have put into the stomach or that some sailing Good hydration. Okay. Yeah, but a little. And I have to know how much. You only change it once. Right? The water? The sailing some of the litter litter and a half sleeping in the stomach. Or you want to take sailing. It's not even water. There's no risk of, you know, if you want to stop all the contents out, you know, you can't you can't go through those clips, You can't go through those clips. If he I mean if he he's he's been NPR for like three days. Even if he aspirate sailing, nothing will happen to him. It's not food. The people put tons of sailing in the lungs with impunity. So, okay, let's go do the the poem. Okay.
