Stavros Stavropoulos, MD, performs a POEM procedure on a 78 female patient with a prior medical history of gallbladder gancer and an S/P resection.
Hey, guys. So for the second case today, we have a 78 year old woman with past medical history of glow bladder cancer that was respected in 2000 and two. Uh, she was referred to us for progressive dysplasia to both solids and liquids over the past year. Um, the symptoms were associated with regurgitation, occasional chest pain, um, £23 weight lost and reflux about 2 to 3 days a week. The G D was done by the primary gastroenterologist and it showed a puckered e g j with abnormal contract il ity. Um, there was no previous treatments done for this patient, and her record score was nine on. That's the space. The three regular education to Richard Central Chest Pain one and weight loss off three. Via suffered, Graham showed a violated esophagus with Tapper e g. J. And that gives her a stage to a Malaysia. Okay, the hln was done and it showed elevated resting El es pressure with an i. R. P. Of 33. There was zero swallows with normal pressed al icis and five swallows with premature contractions, with the distal agency being 4.12 Swallows had hyper contractual motility. And the conclusion was a collegiate type three. So today we'll see upper oil in this topic my Autumn e a poem for with the type three and to flip assessment type three, my autumn e issues, and we'll show you the enter reflects problem technique. Now we'll take it to Dr Stephanopoulos. Okay. All right. So yeah. Yeah. So now on now, this is too far. This is too far there. Yeah, I want. So let's So let's some. There's a question about showing the Urbi setting. So how about we focus that camera? Yeah. So basically, we're gonna do again dry cat and precise sect, And then we could Sprinkle some mando cut in there as needed and maybe when some Sprague regulation, if needed. So this is what we'll do. Precise sect on dry cut on the set. Things are a little different than the way it works is all different on the bio 300. In terms of the numbers, this is it is 5.35 point six. But basically, you know, you got to look at the equivalent watts on. Then you figure out the sad thing. It's not difficult to transition from the via 300 of this one. So let's look now, Um, let's look at the situation with this type three. So there are various difficulty, um, studies for poem, a few of them. There's even a difficulty score and persistently, the things that make a poem difficulty are and stage disease with stigmatization bad. Those people also get you to persistent food infections. Fibrosis in the sub mucosa difficult to tunnel. So the end stage diseases one and type three or a collage or other spastic disorders. Another because the muscle is thicker. The Lumen is very small on There is you know, this contract il ity that basically makes it a little difficult Thio to do the dissection and that the my auto me the muscle can be especially jackhammer patients. It could be a centimeter and a half. So you are cutting a steak so it can be a bit frustrating on it makes the procedure challenging, but these are the two big ones off course. Prior treatment, especially multiple prior treatments, is another. So anyway, so that's why we picked this type three because they also had issues. How long to make the my automate, etcetera. Now let me show you the end of flip. See, unlike a live question, you have to flip rooms. You have the luxury to take our time with these cases. So I mean, normally I wouldn't show too much of the end off lip. I would. So maybe there at the end of leap at the end to save time. But now we can show much of everything. So I'm gonna show you the uses of the end of flip. So what do you What do I use the end of flip for? That's one of the gave a poem lecture last week virtually to the Mexican and those copy society. So one of the questions was how useful is the end of flick? Like what? What are riel Clinical applications for it. So this is this is one this study from Northwestern showing that looking at Rapid anta great contractions in retrograde contractions is assigned for type three that can actually trump Manama tree. So if you have ah Manama tree, that is, which is washed in terms of type two off type three, you can use the end of flip a tiebreaker and this you know this comes up frequently. There was another study that gave tracings of various motility disorders using HRM tracings to 10 experts on looked at their agreement in making the diagnosis and the type jackal, Asia had the lowest cap of value. Maybe one decimal higher than I think. DS. I can't remember. But it was the next to lowest agreement diagnosis. So that goes to show you some cases are clear, but some cases distinguishing type three from type two can be not a straightforward even for experts. So, you know, here you can use the end of flip. As obviously, it makes a difference in treatment because type you have to go longer. Type two. You can be very short. So you know it. Z good Thio have the ability to give a new alternative test to Manama tree in controversial cases. So here you see, I'm inflating Well, er my name? Yeah, do a little. I'm looking for the retrograde contractions here. Great. Oh, come on, You can't catch me early. Good job on this. Okay? Yeah. Overshot a little on the inflation court. Yeah. No, you got to show you got to show that Yeah, right. back here. No, I don't Take it to fire. Okay, so I'm gonna So you the end of flip screen now. Are you getting it? Well, actually, I could put it. I could put it. I could put it on picture in picture. Yeah. Okay. So now let's see if we can see. I don't know. Hopefully you see the screen. So basically, you have pressure again. Um, in color format so you can see contraction similar to Manama tree if they occur. Now, this is behaving like a type two patients so far. See, there's a tight sprinter, but nothing much going on there. Um, that I just saw some kind of activity. So you can see now you're beginning to get some activity here. Sometimes you can better do this in. Yeah, In a lower inflation of the balloon, you might go to 20 or 12. This is a bit of a debatable. Some people think you should go higher to stimulate their self up. It's like a bolus of food. And get it going. I found that wasn't going to say 20. I mean, too much pressure maybe overwhelms the muscle here, going lower. Sometimes you can precipitate this contraction. Now you can see that two rings that formed but no typical, sometimes also giving her with the endoscope insulating the sofa was like I'm doing now gets it going. So now you're going to begin to get this See, so contractions back and forth. So these are rapid anta grade because I go left to right. Um, and now hopefully we'll see some retrograde too. Yeah. So now these are These are typical rapid on the great contraction. So that's what we have here. Now you begin to get I think I begin to get some retrograde Here. I see it. Let me let me take a picture of this pause picture. Okay, now, these are almost simultaneous contractions. Now it's beginning to look like that going, um that these are some retrograde here kind of. But you see, you see what I'm talking about Now, the other thing you can use the end off for is Thio. You can see clearly now it's past the green that has formed several centimeters up from the L E s. So anyway, so that's what we have. Now we are this with this patient is difficult to get a distance ability in the strength to because once you get tighter rings in the sofa goes the end of flip measures those So it's a little trickier to do. Uh, then due to the contraction, there is constantly changing numbers. So it's, ah, difficult together. The good distancing building. Now that's the other thing. What does? Do we use the end off? Look for So you know, you get somebody that had a hell or 20 years ago did well, now is not doing so well and you want to know that would benefit from a poem you can throw trying a Manama tree can be problematic. These people have signaled the Salva goes the Manama Erekat the coils Even if you placed Endoscopic Lee, by the time you move them to the Manama tree, seeing the cattle would have flopped backwards. But you can quickly on the endoscopy, put Ananda flipped position is on the strength and measure the diameter, measure the distance ability and say, You know what? This guy, he's a little tight. He would benefit from point. So that's another very useful criterion. Now, for the last £500 I've got an end off measurements before and after a poem, and I tried to correlate this the subsequent reflects or failure mind you are six year failures are only 9% so there's not much failures. Thio have statistical power here, so maybe because of that reason, we haven't been able Thio Thio get something reliable out of that. We got a little bit of here and there, but the idea was, You get this. You get the statistics to show there's this golden Range where if a distance ability is less than four, you will have this pages symptoms. If it's more than eight, you'll have a lot of reflects and keeping it between four and eight. What whatever technique or technique variation you are investigating. You may be able to have the best of both worlds, but despite 500 pairs of values, way don't have strong. We have some evidence that works on the aggregate population level, but for each individual patient, the viability is too much the work. So. But you know, as I said, it's very useful for many other reasons. So, um okay, so I did. I I measured the numbers at 30 and then we'll measure them after the poem to somewhere removed the end of flip. Now on Get on with a poem, Yeah, Now the second question is, what length? Years ago we were at e Don't know. I've done a 27 centimeter, my auto me 26 some type three patients, but I think that's excessive, I think Now I run between 11 and 15 at most, but also for type two and type ones you want from 10 to 11 to like five or six. So it has been a constant shift over the past 56 years to shorter. My autumn is because it was evident that you don't get in much from long a sofa. Geul bought the my autonomy. So here we start by measuring things. So the beginning of what we call the high pressure zone is here about 38 38. The high pressure zone. Um, and then we decide how much of this contract Il ity toe a blade. I don't know longer favor of blading a lot of it, and there's some suggestive evidence in the literature, but it doesn't help. So it's ironic the one indication where we clearly by the guidelines off mavens are Sapir together may actually turn out to be a bit bogus because a length of over 10 centimeters and actually not make as much of a difference or people think for type three aka later. So, you know, having said that, it's gonna be longer than a type 21 because you can see this distal spasm can have its own obstructive effect. So s so the question is, how far to go. So 38 is the beginning of the sphincter. Um, should we go to about Uh huh. This looks kind of Lopez I'm thinking about. See, that's the That's the pericardium taking in the spine here at six o'clock. I think that looks as good a spot as any after the pericardium a bit. So I'm not 30 three or so. So and then, obviously posterior entries. Easy. Now you have to watch about. You have to watch this vessel. See? Hard to see, but there's a pink vein running at 50 clock right here. It's frustrating because they always show up where you want to enter. Um, so we have to go, maybe over it. So normally I would go right where this vein is, I'm not sure if it's visible, but right here it runs up and down. These are just under the surface, so if you hit it during entry, it can be extremely frustrating to coagulated because the edges are parallel to the to the mucosa. And the more you burn, the more you expose of them so they can be frustrating to deal with eso. I'm trying to go either to the left of it that the left of it, the spine is there. It's very important to pick a good entry that makes your life easier tunneling. It prevents tearing, and it makes the closing easier. So it's very, very important to pick a good entry point. So this is a good possibility here. I'm Africa's human spine kissing each other, and down here it's funneling in. So this we should really cut this, probably so this is the best part, but it has events smack in the middle. Um, uh, sometimes it's That's a good spot. We just have to deal with a vein and, you know, in this case, I'll say whatever. We'll have to go through it. It's if I try to go and clearly to it. The tunneling is gonna be a little more frustrating to go posterior early. The Spanish gonna be pushing the scope to the right. I really want that spot that then is occupied. It's mine on. I'm gonna take it even if I have to do some nasty, unsightly coagulation as I'm trying to enter. Okay, Open. Uh, let me people. Yeah, yeah, but now you have to move the cameras scales because I like it here. Okay, Hope, Soups. So that's about 32 right here. Um, I've got I could go. So the blood is very important. If you don't see any translucent blue stuff like this and you see a pale Caribbean green with white, a pack off bake stuff that means you just tap verify brought IQ area. You want more? Oh, so you know, this is nice blue and translucent if you see white fish with some green tinge that if I brought the chaos so you might as well not even try to get in there, try the opposite wall or some other walls. But here it looks nice. Eso Now the vein is right there to my right now You can see it much more clearly. I'm gonna try T o C. Precise sect is gonna help May overcome it. So I make a make a puncture to find the proper depth, and then I start slicing. Now we're getting to the vein, so I'm gonna do a sustained pulse off precise sec. Looks good so far. But let's not celebrate yet. Yeah, again, You don't need a big hole. Smaller holes idea to close, so I'm gonna extended a little bit. But it's surprising how smaller hole you need in order to enter. And then you can Yeah, it's good not to use a lot off knife. Now that's the vein. Here you see it under there, it's katydids. So that's why they're so difficult to coagulate if it starts bleeding from there. Um, it's just annoying. Now I'm using precise sec to enter slowly. Okay, so you see here we should get down to the muscle almost and leave all the sub because on the mucosal side to bolster its So there's not tearing off the sub mucosal entry side. So you just work at the bottom near the muscle, and then when the tunnel and now I'm just a section with precise sex going down, right? E don't have to be processed. Instead, I got behind the bar. Yeah, I know. Okay. Okay. Do vessels there? I would dealt with with a knife. Um, much. Thank good. Okay, so this is good. Now we're getting I'm at about 38 now, So now things are gonna get interesting. Um, because it can get tired. So this is the strength, the beginning of the strength. And now there's a penetrating vessel here. Um, what we do is we isolated a little, uh, looks like a, uh, vein. It hit us up very easily. So just a vain nothing to worry about. I think I got precise. Sect does the job. So now again, it doesn't matter. Hitting the muscle that gives you your orientation. You want to see the circular fibers, you always perpendicular to them, and you don't end up spiraling little penetrating vessels. Okay, there's some some people advocate doing the my autonomy simultaneously with tunneling in the summer. Because I like I like the way we did for the bankers. Sensory. Um, I don't see the reason. Except when you get very close to the stinker. Sometimes I do what I call a pre cut. So we start cutting the muscle because it's so tight that we cannot get the proper tangential entry into the cardia. So we'll do a little my autonomy before completion of the tunnel. This woman has some using, which can also be irritating, basically bleeding from places that you have already dissected. That can be frustrating, especially this diffuse Susan here. I'm not sure why. Yeah, I'm using precisely which is like a blue blue pedal current. So it has. It has enough coagulation. But just having all this random Muslim don't know why this is under than you cause us. So we have to be a little more careful. Banda is so the ultimate automatically mentioned cutting into other. Uh Okay, So usually so. The high pressure zone was at 38. Usually I end up with ending that none of the motto may at 4 to 5 centimeters after the beginning of the high pressure zone, which is 2 to 3 for the sphincter and about two for the cardia. Um, Okay. What happened now? What happened? Others. Why? Just well, with drinks the Arab I got lost, lost, lost electricity. Okay, I lost electricity. Um, okay, so now I'm at about 40 so we need to go. As I said, 38 plus four will be 40 to 38. Last five will be 43 so but this woman is using a lot. I'm not sure what her colleagues were are we'll see. What's your any anticoagulants before she's coming off off off field, using from places we already cut with calculation currents. Right. Okay. Yes, he's losing from everywhere. Really? I'm having had the switch to spray because this is this news. Er okay, we are at 41 41 so we should need another one centimeter or to finish the tunnel. Okay. And then So basically, when you get here, you start thinking about the degree of cardio, my automate, the angles, the sling fibers. So I'm gonna cover this on my lecture. But in 2018, we started doing this and the that's immediately after we finished our anterior posterior randomized trial, which was a bit of a dot because it didn't show any difference on reflects. That was the main reason for us doing a 250 randomized patients toe anterior posterior and the result was similar. Reflects the posterior waas faster and had less mucus. Autumn is in the cardio and what not, but nothing on reflex. So then we're like, Well, maybe we need to do a little more careful job trying to preserve the sling fibers. So and we did So we did this. We call it anti reflex point because not really so percent era posterior. It's trying to preserve the sling fibers which come off from the left. Here, when you are posterior, we generally stay to the right of them, so we never really encounter them much anymore. You to encounter them, You probably have to go at the six oclock position with your tunnel. I mean, if I dissected, I'm gonna find them for you. But I just think that's a little, um, unnecessary. So they come up from the left. I mean, the deeper you go in the stone mark, they're more likely to encounter them because they run from left to right. Can't oblique, which is the other name? So So if you go far enough, so it's not just about orientation, it's just about length, so you can you can follow down, You can see here. This is Ah, typical circular fibers. So as long as I stay here on the right, I'm OK. But again, if you go deep enough, you'll see them come in front of you on that, we look like circular, because once that come in front of you, they take a similar orientation to the to the circular fibers. So you got Teoh. Be a little sophisticated about them, Uh, and then you have to avoid catching them. So here, about 41 approaching 42. This may be a good time to stop, because I don't feel any any sphincter pressure anymore. I have a wide open cardia on that makes you see, I tried precise tried toe power myself with precise sector. This vessel's it almost worked. Oh, yeah. You have to think that nothing is magic. Like given precise sec. It's not magic. So you can you can actually use some straight now to try and overcome it so I don't have to put the forces down. Now, this is the new cause us. So we have to be more careful. Uh, yeah. So there's a little there now we have to get the one on the muscle side, which is down here somewhere, bleeding up it za supporter. So we have toe overcome into the little spray. Okay, so that's that's what that little Sparta see, These are very small vessels, but they were arteries. So totally different ball game. Um, yeah. No, I was going to precise sex. No, I'm not sure if I need to keep going that you're right. Now I'm at 42 going to 43. So? So I think maybe time to stop here on. We used to just do it based on experience, But you know what? Now, also, because of the study, we put the X speed down on, uh and take it out. Second position, car orientation are length, length off left in the card and what not? So I'm not. I'm at 42 or 43 here, so I'm going to start on my auto May, and then I'm gonna check with the expected to see what? Whether I need Thio do anything further in the cardia. So I'm gonna go here where the main think there is on dissect it. Okay. After this presentation. Oh, okay. I guess he's kind of losing from everywhere. Okay, so these are longitudinal fibers right on. We'll do a full thickness, my art on me. So whether I go through them, that would go, uh, give me spray. I'm really tired off those, and I'm really tired, so it gives Suzanne Suzanne using, so it's gonna be value some spray here. Important. Okay. Yeah. Mhm. But yeah, from the missile cats is just Susan. Okay, Decision from them. Because of two. I'm injection to protect it. Get this line here. Yeah, she's She has some some kind of calculation issue. Yeah. Has he got any previous surgery? Uh huh. You know happened for me? Yeah. This is this is this Maybe she's taking on my God three and didn't tell us about it. Yeah. Yeah, this is a bit frustrating. This Susan, look at this. Okay, Um, okay, we did this finger here. Would suit facilitate putting the XP down? Okay, Lets would be explained and see What's the situation in the card. In the meantime, she's losing and losing and losing that. Excellent. Mick, give me the force that's given a force of I mean, if you use a spray can and toe. Do the tunnel. You are. You're probably gonna get less bleeding. The problem is, the spray car intends to spread everywhere. No matter how careful you are. Uh, you can if the because. See this. This type three patient has a very small Lumen if the because off the tunnel, it starts in them. Because on the opposite wall you can get a burn just because of the way the current jumps on delivers energy. Where where there is resistance. So here, this is on the new cause. And so we're being gentle. Okay? Ah, yeah. Okay. Lets start to do that speed. Okay. This question. You ever tried using a rise jail? We didn't get Okay, there's a question about alright. Jail. Um, I just don't see the purpose because with a hybrid knife, the technique is in that cart in that card in the card. So say you're cutting immediately What you injected. So sailing works fine. Oh, rarely you get somebody that you know, I don't know to Heller's and 15 Botox injections, and you're not trying to bypass a monolithic wall of scar. Um, there you need You need to find the plane a micro plane and then expanded by dissecting the scar tissue and finding a way on those cases. The jail, um, when injected in that little micro plane can have a more sustained effect than the hybrid knife. But I would say that even before the these were the cases where I don't think anybody would be able to do them without the hybrid knives and the, you know, I don't know, thousands of PS I pressure that drives the sailing into that micro plane. Um so in fact, many experts centers have a 2 to 3% of border rate on poem, and it's nearly always due to expensive PFI brushes. So my a portrait is exactly zero, but I've always used hybrid nine from the beginning. Um, so I don't know that I think that hybrid knife is very careful. But occasionally I think having the right gel can give you an extra advantage by getting a little sustained blue plane that could show you where to cut. So but I use it on extreme cases, but you know, But I also used on every years D I do because of how how tremendously useful it is. But for poems is one area when I don't think I think sailing. That's fine. Especially in a patient like this. Without extensive I brushes. Okay, Sometimes putting the XP next to the regular scope can be a little annoying. We have to try on one side or the other, and then we go. That should do it usually. But Caesar, in this type three patients, everything is tied. The upper specter, the Lumen kind of be really fighting us utterly. Female patients to, I think, have some degree of crack offering Geological Asia. Question your patient from your other forces, you know, would have been anomaly, I guess, is what you're asking. Question, but you don't see that? Uh, no, this using is unusual. Usually we have a bloodless poem. This this using, uh, I think a lot of patients take some supplements that we don't know our having meticulously told them to stop. That's what happens. Okay, this is this is unusual. I'm having trouble putting the XP down. Um, I'm gonna try not try the nose, because that gives you a straighter shot to the do es. I used to do it through the nose in the beginning, but then I decided. Yeah, I know. This is not so. Yeah, but knows is no good. There's a small nose and she has a super tied you. Yes, but this elderly females is that people that get the Zanker is because of this reason. Also, you have us dysfunction in a collegial patients. 50% of them. It may be a protective reflects because of food sitting around in the stove. Aggression. Okay, this is Ah, this is unusual. Okay? It's not a loop for us is really tired. It is almost as the beginning of a bankers here that pushes the scope to the side. I hope we don't injure them. You casa. Thank you. Okay. All right. Thank you, brother. Okay, we finally made it. Now, in this difficult ones, you have to make sure you're not pushing the other scope down and perforate the tunnel. So, Dossena, please. But that's a nice holding. The other scopes. I don't accidentally push it in by friction and end up tearing up my panel. So there we go. So this is how the scope going there on this is my XP wiggling down? Uh huh. The light looks a little high up. Let's see. I guess so. That would go so in our usual definitions, this would be a three o'clock. My automate er Okay. It's completely opposite. The fund is a kind of 90 clock or so, Um so it's it's it's approximately. See, the bottom is interior on the part behind us for the topics posterior. So that would be 12 6. And then the fund is nine. On the other side. Three, this is about three. And now the length of the motto May He is a conservative, I don't know. Maybe once at the middle, slightly less. I think that's too short. So when I do my tunnel, I'm going to extend it by another centimeters. So So it was gonna go. The thickness of the XP scope is like 5.7 millimeters. So this is Ah, five millimeter cardio extension. I'd like to be at 15 or twenties. I'm gonna do another another centimeter at the end. A z I'm doing the my out of me in the cardia, but it looks good. Okay, so the orientation looks good. See the slink fibers? You can see them forming the angle off hiss there like they would be wrapping around the endoscope on the left side of the screen, going up on below. So we are right. But number A off this comment off slink fibers running anterior and posterior early. Eso looks good. Okay, so let's go extend the panel. Let's see if she started bleeding again. But, yes, this this amount of the few Susan from random spots is unusual. We've seen it before, and it hasn't translated into any, you know, tunnel bleeds or anything, but it is a bit frustrating. Okay, well, there's no more blood, so we're good. Okay, Now, let's let's extend. Well, let's finish with a proximal, madam, you don't want to extend the cardiac part because if you puncture the peritoneum, then you have very blow. I mean, gas blow again while you are doing a proximal my auto me where you never have any gas problem if you know what you're doing. So you live the card here for last, in case there's a thing into the peritoneum membrane. So we're gonna finish the proximal part of the modern. And again it's a type three patients. So we're going to do at least 10 11. I would say, Yeah, with hair. Yes. What most? So this is the opening of the tunnel. So I'm gonna do just a little more because I'm not about 30 four here from this. Gonna cut this here question. You always look yes. So there's a question about going proximal to distal or distal to proximal the sofa goods. It really behooves you to go proximal to distal because then you can see what you're cutting and you can you can basically, who can card regulating the death? Precisely. Now, when you get to the very tight sphincter, however, going proximal to distal may end up having the knife pulling the muscles. That was the because I'm burning it and creating a perforation in a very difficult area to close. So people there do what Joe calls the push pull technique. So even though here you will do the push technique like push, grab, lift, cut at the at the area of this very tight figure, you do the pull technique like that. But obviously that the depth here is much less controlled. If you if you are a beginner so you can end up getting some in the external structure or something of that sort. So generally push in the summer because it's a push. Meaning you push. And you cut approximately this style in a very tight, stricter Carefully, you might do at least partially a pull technique. They start a proximal. I have to say, this finger is not particularly thick for a type three patients. Okay, So again, you know, sometimes there's a bit of a confusion between type two and type three. So this is a full thing. Is my auto. May on now we are going to extend in the cardia. It's the time. So we're gonna inject here and then lifted God. Well, now. But I really need the monitor there. Why can you pull the cameras to the side? I'll pull them more. I really need my monitor here. You could stay for the SD. Maybe even more important this support. Who cares? But I can I I need the monitor idea. Okay. All right. Now, as I said, Well, we'll need to extend a little off the card A because we stop just a smidgen too early. Yeah, and we need to do just on extra centimeter by us. Another problem. We're just going to extend by a centimeter here. Mhm. Well, it is a bit of a problem because part of the reason I stopped there, that's probably one of the most common reasons of people failing poem is because I run into a bunch of vessels that I really would rather not mass with. But now we have to mess with them. I think they're hiding that at the end of the tunnel. So s. So let's let's extend the tunnel here a little. So we're gonna exact right here. Uh, there's also fibrosis here because the lifting is terrible. People people biopsy over here all the time. Good. Anyway, so So I'm gonna do a do a little tunneling on the top to expose the muscle and then cut it. So basically, um, extending my tunnel a little here? Yeah. Mhm. There's a lot of curriculum on the endoscope. That's why there's all these white yellow reflections. I mean, ideally, I should bring it down, clean it, but I'm almost done with my autumn so I can clean it. And then so your final have you while I'm while I'm doing the end of flip. See, I'm using spray here but very carefully to avoid burning them because I'm hugging the muscle here. I did almost a extra centimeter here. Almost, um, extra served a meter, but I'm begin to get in the public fibers. Here. You see? You see how it's getting a little. Screw it. I got to stay to the right here. There's a vessel hiding there, so there's the extra almost eight millimeters plus 6, 1.4 centimeters. So be fine as a vessel here. Yeah, okay. There was some vessel hanging there. Can see exactly where you always perform for fitness. My protect three. What about another question is do I always perform full thickness? My autumn A for type three. And what about other types? So, Yes, I I I always perform full thickness model because, frankly, that's what the surgeons do want to do. A heller. I've never really tried to titrate the thickness of the my automata. I think that's a proven procedure. Invasive, as it may be, has very proven results. So I I I mean, the advocates of the partial mountain mainly focus on safety, but I think at this level of experience and posterior early, I think safety is preserved even with full thickness. Ah, so I think I did enough oven extension here. Right, Here's the car. Walk for what you've already answered. And that is What do you think? Using trading gastric God, the extent becoming my yes. So the question is a good one. Um, there are some penetrating vessels described by Tanaka that the knuckle vessels or the two penetrating arteries, um, that branches of the of the left gastric that tend thio sneak into the subject. Cars are right between the end of the Blick bundle and the circular, so there may be a good landmark to identify the black fibers. I It's a bit of early Kratz, maybe, and, you know, frankly, I have found it to be not a constant feature, its president, a lot of people, But it's not a constant feature. The anatomy that you are not only there is not as as goes down as you think so Here, for example, we didn't see any Tanaka vessels, even though I'm hanging the end of the black fibers there. So you know, you just have to have an understanding of where the public fibers are. That's much more constant in terms of the orientation on where they started, where they go compared to where you're Cannaday on that I think in the end, after you gave some experience, that's a more predictable and reliable way Thio preserve them is to basically know where they are and avoid them altogether. But, yeah, sometimes you see them. Sometimes. I did a live form at the N Y s G course in December before covered on. I saw that on two reflects poem where you could see very nicely the Tanaka vessels and the public fibers. But in this patient, if I saw them, I would point them out to you. But she didn't really have them, or at least it didn't have them at this orientation. But it za supportive evidence that if you find, helps you orient. So I I extended by think to almost 1.5 Kanye, my auto me here I can extend more, but at this point, we're going to start getting into reflects territory. This is a type three patient man uses a woman's is also it is not going to reflux anyway, but there's no you're not going to get any further advantage beyond this point here, So yeah. So that's what we did. The extension. So now I'm at 44. And the beginning of the high pressure zone was 38 So yeah, I'm six centimeters beyond, So I'm good. I'm good now. Okay, We're done with the madam. Now, let's do a little tots up because he has all these users. Let's let's starts up like this one here. We don't force her. Of course. Let's start off this one, and then we'll do the end off lip. Um, mind you, this point can be done in. Usually done by made half the time. But here I'm taking my time. Thio make it more educational. Well, maybe not half, maybe 20% last time. Okay, so now let's find all the users. There's another little loser there on them, because outside say, I wish I could inject a little, but yeah, smoking. Okay. Little more using their from somewhere. So in, like, 700 forms, I think we have to tunnel bleeds. Uh, on one of them was because they had to go on helper in the day after the poem. The cardiologists insistent. So we really had one. True bleed one out of 700. That's probably because of the electrical profile of the dissection that we do. But also, we never live any users at the end of the case. Now, this kind of pre emptive calculation at the end, I don't know if I do it in 2% of cases at this point, 99% of poems are fully human static. And this this room on everywhere I move my skull backwards to get out, she starts using. Yeah, usually smoke. Huge concept. Yeah. I mean, for these minor losers, you don't have to grab and pull and regulate just a little bit of touch on the soft calculation carrot that ensures you are not gonna go too deep. Yeah, I do. Little taps off soft coagulation tow. Avoid that in your because our ledger is I think that's good enough, I think. Okay, Alright, that's it. This is the defect that you have to close. So the reason I do transfers different is obviously because for the last 600 poems off, shooting them closed. So this it looks nice and open now, but not to open. Yeah. Okay. Now I'm not clean. The scope and put the end of flip down and we can do we can see what we have It's gonna be in most poems. That preformed distance ability is the 1.5 to like 0.3 range. And then after the form, we get it to somewhere between 3.85 on that zey, you know. Ah, well done for, um without tremendous risk of reflects. Ah, and my story. Um so another utility of the end off lip is this, you know, fest of a disorder called the day after obstruction, which is, you know, it's like this figure of what I dysfunction off people that do pawn a detestable disorder because it's often functional on a poem would not only not work, but make the patient worse. So who do you pick with the needed? The outflow obstruction, which mind you is defined very loosely. A very permissive lee. And that's probably why we over diagnose it. But the scalp declassification is working on making a more restrictive set of criteria. But you know, so you get this thing people with kids you have How do you pick what to do? A poem on you know one, uh, one essential. I mean, you have to do a very good evaluation. Can jump into a poem that will be a disaster. At least half of them may not benefit. So you have to dio try Botox, maybe try medication. But, you know, end of flip. If you do have a distance, ability is less than one that slam dunk, maybe earlier collision or the beginning of a collision or in a collegial like it is the outlaw obstruction. Um, on. If it's if it's more than if it's three or more clearly, you should stay away in terms. Off Poem 2 to 3 is a bit borderline, but you should probably stay away anyway. Um, less than two is what you want to see. If you are considering poem, it still doesn't guarantee success like like it would in a typical like a leisure patient. But you are in safe territory, I would say, uh, distance abilities clearly below two. So that's a very useful application, because there's a lot of it is the offload diagnosis out there, and everybody's trying to do a poem on them quick, a lot. Mhm. This is for more. Have the biotic prophylaxis is a bit debatable. Like we give you, use it at least one or two days. And then when I go home, the length depends on how complicated the poem is. What comparability is immune Suppression. The patient has, um, things like that. But, you know, the least would do is today tomorrow in the hostel and maybe one day at home. Could it be too much? Yes, but this is a big It's a big downside. Now you don't want to get any any infections? Um, it covers. What does it prophylaxis? Maybe the small in document of media Steinem and maybe some little aspiration during the incubation. Also, you cover those. So yes, I think antibiotics A few days, Not one day, not seven days. A few days, like one day, one day in the hospital. If they stay, we send some patients home the same day. Some people stay and go the next day. So they get antibiotics in the hostel. Then when they go home and be one day, maybe two days, maybe three days, not seven days or something, depending on you know, various aspects. For example, Sigma The Sava goo is full of little money. Liel candidate spots here, there, they get more antibiotics. So we're doing the end off flip now. So again, you want to see this sensibility off 4 to 5. 50. What? We do it. Something, like, seven or eight at 30. That indicates a good poem. Sometimes you get smaller numbers in young, healthy males with a nice, strong hikers. You get smaller numbers, but you know, that's that's okay. I used to get concerned, but they do, Okay. They just have a nice on stretched muscular diaphragmatic height is that it's almost like having a second finger there. So this is the Elias here? Uh uh huh. Yeah. Give me Oh, yeah. Okay, so here we go. Um, you let it a quick liberate a little, but it's in the upper force, maybe upto 54.95 point zero. It's smack in the range that we like. I haven't been able to statistically prove that this is the ideal range, but that's partially because I don't have enough failures on, you know, other reasons that have to do with statistics, but so I'm gonna freeze it. They're not. Went up to 5.6. Because with the layers 5.6 Very good distance ability. At 50 we do measurements at 50 and then we do them at 30. Any other questions? Direct? Anything people were asking about the solutions used, the solution. The solutionary. I answered that human gel gel. Uh, yeah, for this year's sailing, apparently you can put a rise in a hybrid knife, but it z not needed. Napo, I'm Except if you get severe fibrosis. Yeah, please do it because I'm getting distracted. Okay? Deflate. Okay. Uh, can people hear me? Wells still the South crystal who used to be a nurse? He's our ears in California. Assuring has that people can hear me, but I just keep checking now. Here's because I had some the morning. That was the issue. In the beginning, we had some audio issues. Video. Okay, let's go to 30 males. Yeah, and then take another set of measurements. Some people take even three points off measurements and that create nice little beautiful compliance grounds. And then you can then look at slopes to So not only can you see a started compliance at some inflation, you can see how rapidly compliance changes at different balloon calibers. This is a nice extra metric. I think it's maybe a little overkill. Uh, what's right? So the distance ability at 35.8 as well? Normally it's a little higher when you go from 50 to 30. Another question. All right, You got the numbers. Oh, postpone 30. Okay, so that's it. Now I'm gonna shoot you. Deflect on deflating along our search. As I said, how do you close? Um, e I mean, you saw how anxiety producing the bankers closure is, uh, dealing with little mucosal clips. I mean, I was doing a lot of shooting from the beginning. Just putting the scope down and doing some featuring is very easy. So So very early on, I could see that we did a study that we published as part of a review of suturing off 70 clipped poems. That's the only ones I ever cleared. The 1st 70 versus the subsequent 70 that we shoot. Heard. Yeah, on the time for closure for both was essentially identical back then. It would take me nine minutes with the clips and 10 minutes with the over states. Um, now people are What about the cost well in the United States and over states. Plus one suitor is about $1000 which means that if on the average poem all the publications say you use five or six clips, even if the clips are $150 or $160 the cost is equal. So we found out that cost was equal, based on US numbers, for the overstates, much more expensive in Europe and elsewhere. But it's very equivalent, and there was no other difference in complications than anything else. There was a slightly better length of stay with the average states, but then this was later in our experience. I can can be a learning curve biased so but there was no difference. So in which case, if you have a much more secure closure, why not avail yourself off it? So I've been shooter, and now the average structure duration is more like three or four minutes or so. So uh huh hello, It is greater than the call. Are you considering reports procedures? Yes, that is Okay, So there's a question from the audience. Uh, that says if you do the distance ability and it's more than eight, Mind you. As I said, there is very flimsy, if any evidence that this number means anything. There is some Northwestern study where they based on 30 patients and some statistics that my statistician does not agree with because I try to make him do it on my data. And he wouldn't, uh, they found, like, maybe a 4 to 8 golden area. But, you know, it's very flames. The very flimsy evidence. So let's say you believe that, you know, would you go then on the same at the same time during the poem and do something like a thief? I, you know, don't agree with this because even if the distance ability of eight or more is useful, it's ah area under the curve is not gonna be more than 80.7. That means maybe a good third or 40% of patients with that distance ability will be fine with PR NPP, I or maybe once a day or whatever. Eso. Now you're gonna talk about put down a device in a fresh tunnel on do a thief. Obviously, the complication is going to be slightly higher than doing that later, and you're going to close down a north face. That may be just fine, with a 40% probability, I mean, then end of flip of state on eight or more. It doesn't mean it may mean that particular patient will have a 60% probability of reflects instead of a 30. Why would you be shoot oring at the same setting, The other 40% of patients decreasing, increasing that cat scored by a little the Christian? Maybe the possibility that 10 years later there will be more likely to need further treatment than patients with a bigger hole. It's just, you know, it's a very simple way. Toe haven't area under the curve that is one. You do a Broadway three months. Ask them about their symptoms, check for principles of justice, and then you go. You get as close to 100% certainty that this patient has reflects number one number two. How severe their reflections because if you can be managed with prn or once a day, PP ice or even needs to blockers. Adding a gift to the mix has a lot of potential for problems, so check this slack does not Okay, so so this is this is the issue with the same. I'm not a believer in same time teeth. I mean, people get all excited. Oh, we can do the same thing as a surgeon doing a killer plus door, but I'm like Why? The surgeon has a reason that he's doing a door. The initial studies with no fun duplication so that the reflects rate running the 80 to 90% range for for a tradition, Heller, and going back then to do a door as a second laparoscopic operation is obviously a whole different ball game. So then, if almost all people will have reflects and doing an anti reflex procedure, involves a second operation in a non virgin abdomen off course, doing them together make sense. Now, if you're doing a poem, you gonna scope the person again in three months. You can't do a brother. You can't do it. Check For us. It was about that is doing another endoscopy to do a teeth. It's just another endoscopy to do a thief. I can't say I can't do them now, and I don't know, 25 minutes. So, uh or so he says. So what? What what does it mean? I mean, why do it at the same time? Way to see if they have reflects how much reflects. And then you can do your I don't know, 40 minutes super expressive on trying to fix that way used it for severe reflexes. I have to say I having. Even though I have 700 point patients and the reflex right now, we're all is in a 40 50%. And the severe reflexes 15 to 20%. Funny how to convince people to have a tape. So done, um, recently one. But it's ah there. A lot of them are happy with the PP ice. Okay, we have a lot of questions coming in, so maybe let you get shoot during What about Europe? Spain. Okay. After. Except And so I'm sorry. What's the question? Actor and acceptable rain, right? Yes. Have we have seen this page I Even though the distance ability is at the except acceptable rains Absolutely. Number 11 out of five of my patients are terrible. Hail Mary, End of the road, people sigma the sofa goods. Um uh, Rosia and some of them have partial peptic stand noses, you know, really bad material you know, you're you're gonna get some this page on those that a spastic patients can still have some. This page and maybe related to the spasm may be related. Toe hypersensitivity of the sofa goods. Whatever. Um, you have so many reasons where some people don't understand the concept of a nickel Asia, uh, diet. So the first year they tell you I feel fantastic. And then on the second or third year, I'm having problems and whatnot, and then you find now to try to stop themselves in 10 minutes in a short lunch break with a big hamburger. They're like, Hold on. You're not normal. Okay? The first day you felt normal, but you were careful. You still have to take 2030 minutes to, well, occasionally lubricate with a little water. So you have to do a little re education, so yeah, you can get this way. Job. Uh, these are difficult sometimes problems to solve. Like that. This is a bit It looks good, but they have this pages and then you have to do barium is you have to do It does come. You have to look for things like sad ski rings. You can have a callous and the such caring. You have to look for peptic stand noses if Dema from reflects because they're not compliant with tp ice, you know, evaluating, um continued or relapse symptoms after a pretty decent looking for and based on the distractibility requires, you know, some experience, but it z definitely it definitely happens. What about far away? So I'm losing the air. So please, somebody has to do the the 41 right? Well, for some reason, the double channel Olympus go. I hate to put on Olympus, loses the air when he tried to shoot her. Um, on it can be frustrating. Uh, you can sometimes overcome this by giving crack wide pressure because it's the losses somehow around the scope or between the scope and the overstates cable that generates a little sneaky pathway for there to live. Now, Dr Peller, my chief of anesthesia, you know, a person that does 80% of my cases and who is incredible. He's also now famous around the country because he was on a sociologist that did my 23 hour s D for the whole case. Um, but anyway, he's giving crack weight pressure now I can see a little more. So what? What other questions? Is there a calling? What measures? Yeah, Yeah. Bye. Hi. Yes, the earliest pressure. So the question is really for somebody. It's really more of a question for a motility person than myself. But the question is, eyes that a correlation between El Es Pressures and Manama tree on, um, on and off. Lip distancing. Build another metrics. And yes, there is correlation off course. It's not a perfect correlation, but it's very it's very good. Correlation eso That's why we use hand off very liberally. Um, as a substitute for Manama. Let's say the person had a bad Manama tree and refuses to have another one. We do handle. Flip patient has this Faget, despite another quick poem. How do you evaluate you control to Manama Tree? But people hate it. Um a sigmoid patients, you may still not get it toe sit at this finger. So we use end off lips. Oh, yeah, Z sort of a poor man's Manama tree that can be done in une easier way. Watch pressure will be measure and only 30 like you did in this case, or you go to 50 right time. There's a question about what balloon inflations we measure and off lip odd. We do. 30 and 50 other centers do 30 and 40. Some people do 30 40 50 0 r. Something off that sort. The long balloon from a tronic goes up to 70 or such, so you can do even more. And as I said already, you can use this to generate a graph off compliance or distance ability, meet a different a different balloon volumes. Um, okay. And that creates a new metric, which is the slope of that graph as you go from 20 to 40 and 50 for example, if you have somebody with a very tight diaphragmatic part of the sphincter, you're gonna see in almost vertical increasing distance ability as you go from 30 to 50. Because once you hit the start down from boom, you hit a wall. Someone has a very loose diaphragm. You're gonna go gradually as you deflate. The distance ability will not rise very much. In this patient, for example, the distance ability was identical of 30 and 50. That's what it means that diaphragmatic Specter is just not that tight at all. know of any comparisons or anything. He's okay. Good. Okay. I'm sorry. What the He sense of the shooter is unheard of. In my experience, I've done maybe 600 of them. The hidden off clips, people that do people that do this and that. So secure here. Yeah, I'm gonna go empty the stomach of there. But people that do second look at dot scope in Europe. I think they have reported there was a study from Hamburg that showed that they had the distance off clips. I think in 10% of patients that did not necessarily translate into leaks. But it's pretty sobering, I think. Just Okay, So this is the whole looks. Nice. Open. But not to open on, then. Not to open. That's it. That's what. So now we can go, I think I don't know. Is that a break now and then a lecture? Or are what we're gonna do? A 10 minute break, then do the lecture. Or 10 or 50. What time is it? The last time. 5 to 10. So should we. You guys can visit the exhibits. We have this up that maybe our CMI department sent to your do you by email, but you can have on your phone, and you can go see all the sponsors that helped us. And it's really cool because it's a ritual booth. And some of them apparently can have a 1 to 1 communication there. Uh, you can go check out the end of lip on the new end off at the end of 2.0 and all that stuff. Or you can take the bio three or, you know, whatever you want for good. I'm not supposed to mention even names. I think so. I don't know if I just Sorry about that. Well, visit all the exhibitors to see all the stuff I discussed. Okay, so whatever, whatever does might be. So, uh, I'll go get some coffee, So eso 10. Should we meet again at 10. 15 than 15? Okay, so we'll regroup at 10. 15 to do the poem lecture. Okay?