Chapters Transcript Video Lecture: Innovations in GERD (ARMA, EPSIS) Haruhiro Inoue, MD, PhD, gives a presentation on the Innovations in GERD (ARMA, EPSIS), and follows up with a Q&A session afterwards. And so at this point we have the pre recorded lecture because it's 13 hours difference in Japan right now. So it's uh about oh it's not too bad, I guess 10 30 here should be uh about 10 30 I hold it but 13 hours. Okay. Anyway, so with the lecture by Professor Inui and he's been a great contributor to this course over the years by the way, I think he's a great partner with stavros and uh dancing uh the uh the third space and and more innovations in endoscopy. And we're particularly pleased to hear about his discussion of innovations in in good management. So we'll now have the prerecorded lecture. Doctor, Professor I know we may or may not be with us. Professor Shimomura, maybe. And we'll find out after the lecture if Professor shimomura may be available for a question and answer. So let's go on to the lecture innovations in gourd from Hero. Hero irony. Hello, I would even I'd like to talk about the noble endoscopic diagnosis and treatment for a reflect regard. This is my C. O. I. And I shortly I like talk about the description of higher to hana. Um uh so for classification uh most popular classification for hire to Hania. Yes. A huge great classification in endoscopic um evaluating the flat bulb morphology. So we think as a flat body is also important. And the we also think they're simply describe the horizontal uh change and uh vertical or longitudinal longitudinal deviation. Uh So horizontal opening is a cardiac opening. We call and the striding honey. Er It's a vertical deviation. Sfr go gastric junction toward the media still. Um Mhm. So like this way horizontal and vertical Are we evaluate yes, in a little frank's view from their stomach. Just in some places stomach full and then evaluate. So how do you go? So statistically analyzed demonstrate uh cardiac opening, horizontal white whitening of the s of gastric junction more than three centimeter. Uh Crossley relating to our uh reflect triggered offender cardiac opening is more than three centimeters. Are then closely linked to our uh ph abnormality and the striding Haniya more than two centimeter are deviation of our sofa gastric junction is closely relating to our GERD so uh ph abnormality. The statistical re difference with the statistical difference. So we can say that if they are striking Hania component is a more than three centimeter and more. At the time we recommend the surgical treatment such as an instant laparoscopic nissen kind of application and to pay from the application. Uh huh. Place over our thriving Haniya is arrested in our uh two centimeter or less. So at the time so we can do our endoscopic treatment. Next I would like to talk about the uh uh functional evaluation of the lowest softer sphincter. Uh We can evaluate the areas function very simply using the endoscopic pressure study integrated system that is it's as we call. Uh so lower soft your sphincter is a one way valve. Uh the functionary identified not anatomically. This is from a better description. Okay arthur this is an endoscopic view of the distal esophagus. In this endoscopic image we can just observe the okay approximate end of a gas leak forward on the party said vessels of the study esophagus and the scrum common junction. That is an endoscopic aly uh recognisable landmarks actually when we are in self late in the distal esophagus so areas yes, actually relaxed and the area is open then we cannot observe anything. So but in the resident frank's view, little flecks view or once we separate the stomach well so we can observe the activated every yes contraction uh like this. So every year's contraction hold the scope shaft tightly and avoid the virgin. So over in separation in their stomach induced elia's activation. And in elia's holding the scope and then we can see it. So these two are endoscopic video clips are in the same case in the same case so front view we cannot identify anything but in the retro flexible from the stomach with uh full gastric in separation el es activated and then we can see the scope holding sign. So in this case is actually hired us is a little bit open but this patient has no symptom of good. So in this case we can observe the scope holding sign very well. So in the case of a reflectively good. So we cannot observe the scope holding sign then so no contraction. Various no activation of various. So in such a case if we are in separating the stomach using and through the endoscope so gases automatically out from their patient mouse. So that is a long burping like that during endoscopic examination. Uh So this is the case our scope holdings high negative. This patient is a higher just open a little bit and the button nose riding anyway so often we in separating the stomach. No contraction of the lower software spinster in this patient. So patients have the civil severe leaf like symptoms. So with that head out, head up position aspiration actually occurs and ph mp has demonstrated uh big abnormality. So or this is a study using a high resolution manama tree is mounted on to the uh pediatric scope then so we can evaluate the scope holding sign. So first uh this patient has their scope holding signed positive. And then we keeping separating like this as a scope holding sign was positive and then keeping separating so L. E. S. Release the holding the scope. Then uh monumentally demonstrated the pen pressurization of the Holy See's office and the low I substance speaker released. So uh in this image we can say that um scope holding sign is demonstrating the areas, function areas uh contraction. Uh So in order to uh describe this phenomena objectively we thought that it's better to uh measure the interest gastric pleasure uh in the case of a normal are like uh a table, a cell or intra gastric pressure is gradually increasing. And then finally at the time of burping, the pressure is a lapidary down. So in the case of our reflect triggered uh burping the patient has a wrong continuous burping then so into a gas gas gas with pleasure has no increasing. Then we can say that the if we can observe the uphill pattern of the wave uh of a pressure uh then we can say elia's function is quite normal. So statistically other resistance rate that the uh it's it's got positive criteria uh is uh flat pattern plus And I introduce ask pleasure maximum is rest than 18 million mockery. So specific city is 85%. A nerd is also saying flat pattern No increasing of the inter gastric pleasure. The inter gastric pressure maximum is arrested, 18 million mockery. So with the specific city of 80 more than 80% of the Nerd. Yeah so marty valued analysis demonstrated. So if this good positive uh using this quite failure are good patient nerd patient. Are there all positive? Uh almost positive. So after that we are think like this. So even when we cannot identify the maximum uh into a gastric pleasure before burgeoning. So uh just uh in suffering the stomach and then everybody is a pressure gradient if it's increasing its uh one of the sign is an important sign over uh normal. Oh I software or function. Yeah. So we can say this is a short summary um um FCS endoscopic pleasure study integrated system is a tool to evaluate G. I functioned yelling an endoscopic examination. Uh This is we can say endoscopic motility study. Uh And the uh it's a very similar to our tolerance test. Everybody knows uh like Andrew klein Torrance test. So but anyway so this is the beginning of I think a functional indus copy. We can evaluate the G. I. Function or using endoscopic image. Next I'd like to talk about the nova endoscopic treatment for lee factory GERD. Uh First I'd like to talk about anti reflux McKusick to me and the raider. It's uh advance to our population. This is a report of a country front because it to me. So the purpose of this procedure is to creating lee building the mucosal flat bulb. So like this image we place the mucus ectomy and then are in this uh ulceration heating process. So this observation make a shrinkage then so junction becomes tight but now we know that the without mucus ectomy. Just upgrade the new cause er we can do do it and then we can get the same results that is anti reflux. Um because our population. So this is a report of an armed procedure. This is a demonstration of actual case. So left or you can see are so high interest is already open but no sliding component. This is a nerd patient. So uh we place the mucosa population like this way uh then uh this a plated Elliot, our shrink um by the uh in the healing process uh observation. So symptoms score good H. L. Q. L. And the F. Scale boars are symptoms scores improved. And also a ph study demonstrate good liquor volley after this procedure. So once again I want to summarize the technique of tabulation. So we place the horseshoe shape, same circumferential appellation at the gas recalled earlier. The great curb side that is a phonic side. Uh We preserve the one centimeter untouched mu closer this part is a yellow line and demonstrate that this yellow arrow demonstrate. Um So this is a lier is the mucus of la pau. And uh green alone demonstrate uh it's better to preserve the approximately one centimeter mu closer uh cross to endoscopic shaft because this uh preserved mucosa walks as a christian. Then uh we can avoid the temporary stenosis or systematic feeding of the patient after this treatment and brew roo demonstrate the operate operation, longitudinal links with us of operation. It should be uh one scope diameter plus half under to scope diameter. So I mean one centimeter or two tends to centimeter. So energy setting should be uh argon plasma coagulation, 8200. What the organ floor is a one liter per minute. Mhm. So if you want to learn about the armor more. So please visit the home pace over Turkey arrive and the Skopje one, you can see it. So this is a clinical data Number such as six cases such as. Yes. So anyway um uh symptoms score improved after armor procedure on the ph study demonstrated that our recovery On a side effect. Um so to patient, less than 10% of patients have the hemorrhage after procedure but it's not a small hemorrhage. It's a small hammer agenda. At the time of observation, breathing has already stopped. So no preparation in the case of armor Operation a operational population. So transients tendencies may happen in the rest and 10%. So we can say uh lee building of their miracles of flat valve using the armor arms technique. So it's uh power of our anti reflux is in between to pay fund application and go fund application. Yeah. Yes. So once again I hope this armor, there's a very simple message. Just update the gastric cardia musicals are this technique? Hopefully feel the gap between PP. I. Treatment and such culture treatment. Thank you very much for your kind attention. Hello. Hello. Hello. Good. Good. Uh huh totally. The innovator. We we love everything you do. We love it a quick question on the on the excess uh the endoscopic pressure assessment. Can you comment on the impact of anesthesia on these measurements? Conscious sedation versus propofol intubation. Does that affect the burping or belching or the pressure tolerance. Uh huh. Sir. Thank you very much. It's a very nice christian. We uh can you hear me well? Yes yeah. So the question is very nice, very important. So propofol sedation. Um We can nicely evaluate the uh areas function just in suffering the Uh co two gas in the stomach. And at the time so normal every year it will be activated and they're holding the score and the kids into a gastric pressure is going up. So opportunity family the way. So um it's a good and the result solution is impossible uncomfortable and in the case uh intubated so into a gas pressure increases more because so a placement of the intra trade kale should place the upper speaker so that will uh interfere the opening of the upper spoke to them. So uh that means the people find the patient wants you are barking so it's impossible. So like like that so uh No it's very practical. Looks like it's relatively simple to do. It's a very good measurement. Um Let me ask you on the mucosal ablation. I think the great the greatest fear that we would have is preparation at 80 watts. Um And yet you only had one preparation from 109 cases. Uh is there any advice you can give us to reduce the risk of preparation? Like do you uh for instance to aspirate the argon gas frequently or other other tricks to minimize preparation risk. Thank you very much. Again it's a very important question on the so you mentioned that we have uh we have one perforation in the series of a Nico secretary anti retract looks actually but never have cooperation in the case of our population. Okay, so uh, we use the album plasma cooperator. So that is a very safe procedure, technically easier than them because it to me, of course, you know, so little flex, fuel cap PMO is not easy. No. Uh, so, uh, but we are using the uh 80 C we can make uh easy operation on the roof of the stomach. Uh, so maximum uh, voltage, maximum power. Electric power is 100 what? In a machine? Uh, in the case of a little bit so we can control the 81. But so us guys us guys 100. Maximum power. No problem. Okay, haru, I have a nice life demonstration. So you are stop you right here in the evening and the morning. You're really you're really stuff. I thought it was okay for you to be here only in the morning. Nice to see you. Oh yeah, yeah. You look like you have three coffee already. Thank you so much for joining. Thank you. Harry. Thank you. We'll see you again tonight. Right, or tomorrow morning for you. Yes, that's right. That's right for the boys. Very exciting. Yeah. Thank you. Yes. Thank you. Thank you. Bye. See you later. Published August 5, 2021 Created by
