Originally Broadcast: September 29, 2022 | 8 AM - 5 PM ET
Case 2 features an Anti-reflux POEM procedure on a 31 year old patient with Type 2 Achalasia - initial presentation showed dysphagia, chest pain, regurgitation and weight loss. EGDs performed found tightening at the GE junction and a Eckhardt score of 9.
Alright we're here to start case number 2 31 year old male who presented with chest pain regurgitation and weight loss. He has had a G. D. S performed with findings of a tight G junction there was some improvement in symptom Atala ji with savory dill ations and some change in diet. On his part. Barium study was performed which showed a very smooth taper G junction, High resolution nanometer performed with finding of i. p. 2 24.5. There was 100% failed swallows and there was 80% pen esophageal pressure pressurization. Eckhart score 93 points for the two points for regurgitation. One point for retro sternal pain and three points for weight loss diagnosis is type two actual asia. And the plan is for dr stavros anti reflux poem. All right five to patient. So we're gonna start you know the way we always start with the end of lip. I okay. No. Okay so the end of live I used to have a baseline. You can also use it in untreated patients that are question marks. You can have a patient that has a manama symptoms that are suggested by Malaysia. But the nanometer is kind of plus minus or it shows you the outlaw abstraction which is a very um problematic. You know um anomaly diagnosis. There's a lot of such diagnosis and it's not always the best thing to jump to a poem. So you can use the end of flip as a tiebreaker. Hopefully the volume shows some abstraction. And then if the end of flip shows a distance ability. that is less than 2. 2.5. Then it it could be what I call a coll asia like abstraction that may benefit from a poem. Whereas if it's like three or 4 this is not a abstraction that you should be doing a poem on for classic poem patients like this patient. I we use it to look how tight the patient was before as a quantitative marker of that because that may correlate with poem difficulty we use it for and then we use you look at the response of the distance ability to assess the effect of the anti reflux poem. Then we can compare this data with conventional poem basically. It's a quantitative way to figure out how tight it was to begin with and how much it was loosened by say a conventional poem or an anti reflex poem. So it's very good. You know, quantitative data. So we do at 3850 miles in place. So we're gonna measure it at 31st and then at 50 In the literature people have used anything between 30, 40 and 50. But I now have data on Probably close to 600 poems at 30 and 50. So for me 30 and 50 is gonna be it because that's the only way to compare with the previous data But some people do use 40 suppose. So you can see now if we can focus the camera on the end of flip. Then I pull it. Is the plugs. Okay so we have a very tight typical type two patients here. Like the distance ability. As I said, less than two is very consistent with is a 1.3 little red number down here. I'm not sure if it's visible next to my finger but you can probably see the very tight waist on this finger. The compliance is 36.4 so very low. Then you flip. You get the minimal diameter six. If you are less than 10 that's pretty tight situation like Alicia and the C. S. A. Is 30. This also comes handy. Somebody at the healer and the opening looks kind of open. So maybe the symptoms are from reflux or from diet. No inappropriate diet. You can do the The end of flip if his diy sensibility after a killer is five say poem may or may not be helpful if it's 78. That patient doesn't need a poem. That symptoms are due to other things. So this is a pretty tight, very nice. It's what you want to see on an untreated patient. Okay So we record the data like the distance ability is 1.3. The compliance is 36.4 That the mean is 6.1. The minimal diameter is 6.1 And the c. S. A. is 30. Okay. And normally we do that 50 but here for the life course to expedite things. I'm gonna skip the 50. find the 30 on all the analysis of the data we did the 30 really is more reliable. Once you get to 50 the maximum inflation of the balloon you can get distortions. So 30 is good. So we're gonna also repeat it after the poem. Now we're gonna deflate and proceed with a poem. So now what what so what do we how do we think about these things The last 3 4 years I'm doing the anti reflux poem. We presented our data at D. W. As an oral. Um This year We matched 116 Anti reflux poems. 216 conventional ones for with propensity score matching for age, gender B. M. I. Type of Akhil Asia stage of Akhil Asia. And um I was the last great idea and I can't remember the 6th grade type stage oh and previous treatment. So then we um we wanted to see how much difference in reflux there is and there was an amazing degree of difference. Using the international criteria that leon criteria that ph more than six. So it's definitive reflex. The there were 29% positive studies on the anti reflux group and 60% 60 something percent studies in the In the conventional group. So it gets reflects by half more or less the same thing with a reflex episodes from 55 to 31 same thing with total acid expose the median total acid exposure Was 4.5% in the anti reflux group and 10% in the conventional group. Ah So very good data. The ideal thing we do to do a randomized study which we are trying to get going. But the initial case control data is good. So how do we do it? So this guy has a stage one non dilated, freshly diagnosed score was eight I think. Yeah. So he's a you know as as straightforward as poem gets. So we're doing an anti reflux poem in a 30 year old who is very thin and even before he lost weight, he's very thin. So he's at a relatively low risk for reflux because of low B. M. I. And because of a nice um straight so fingers no higher dal hernia. So he's he's uh he's probably gonna be at he his reflex rate for the conventional poem might be maybe 30-40% and with anti reflexes could be half that. So he's a good candidate for entities like now, if I had a previously treated patients with the sigma, the sofa goes that this 10 centimeters extremely sigmoid previous treatment with pneumatic five years ago, the finger is a little kind of open this and severe symptoms. This patient really is looking at at least a 20% chance of needing an object on me In the next 5-10 years. So whatever you can do to save them from to me is worth it. So the bigger the hole the better in that patient. Uh And if I have to take B. I. D. P. P. I. I'm sure that would like this better than losing the rest of a bush. So N. P. P. I. S. Are uniformly in this population. Super effective. We published our series in G. I. E. 610 patients over 20/10 years. Follow ups. Still 92% success at 9 to 10 years. Highest success reported in the literature. Um And only like 1.6% of patients required some kind of application. And this coptic or surgical all of them are back on P. P. I. S. Maybe they would have been twice a day but that once a day. So you still are gonna be on P. P. I. S. And then 1.6% developed ballots. Or peptic strictures all easily treatable. All of them. Due to the fact that they didn't want to take their P. P. I. S. But afterwards they got chastised enough to do it. So is super effective. So this is this is the thinking here. So this guy is very nice for anti reflux poem. We cut down on his PP. I use it for the next decades. He's still gonna empty. Great has nice traded. So we're gonna try and anti reflux form. So let's so first we do the measurements of the the the top of the gastric folds is uh 46. So our poem would start about four or 5 cm upstream of that. Say at 41 ISH. But again, we're not married to this number. The tunnel you can start anywhere you want. My autumn is the important thing. So if at 41 there's a particular you start more proximal. If there's a big blood vessel or the spine is bulging into much. You can just pick a nice flat area and start. You may have to do a few extra centimeters of tunnel but it's worth it because that will make closure easier to. So you start wherever it's convenient. But then for the my autumn E. We should probably cut starting where the pins starts. So about 43. Someone should write the numbers down cause I'll forget where's where's my mark? Where is all this stuff? Where's my marker here? Where's the market? Where is everything? So let's say so the top of gastric falls would be at 46. The start of the pinch or what the high pressure zone start. He's at 43. So we need to start them out on me at least at 43. Now for the anti reflux poem we call it also to two centimeter at two o'clock you don't want to do more than two centimeters because you're gonna run into the sling fibers. And the whole concept of the anti reflux poem is you cut the class fibers but not the sling fibers which is the most powerful part of the L. E. S. So to do that usually you have to stay to less than two centimeters unless you get the perfect orientation where you are in the middle of the class fibers. But if you encounter I go posterior. So usually you do encounter the sling fibers and you don't want to cut them. So normally you have to be one or two centimeters long. So so maximum that cardiac would be two centimeters which means with the top of gastric falls at 46. We would go to a maximum of 48 for the my ah to me and we'll start at least at the high pressure zone which is 43 for the Maya to me which means 43 to 48 is a five centimeter. My autumn E. Which is now typical typical type two type one poem. No type 35 to 6 centimeters is our typical we used to do much longer. I mean when I started the average was 11 to 13. And then it fell to probably 9 to 11. And now we are running in the six range, 600 m range for the type one and type two. We also shortened on the type threes. We should do twenties and now we are more like 12, 13 for the type threes. So this is what we're gonna do. We're gonna start with a bit of a diverticular um there interestingly there. So we are going to Um starting a nice area maybe here around 5:00 which is actually it's 32. So he clearly has a little bit of spastic segments that pretend to be this finger. So we're not gonna start at 32 obviously. Let's see where the real finger is here. Kind of got opened and bruised by us going in and out and stretching it with the end of flip. So this So 43 where the will start is three here. So if you're gonna start the bottom at 43 you probably have to start the tunnel at 41 to have some panel. So this would be the lowest possible. We cannot start lower than 41. I don't like this entry point. So I'm gonna like this area here Which is you know 39 that's fine. So here we did one litter wash, decreased the bacteria load, dr Ryan dr Buchanan did. So now we're gonna do a big blob to start with Again at around 5:00. The spine there is at 6:00 bouncing in. So 5:00 in a nice area. Might be here. 39. As I said not too close to the spine because that makes suturing at the end difficult. You're bumping against the spine. So anyway right here looks good. Huh? So we're not try to injection is important. You don't want to get into the muscle There you go. Nice translucent blood. I want to get into the muscle and then blow it up because then the minute you get in you'll be you'll have cut a muscle perforation. People have done this and then they got into a tunnel. But the tunnel was the the advantage of the and it can take you several something just to realize that it doesn't quite look like sub mucosa and then start seeing fat and realize that you're tunneling in a deeper plane than what you intended. So this is the blob at five o'clock. I kept my scope there to try and prevent it from going approximately. So I created a little ridge but it's still blown enough to get in. You're using the fuji scope here, right with the water channel at seven Or is this? This is the Olympus. Alright. HD 1 90. Okay. Open. Alright, so here we go. So entry point again we are doing a little puncture and actually don't get into a vessel. And then since I always closed with suturing I'll do a little smiley face. Not too big. I'm using The via three. Again the I'm using similar currents to the S. D. to get him ecstatically through the Mucosa. I think the best current on the Vaio three is dry cut. Um Especially if you encounter some vessels. So I do dry cat to get in and then um then depends on what I'm doing. I mean if there's fibrosis, you may use end a cat. The fibrosis has very long gone back tons. You need something that cuts well. If you know there are a lot of little vessels, a lot of popularity, you can continue with dry cat as I'm doing here. Or you can use precisely which is a blended current would be it would be something similar to some degree like swift on the old Derby, which is a pretty good combination for he is D and particularly I mean for poem and particularly for the drive for the mucosal incision and swift for the dissection. That's your haggis. That was your favorite currents before the vaio three. So if you still have the via 300, these are the currents for poem. I got to say instead of instead of swift, sometimes I would use forest. The force doesn't cut very well compared to the swift. So you have to use only the tip of the knife to be able to um cut instead of coagulating. But here in the bio theory so far I'm dry cut. If I encounter area with particular vascular charity, I'll switch to the precise sect and also use the precise sect on the my ah to me. So anyway, so you know, this is typical. Um Tunneling. Now you don't want to lose the orientation, right? So you know, I don't do that for short poems anymore. But if you are just starting on poem, you can do it. So you can see here. I start at five o'clock I'm gonna stay at five o'clock initially. Um a little bit of bleeding. So I'm gonna just precise like that to kind of coagulate. Try to find where the bleeding is from. Okay now. So how do you keep your orientation? So this is the muscle at six o'clock. So you want to make you want after a few centimeters when you put the muscle at six o'clock you have to make sure that the scope is in the same torque angle as it was when you started. So so to keep track of your torque angle, you can look at the numbers of the scope. But that gets confusing Because they are written on 180° on the scope. And you can get confused. So you can just put the mark on a piece of tape. So with a muscle at six o'clock here with a muscle at six o'clock at the entry here like the middle of the muscle there. You put that line. So now this is the neutral position That you have marked. So if you get three cm down and now you put the muscle at 6:00 and the line is 30° off. That means you your tunnel has veered off 30°. So we are continuing the dissection here. It's all I guess a combination of dials and torque. I use more dial work especially at the section in poem than on the S. D. Because they're in a very small space. So especially for the left side dissection, you need to use some dials for the right side. You can just use torque pulling backwards like this for the less you need to use a little some on both dials to um be able to move laterally to the left and then you keep watching the muscle. The other thing that tells you that you're not veering off orientation is if you are constantly perpendicular and that's why you should expose it perpendicular to the to the circular muscle. I'm exposing it here. So you can see the the grain, so to speak, of the muscle. So so you have to stay perpendicular to this. Now for a good demonstration of the entity flux poem. Um you do a less good anti reflux poem because you want to get close to the sling fiber to demonstrate it from a bit of two minds on that. And I try to demonstrate it. But then I um have to very close to it and also close to all the penetrating vessels. Because the classic landmark for the um oblique muscle or sling muscle that was discovered by tanaka and japan is the penetrating vessels that are just to the right border of the muscle when you do a posterior poem. So, so you have to get close to those vessels. Okay, this is an artery here, pal satan can tell because the wall is firm and twisty as opposed to soft, large and compressible and red there. So what you can do is ok, as a beginner, you should put the four millimeter co a grasshopper and take care of this and try to stay near the muscles so the heat doesn't spread to the mucosa and you can protect them because of by injecting it too. Now we can try and demonstrate what the japanese have been described as an F 1 10. You can coagulate a vessel by slow cooking into the with a knife. So you have to keep switching to the co a grasshopper um by using local and density. That means a flat knife like that. Right. And a very slow coagulate, very low intensity calculating current. So in the region is called an F 1 10 is in the Old Derby. That would be a forced effect. 1 10 watts on the new vaio. That translates to something like first coagulation with a very low effect 0.6 super low effect, which comes down to a max of about 12 watts. So very close to the 10 watts of the Old Derby. Uh huh. Okay. I think it's not a clean situation because I think there's other vessels behind this one. I think. I'm not sure. Anyway, let's see, I think there's another vessel there. It's a branch of it. I think it's a branch coming down from the Big one. So anyway, so there you go. Your big contact that means local and density and slow cooking current. Blue pedal. And then you can slow cook it without you know having to change to a grasshopper. So you cook it until you're sure that lumen is completely obliterated. As long as you can see a cylinder like now. Even if it's white cylinder, it's not, it's still alive and could bleed if you cut it. So you need to um make sure that the cylinder, this rubbery thick artery elastica cylinder is obliterated. You can't even massage it a little and there. So this is that vessel done now. There's some troublemakers down here. Um We can leave them for the my Autumn. E I think if I tried to calculate them and injure them, they're under the muscle in order to calculate them. I'll have to use the koa grasshopper to grab muscle and vessel. So we're gonna skip that now and continue our pathway to the cardia some dry cat and precise that again. Any questions. How are we doing with no questions yet. So right. Talk on the right and sort of left dials on the left. Oh y'all. So we're getting now to what? 41 ISH. So we have some while to go again. Not, there's no point in rushing. And poems are generally short procedures. Unlike es de more important to avoid any possibility of any complications. I see a vessel. There's a pale vessel behind there, right. Which is the reason I keep the injection very pale because this would be hard to see with a darker injection brand. And the paler vessels are generally arteries because the pale because they have a thick wall that obscures the full effect of the red of the blood. So this may be a small battery. Now the other thing you don't want to do when we calculate is keep the battery tented like that because even even very soft heat would end up having it ripped before the lumen is is coagulated. So you want to suck down and wrinkle it out. Don't keep it under tension like like that. And then we're gonna do it again. The slow cooking at 1:10 or the bio three equivalent of f 1 10. So there we slow cook it again. See I took the attention off of it because otherwise it would have ripped by now the medical thin and maybe before it was fully coagulated. There we go. But I rarely use quad grasshoppers anymore for oops. Yeah I see. I jinxed myself except now. Yeah. Right. Uh That was a jinx. Yeah. I'd say most poems now we don't use a quad grasshopper but he has enough time to fate and I still avoid it if it's not a big vessel. But see you want to avoid these things. It's stained now doesn't look as nice. You might not be able to see vessels as well. Yeah, we need um God punished my arrogance clearly. Yeah, this is a tricky one to do with a knife because it's all buried there. I cannot know that This is a lottery. Again, I'm using the same F110 here. See now, what do you do? See? See now, it's it's stuck to the vessel, right? So when you pull it's gonna rip and start bleeding again. So, as you pull you do a little blip of dry cat or whatever to let go of it. Alright, alright. How are we doing now? So, we may begin to see the oblique fibers. Here we are. 40 three. But we'll confirm as we go. I think there's a cluster of vessels there. See now you really don't want to get blood in the obscures your ability to see the vessels as well. There's some vascular it here or not protect them your cousin. And then again, use the force. How are we on the first? Yeah. Okay. Nice. Okay. Right. And that proves that with proper Knife handling. You can even cut with a 0.6 effect force as you see. I did a little bit of this is the very tip. Sorry, it is the very tip of the knife. And you can even cut with a super low force there. Now you have to get through this dirty some your cousin without accidentally cutting another vessel. I think that's quite latent. Okay, I'm cleaning out all the pottery. All right. You know, I'm going more carefully because the color of the salmon casa is not as transparent as it was before. And this is now as we get to the cardio. This is where the big vessels are branches of the left gastric. And these are the penetrating vessels of Tanaka that basically penetrating branches of the left gastric artery. We are at 14. My man. Hold on, let's do it again. We're actually at 48, wow. Yeah, so I got a little carried away. I mean we should be sure that's still there were 38 48 a half. So let's see, wow. Well this finger because of all the going through and out has gotten pretty obliterated. It's not very tight. Um Some people think that the C. 02 has a my elliptic effect too. So if you blow a lot of C. 02, the muscle relaxes. Let me see. And we also use gas. Gas definitely has a myo myo relaxing effect. So that's why when we do End of clip assessments of type three patients, sometimes we switch from gas to proper fall. So this is 48 here. Okay, so It looks from inside, it looks about one cm beyond the G junction. So I'm gonna need to go more. So there's a question starters. Exactly. How did you identify the g junction? Well, bye bye. In this particular patient was the straightest was like a shot. The numbers at the mouth are super accurate. So I I realized I was at 48. And we said that's where see that's the sphincter here. So this is he has not as tight as we know it from the manama tree. Because on the manama tree his I. R. P. Was 25. 26. I'm on is not here. But I think the manama tree, his I. R. P. Was 25 or 26. So like you can have patients with 40 50. These people these poems are very difficult super tight sphincter. You have to use underwater. You have to do use special techniques. You have to pre cut the muscle. These guys uh it was nice to us is only 25 on the I. R. P. So you can see here You can also tell because we burned the muscle here and not here. That's because we are entitled quarters so you can tell where the muscle begins. The muscle exposure begins. That's probably where we we actually look. This is 40 four 44. We said that the high pressure zone from inside was 43. So close enough so 43 would be here. So that's where the muscle starts. Usually the high pressure zone is three cm sometimes forced to stop at 46. Which it does. That's the that's the tightest part of the muscle. And then boom 46 is here. Now it's trying to lose from here, we can pass it, we can pass it. So when you can see where the bleeding is and it's very mild. You can be a little sloppy. Yes. And you spray the way you know almost like an A. P. C. Kind of way. This is a hidden vessel under the muscle. So we can try to sort of blast it with a coagulation bomb, right? That like a stand bomb of spray coagulation and like it stops. Or otherwise you chase it under the muscle and it doesn't stop. I don't think it's gonna be nice to watch this one. Or maybe it will. Okay. Alright, so now so if you want to clean your knife, you use a little drive but that might work and that cleans it like that. Okay. Um So here so this is the penetrating vessels. So you can see the oblique fibers. They're coming from the side. It's the it's the edge of the bundle. I can expose it more. This will be good for the patient. So this is the oblique fibers coming in. This is the class fiber straight ahead. Okay, coming in from seven o'clock to six o'clock to five o'clock to four o'clock because they go publicly. So if I cut here, I'm gonna cut them, right? If I cut up to here, I'm not gonna cut them. And I could even beer October 2:00 or 3:00 and go even deeper without cutting them so it's all a relative insertion kind of thing. But this is the oblique fibers there. This guy didn't have impressive vessels bordering them. It did have one that tried to bleed over there. So so we're gonna stay to the right of that and cut only the class fibers here which are clearly circular. Okay. Um so that's it. So we need to do that's pulsating impressively here. Okay, we need to cut um the porta that we're going to cut the The spin case from 43 to 46. We said we come to an ultra short poem. We can start here because this is as I said, where the burn is, is where the finger starts right there, where the muscle burners, we're gonna start at 42 ish And go to about 48, m mild. Um as we said, and stay to the right of those oblique muscles, oblique muscles Right here. 42, is where I want to start. Okay, let's do it. So how do you get into the muscle? Generally take off layer by larry the muscle. That's the safest way to. You don't try to make a hole down to the longitudinal. And then who can who can cut it just, you know basically you superficially takeoff fibers until you find the right layer, which is right there. You see that you see that you begin to see the longitudinal fibers there. So there they are. You can do underwater to magnify them. Near focus there. So there's the there's the depth we want. And so what are you seeing through that hole? Is the longitudinal fiber? It is right, There is no fiber. So again I make a small depth hole to find the proper layer. And then you can inject underneath which is basically injecting through the muscle. The advantage of the protect what's on the other side of the vessel there. So I that that most of the vessels and the masculine theories are either between the layers or deep to both layers. So the so basically what you want to do is for the first part of the cat, you give something like precise or spray. And for the final cut, where you want to be precise. And without no vessel, you can use dry cat or endo cut. We wanted to cut a dry cut. What do you want? Um Dry guide is fine. This guy has very good conductance. So everything works. So we're gonna put a little sailing underneath, especially to our vessels to um to basically separate them from the muscle. Try not to cut them. But if we have to cut them, at least we're using precise sector or spray. I'm using precise sect here. And then the final part boom cut. So initially precise acted. Did it then dry cat boom, inject their little bit of precise sec. And then dry cut. And then you you start veering off to the right here, avoid the oblique muscle. Right so there you go, precise doesn't get there's a vessel that inject precise dry dry. There are some vessels lurking there. So this guy has lost 30 lbs. I think it's gonna gain it immediately back. The average patient on our series like 610 Foreign Publications from 2021 had the 7th I think it's 17 lbs. The average patient gained 17 lbs. Okay, so there's a question just stepping back absent hrm and flip, is it possible to select patients for foreign procedures? Um I mean why why not this? I mean why not do end of clip. I understand but why not do manama tree? Well look if you have a patient where from cancer is not an issue and this generally initiatives over 50 and have lost a lot of weight and it happened within the past say six months. This is the classic flags. If you have none of these red flags and you do a barium and it's a classic bird. Big. This is nearly 100% ankle asia. And and they see that there's no peristalsis too. So a barium is efficient if you have all the proper conditions. Not. You know it's it's a pretty much classic barium classic clinical picture, classic symptoms. There's no concern for something you have to do an endoscopy because some of these people could be a. Ski severe such giving or it can be a peptic stricture and this this peptic strictures that reflects for years. And they are very low peristyle, like very um hypertensive houses. And you know. So So yeah. If you have the right patient with a classic clinical classic barium, I can see if you're in an area where somehow you can get nanometer. Sometimes the patients refused. I had nanometer years ago. I don't want to have it again. It's a terrible test. I don't like it. Now with these patients you can do endoscopic placement which is okay for them. Most of them some of them will wake up and gag the catheter out. They have really completely hyperactive. So for such selective situations, I can see a classic barium And classic symptoms. I'm okay with that. I think you are close to 100% accuracy. If you say this is a so yeah. So this is the end of the Maya. To me, you can see the ability models there from coming from here. And we stayed to the all the way to the right edge of the tunnel to avoid them. Right. And how long is the so we had 48. All right, 48. And the proximal land is at 40 promising like there. 40 43 or 42. 43. 43 to 48. So five centimeter model. Alright, so, we'll get done with a poem. Now we can do. I'll show you. So to confirm that you do, we did the sword two centimeters or less my anatomy. And to confirm what orientation is. In this case, I try to show the fibers. It might not be two o'clock. Exactly, maybe three o'clock. The orientation may not even be four o'clock. So I can show. So we do the double. Where's the XP where's the tower where? Okay. Okay. Let's do it. So anyway, that's the end of the time. So you leave the scope at the end of the tunnel and we're gonna do see people think that's a big deal. So let's say it's like 10 10 17. It's gonna take 34 minutes to do a double scope trans illumination with this technique of a second time in the room. I can use your travel card and immediately you know that you you did an adequate my Autumn E. Not too short, not too long. And you can also see that you have an orientation that is appropriate somewhere between two o'clock and maybe 34 o'clock. Uh You If you see an orientation at 6:78:00, that's usually not. You probably did not preserve the sling fibers adequately unless you did a super short my autumn E where you can see the light at the Z. Line. Um So yeah, so let's see. So that's very invaluable information. I'm going down with pediatric XP scope next to the other scope. This guy is gonna be a little difficult because he's a he's totally non dilated. So you can try on either side of the other scope to find something that will give you less resistance. Um Put some water. Maybe we have water. No, we don't. Yeah, we have water. Right water. No, I don't drink. Not to the pediatric. So you can use the water from the water button very tight. And he has passed the area. He's unusually difficult to put the XP down. You can put some water to lubricate things. But the problem is that he has a very stage one narrow esophagus. Okay. Okay. Yeah. Alright. Lost my cap. Now, I don't know it's on the syringe so it should be able to find it. All right, okay, that's good. Hold it there. Somebody has to hold the scope. Surely miss your duty. So it doesn't go in or out as you manage for the pediatric scope and the emperor not to end up in the tunnel. But the other scope. This guy can be difficult. It's very tight quarters here. No. Yeah. This Okay. Right. Okay. Better that that's the tunnel. Stay away from it. And tried to very gently we're going to the store mark and retro flex and boom, this is an anti reflux form. So this is behind the scope is about six straight under the scope is 12. So this is between three and two. Between three o'clock and two o'clock. Mind you, these numbers are the numbers that you see when you come down the esophagus. So you have to translate when you are retro flex. So basically what is 12 o'clock when you come down the esophagus here is on the bottom wall. 12 o'clock is bottom wall. Six o'clock is behind the scope And 3:00 is about where the light starts and 2:00 is where the light ends going downwards on the picture. Right? So this is it. And then how many centimeters you can do a little N. B. I. To show you the Z. Line even better. So there's the Z line there. How many scope with the scope of the pediatric is 5.95 point eight. About 2.5 wits so about 36 millimeters times three is a 1.8 centimeter my autumn in between two and three o'clock. Did you write it, yep. Alright so that's it. And 30 flocks form. So we're done beautiful. Now we're gonna close with. Okay we're sheltering the we need to do the end of lip. Right okay. Not too exciting, I'll try to do that really fast. Where is the? Okay put the section there. Okay quick kind of lip again. I'm just gonna do 30. So there's a way to put the end of lepine which is easy. You put it in next to the skull and you just do a little kind of lean out with both of them like one next to the other and that gets the end of flippin. Just do a little 12 between the scope and the end of that catheter. Um, I don't know how to explain it but gets the end of living very easily. So now we are the main thing is not to get it in the tunnel and this very narrow guy. All right. Is it trying to go in the tunnel? Yeah, he's a sofa because it's very narrow. Where? What? Okay. We made it so there we go. We landed in the stomach. Then we will just go back. Okay, let's measure inflate great one. So where did I go? I don't know if you asked scott. If you want to focus on the Okay, so 13 miles. 14 miles. At 30 miles inflation of the balloon will take the measurement that you have to at the end of it. You have to stick to your exact protocols. So we tend to we tend to wait About 10 seconds to acquit liberate when we do the post its um because sometimes you can see the distance ability rising for the 1st 10 seconds until it stabilizes not stabilized. It's 6.76 point 86.76 point eight. So it's stabilized now we deposit. So 6.9 is the distance ability. Um the it used to be 1.3 so you can see the difference the compliance and 1.3 before we did the pond compliance won 40 949 Um minimal damage at 12.9 more than doubled. I think it was six before and see cross sectional area 132. So very nice data. And six is not a lot you want for an anti reflex poem. We usually see something between four and six. We used to run in the 8 to 10 to 11 range with a conventional poem. So you've got the data. So okay I'm coming out this late. So this is at 30 miles not 50. This is at 30 30 miles. Okay If you put it under 50 you can cross out the 3050 and write 30 miles. So we are going to do a quick suturing for another five minutes and then move to the A. S. D. Come on you. It's always my fault are you doing? Is it deflated? So shoot during. Why should during are not clear? Well It looks it's more secure I would say when uh Thomas rose in Hamburg that second look endoscopy routinely when he's looking at those poems a day later. I think he found 10% were missing clips. Uh and that's 24 hours later. While n. p. o. So that's significant. You'll never see a decade since from a future done properly. And obviously I don't do second look endoscopy but I'm pretty sure that you won't get the future that is missing. Um So I think I feel more comfortable with future and people like oh it takes more time. No it doesn't. We did a study when I had done the 1st 50 or 100 suturing and the previous 50 with clips and the time was 10 minutes for suturing and nine minutes for clips. And the cost. If you use something like resolution clips was an average of six clips I believe at 250 each. That was 1500. And the overseas was 1000 less because back then the overseas was $700. But you know let's say 900 it's now and $100 for a seance in clip. Just 1000. So the cost is similar. The time is similar. Um Yeah and it's more secure. So let's do the over stage. Any any questions questions. Um Pretty much it. That was the last question about Hrm. And do flip. Is that necessary for a point? Mm. No. So can you talk about maybe mucosal tears if you know someone has mucosal tears if you get them. Because that's a classic learning curve effect. So your mucosal tears in poem go from something like 20% when you start You're on your first, I don't know 50 then it might go to 10% in your next 50 then goes to 5% in your next 50 or 100. Okay I got a message that all my family and his family from Winthrop is watching my previous hospital. I miss you all. Thank you. Okay. 100%. That's the temperature probe. What is that thing? Wait a minute. What is this? What is that? That's the temperature probe to the nose. Is that what it is this blue thing? Okay, temperature probe on the way down. Okay. So now so obviously the way to do the overstates is to turn it sideways when you get to the U. S. To get in. Because the US is sort of like a horizontal slit. So I could do a little sideways turn and get in. That's the trick. I never really never found a use the need for to use an over to it's easier than it's easier to insert on any US cope. I can tell you that. So um if you do this maneuver. So now we said the opening is what? 39 or so. Yeah. Okay. So here's the opening and we have a bit of a round hole. So we generally close it left to right. I thought I made the horizontal athlete, but it turned out to be as much vertical as horizontal here. That's that makes it interesting. Let's give some air. Give a little crackhead pressure please. So with the overstates, you have the situation where you lose their in some people because of this cable that is outside the scope. So my trick for that is to use crack oil pressure to compress the US around this metallic extra thing that goes next to the scope tonight. He's keeping the air because a nice anesthesiologist is giving expert crack wide pressure. Don't worry. It's only gonna be three minutes. It's sore arthritis on your hand. Okay? So anyways, I will start left and go right there. So in one pass then we'll do another. Somebody timing, I hope. All right. Okay, this is it, Grab the surge just 38 not too much tissue. This guy's a smaller. So because you don't want to get the big bounce up of tissue, they're trying to catch delicately just the edge and again. Now in the middle usually takes three passes. So let's try here cutting too much tissue. A little less tissue. I'll be there and then we'll do another press right here in the middle of the top side so right there. Just a bit. I'll just grab it just a bit there. Alright there. You do a little test bite If you have too much tissue. You do another test bite with lush. Make sure you don't end up bunching up too much tissue. You know, I didn't like this bunching up of tissue. So I started for some poems too. Not tighten that suture as much. I would tighten it until the two edges were opposed and not tighten anymore until they get to start bunching up. I got to bleeds that way from the vessels at the opening. So I stopped doing it. And you really got to. Since it maximally because their catch vessels right at the opening that could bleed later. So, can you comment on anti reflux procedure? Following point procedures. That's a long story. I mean, yeah, I guess you're talking about teeth. I mean, you can do you can always go to a door or to pay some of these severe refractory very rare or you can do a teeth now. I don't believe in doing a teeth at the same time. What am I doing? I don't believe in doing a teeth at the same time as a poem, because it makes no sense. You can end up injuring the tunnel and over 50% of the patients will not have significant reflects. So why do a thief on somebody that doesn't need it? Um Now, the data on teeth are even kind of being developed for regular reflects. Now, what you can do with somebody who has no paris styles? Do you do a loose teeth like the surgeons do a loose to pay at the door? Like how do you lose an active? We don't even know that answer. So, I think I would call it work in progress. I believe that it would have a role in a small set of refractory patients that have real reflex. But medication pp I don't work because of genetics or um but don't take them or whatever. So severe refractory reflux. This might be the answer, But not at the time as the point that Mr wrote an editorial not to it just doesn't make any sense to the teeth at the time of poem. For the reasons I mentioned. So, yeah. So, that's basically it. I think we did a good job. Sometimes I do an extra one, but this guy will end up narrowing his loom and if we overdo it, so, I think it's good. I did the three passes. So we drop the needle and we sent it and we have three minutes and 35 seconds. So it doesn't take that much longer than clipping. In fact, clipping can be very annoying because you don't want to catch too much tissue with the clips either. So you have to readjust the arms and just catch enough. Don't let one edge overlap the other because you cut more tissue on the right and the left clips can be I clipped my 1st 50 poems and it can be, you know, pretty involved. That's why I don't think you save much time. What about X tech? They use an extra. Just doesn't have the proper is a small defect. I mean, you can use it, but it's um it has four clips. Not six that extract. It's cheaper. And I guess you could use it. I wouldn't use for full thickness defects. Or if you have a perforation and you have gone into the media steinem because I don't think it's watertight closure. Like the overstates or the clips are because of the way it brings the tops of the metal together but not the bottom. So you're not gonna get water tight. Um And I don't know how durable these little screws are in terms of accidentally ripping out this future. What will pull it out? Nothing can pull the future out. Nothing. So what's why use I mean 600 instead of 1000. I just don't see it. You don't have a double channel maybe. I don't know maybe. What about if you had a further down would you use suturing or same thing? Because happened because you burn the mucosa. Which means that because ice is thin and afraid putting X. Tax in it. You have to go very far out from the mucosa. Which means you're gonna bounce the sofa, books, clothes. Not in terms of how would you close a small clip like the ones I used for the bankers. A small clip, not big clip, that's what I would use. That can be very difficult if you run out of options there on the g sanction the mucosa is burnt. Everything looks terrible. You try to clip and you are tearing you stop the tunnel with vibrant blue and do extra N. P. O. That's really the stenting an option on a on a the vascular channel. I it has been described by chinese groups. I wouldn't do it. So this is it's a good closure there. Right? Even food goes through, No problem, nothing will dislodge it. So now I'm gonna take this off and go empty the stomach from air and well done. Alright, so, well I'm here. Very nice opening picture and then there's a question, is there? Okay, let me check Um data of poem success after three years and after five years. Um Three and five. Well my data which are G. I. 2021 I think it was something like 97 or three years and 94 5 years had no failures after six years. So whatever failures you get for the first six years, that included my learning curve with some of them failed on year 23 to 7 maybe because I wasn't doing the poem perfectly. So but after six years, zero failures. So so the plateaus about six years. So the failures Can be because the poem was inappropriate. Had basically previous heller. And there was kind of open and their symptoms was not because the opening wasn't big enough. So they then they continue having symptoms. So that's a failure. It can be because you didn't inadequate. My Ottoman, that's a learning curve failure after 200 cases that should be minimal. You didn't do a good my Ottoman. So which was about six years. So so the failed. My Ottoman dropped. So really after six years, if you pick an appropriate patient, some spastic pain, people will not get better. Try to do exact camera nutcracker. So so if you pick appropriate patients that are not already open and the symptoms are from something else or that this is weird pain, heavy spastic time that you may think it's but maybe also mixed with Jackhammer this or narcotics, chronic narcotics with motility disorder. So if you get if you if you're picking an appropriate patient, they're not going to get better, but I'm gonna fail early the first year. They'll be like, I don't feel better if you're doing another to me. They also fail early one year, two years. So very ready to get after six years. If they were doing well for six years, why would they fail if somebody feels after six years the other started dating like maniacs scarfing down a meal in five minutes because they feel normal and you tell them to tone it down or they became more sigma because they d innovated muscle continues to become flabby. So now whatever hole you had is still nice and open but not adequate to the huge and you might be a second point to adjust the hole to the side of the or a peptic stricture because after three years they figure they'll stop taking their P. P. I. Because they have no symptoms which have the patients that have silent reflux and they developed a peptic stricture or oedema from their reflex causing an obstruction. So so late failures are rare if you follow appropriately patients for reflux and if you don't pick Cases that may not do well with poems. And if you don't do inadequate my autumns, which is you should only be in your learning curve after 100 200 poems, there shouldn't be inadequate. My autumns are hardly ever, Yep. Very good. Alright, thank you so much onto E. S. D. Yeah.
