Chapters Transcript Video Lecture: Submucosal Endoscopy & NOTES. US Perspective Stavros N. Stavropoulos, MD offers opening remarks, and gives a lecture on submucosal endoscopy and NOTES, US perspective. a few words of welcome to all of you that then in the course put together under difficult conditions. Um The second year we're doing the course on the covid restrictions. We tried to expand it this year with a live portion from Asia as you'll see. Um You're no longer gonna see our beautiful lighthouse at Montauk in Long Island as the logo of the course. I'm from a nautical country myself. Greece. I always loved this logo. Winthrop merged with Y two years ago and we are not allowed to use the lighthouse. We'll be using the garden in front of our hostel which is no longer called Winthrop. It's called N. Y. U. Langone Hospital. Long Island. There you have it. So this is our cause this year the 13th annual long gonna live endoscopy course frontiers of endoscopic surgery. Uh Big thank you to the whole village of people it takes to make longer than life success. Um particularly notable honorary mention ones are in yellow here. But obviously everybody held tremendously from the very top of administration to all the way to our categorical fell those nurses tax and many many others. Um Big kudos to roger via Zarei V. A. I. T. Master at Winthrop. And in the leadership in the end of unit came and Pasadena. Um The tremendous pulling to make the course of success and are and advance team but also other nurses and techs, particularly recovery nurses that will keep the patients safe. Um The my interventional attendant colleagues on the anesthesiologists have to do amazing work in these very complex cases. We have lined up and maybe a with a research nurse Maria polaris on the practice side, slalom run er inpatient interventional P. A. My last year's advanced fellow Tareq al Ansari was back to help with the case is doing complex things like placing various devices the alumina etcetera to help speed up things. And our current fellow who started in july Probyn Sharma helping along and also our categorical G. I. Fellows will be essential to keep an eye on the patients, keep them safe and make sure everything is done with proper concern and care. Now we all happy people we all love being together working together. Uh you can see here are cmi stuff robert martin peter Sandra, you have interacted with him I'm sure Marilyn um used to be mostly involved with longer than live after last year maybe this year Maria colours my research nurse And I see Jeff Leader of the three company um pretty expensive. Every crew we've put together for this and roger via a very the Bonaire amazing ictv guy at winter up he's gonna be the coordinator of all a v technical aspects VP leadership with our roberts. There is a cost. Tell you might be a uh joseph gallop of dealing with authorizations, talking to patients last minute things cancellations, he's the man for that. Um And then our interventional techniques. Dr Witman dr Friedel myself and dr model running model last year's advanced fellow direct back for more. He's here with john day learning is the in my office, believe it or not. And then this is uh you know a time out in a nice restaurant on the on the port Washington bay. This is the newest member of our team, my daughter Irini who is nine. And you know our anesthesiologist and civil anesthesia Doctor Peller, his horizontal just to show his laid back anesthesia style. Is that good? Hopefully he's joined us. She'll join us this year. A paler, the top interventional nurse maybe in the country to Sheena. So you can do better yesterday than I can. And our text kelvin, our current advance fellow problems are interventional P A. In the hospital. La la. You can see here our team, the top tax interventional tex surely skilled in and steve our intervention. Attending Doctor Wittmer, Doctor Modell or two years ago, Advance fellow myself and Vanessa, probably the second best interventional nurse after passing in the country. So this is this is our group or at least the part of our group. And then as I said, thank you to judge Malevich from any white v Phil joseph advanced concepts and Donna fontana. Broadcast made a very, very extensive victim. Hopefully everything will go without any glitches. And this would truly not be possible without our sponsors and exhibitors. You can see here the platinum and the gold sponsors. We are very grateful to them and their support And our silver sponsors and braun sponsors. also extremely grateful. It takes all kinds of purses to put together the budget for the course. So thank you to Greg Haber Who graciously stepped in. Normally Chris Gustav has been the moderator for the last 10 years. Well again alive, but now with his retirement he's taking significant amounts of vacation. He's on vacation in August Greg Heber who needs obviously no introduction. Amazing endoscopy is the amazing commentator. He's gonna take the baton this year. Um he, it's gonna be a long course. Our course is legendary for its brutal pace and procedures. Um chris go start with moderate 12 hours straight every year for the past 10 years now Greg is looking at the same thing, he's gonna need some spinach like Popeye, he made very clear what the spin at this is actually, I should say Sofia um his lieutenant made clear spin. That's number one plenty of Starbucks coffee spinouts number two per year, water, not in plastic bottle, glass bottle and last but not least some good amounts of sushi and I'm not sure how this got in here. Japanese whiskey, not for the course, but maybe later to celebrate or you know, try to forget our number pain, thank you to all of you for returning to London alive. Year after year. This is the link you can take your cell phone and take a picture, you can, somebody wants to attend on the day of um you can send them this link that can go directly to the live webcast. And sorry, this is the agenda will start with the zippo. Um immediately at the conclusion of this lecture then moved to a poem. Then another lecture somewhere in there as we move to a full thickness reception using notes of an extra Luminal distant deciding duodenum, very advanced case. Some more Gordon LSD lecture from joe hockey as we move to a challenging colonies D behind the musical valve using the lumen pro knife or I tell attraction devices etcetera. We'll also put a lecture from pingan joe. Are we now ready to take the third space? Training wheels off and revisit traditional knows in the second space. That's a good question. The first foray on notes was by operators that hardly knew how to hold a knife to perform resection which made obviously taking the gold band out difficult if you're trying to beat laparoscopic surgeons. But this year as we move to live from Asia from 5 to 8 p.m. 5 to 8 P. Mpinganjira will show us a new notes colleges document with endoscopic technique through a trans gastric axis. Live from shanghai. We'll also have a duodenal SD from now is a hockey probably permanent orginally SD guy in the world. Uh And uh here I know it will will discuss his amazing poem. Place for poets procedure. I touched on that in my lecture and his current data current technique and how this will fit our armamentarium to prevent good after poem. And finally we're going to move to The sign of Chinese component like our our course will give the baton to China at 8:10 pm for chinese audience. I will do the welcome for that and you can depart or follow to the chinese course for some additional lectures if the time in your part of the world permits. Um so thank you for attending the final logistics filled online survey for cmI credit feedback on any issues about the course or the transmission, anything to peter sander or and or meet me my secretary. The end of the day I already discussed on the agenda before there will be a welcome to china as the coolest hysterectomy winds down and then we'll move the lights will go out. Um and then all of this will also hopefully over several weeks become archived at Winthrop endoscopy dot org. Um for on demand viewing. Now this side has one healthcare awards both in 2018 and 2019, tremendous amount of content. All the last eight years of long gone in lives are archived there lectures and life cases. So you know, please visit it's free for after registration. So on that note, we'll proceed with my lecture and then we'll start to live cases. Thank you a lecture today will focus on seven capsule endoscopy and notes. A U. S. Perspective. The focus will be on poem versus Kayla. And obviously the big issue is good and that's what we will focus on. No relevant disclosures to this lecture. I will first touch briefly upon african same. Um basically this is the literature review of series that had over two years of data. East versus West. Um West is in blue. You can see you know the efficacy persists uh pretty well all the way to five years. Um it starts at 90 200% or two years and even at five years generally it's at somewhere between 80 and 90%. Um the Asian cities in organs here suffer from significant loss to follow up in this uh study from the plant 42% 56% at Three years and that over 10 years. This is 79% success at 10 years but a lot of data missing. Um and then uh you know this study also 37% missing fall about three years 58% missing for about four years. In the Western studies. There's a little better follow up our studies down here. Just published as an EPA head of printing the I in May 610 patients. You can see even at five years, 92% with 126 patients being at five years or more With only 2.3% over you for follow up. This is in more detail here. Kaplan. Meier analysis From our publication last month in G. I. You can find it online 610 consecutive poems over 10 years from October of 2009. Our first poem first in the world, outside of Japan. All the way to October of 2019. You can see other way to seven years, successes maintained all the way to 91% at seven years with only 2.2.3% of patients over your missing follow up. This is due to the amazing herculean efforts by our collaborator Animal Dale and our research nurse Maria collage and also La La Amrani. They have been calling these patients and one third of our patients out of state or international. So a lot of work to collect all this follow up. So this is a very accurate long term success estimate. Uh did it w we presented another year 11 years now, all the way to october 20 2700 and 20 we had another 110 poems over the past year And you can see here only 5% missing follow up. You can see now six and seven years. The success is a little better because as our initial learning curve patients are being diluted, Buy new patients that read six or 7 years. The results get better And then 92% basically plateaus from 6-9 years. You can see here, most of the failures happen at one years. Usually not so much technical failure of poem, but due to end stage disease and you know, terrible as of a gl geometry And then a few more failures out to 56 years. But then not much failure. Once you read successfully six years now, how do level one evidence data from the randomized trial were look on poem vs. Heller with regards to advocacy. Um, there there are some issues here. The poem operators. Um, we're in 2012 to 2015. The enrollment period very early in the learning curve in europe and even the adoption curve and five out of the eight centers were low volume poem centers and also there was low operator experience. All that was required of the operators in the studies, 45 observed poems and 8 to 10 run in poems. Um, so even though the poem about is relatively an experience that still were slightly higher at poem efficacy compared to the patients randomised to heller 85% at one year, 83% of two years versus 83 and 82%. So despite the experienced poem operators against inexperienced poem operators against expert heller operators, you know, very decent results. However, these are 10% points lower than what you expect from experienced poem operators. Now, a lot of most of the compartment analysis confirmed that there's even a slightly higher efficacy of poem vs Heller if you look at the card score persistently 0.6 points better in the poem group than the Heller group. You look at percent that have a naked scored three or less at 12 months 94% for poem 91 4% for Hillary at 24 months, 93% versus 90%. Both. Statistically significant higher short term failure for lap Heller by inauguration of 9.9 18 this month analysis in this meta analysis Echoed score again, 16 versus 1.29 poem seems to be slightly better than surgical amount of in reducing the air crash course. So good stuff. You know, a little lower success in the Heller. Maybe because hello operators now have lower experience as Heller has spread broadly around the country. But poem is still largely concentrated in high volume centers. Maybe that's what makes the difference or maybe the found application makes it a little tighter and the dysplasia relief is lower. What about safety Safety? This is from our poem series and you can find it in our publication again for 610 patients. This is the 704 presented at the Dw as a neural this year, serious adverse events, events requiring surgery or er or drain perforation. Leigh captures my guest tonight is a rather superlative complication. Events leading to lower functional status disability or death Or any conversions or a border poems at zero. clinically significant adverse events, mild to moderate all of them. Only three three people with minor the essence of tunnel opening without a leak 30.4% minus conservatively delayed bleeding. Again, man is conservatively 81.1%. Many of those had to go into calculation the day after the poem. Other events mostly mildly mile 1.6%. Again, not requiring any surgery or I are anything like that. Post operative pain require narcotics, mostly mild and limited to the 1st 12 to 12, 24 hours. Like maybe 12 or three doses of narcotics only requiring 42%. What about the randomized data on poem versus kelly from the european multi center study, you can see even though there was no statistical significant serious adverse events in poem 3%. Lab Keller 8% more than double perforations and surgeries. 00. Whereas on the lab killer group three perforations to re operations. It's a very significant. Now let's get to the main focus guard. So good. We're gonna focus on Western series because there's a lot less guard in asia whether after Poem or even in the normal population Western series that we evaluated all three components symptoms of arthritis and ph studies. We will tend to focus on the ph studies because as I show you assessment of esophagitis has an important caveat and we'll discuss these and symptoms. Can can be difficult to differentiate between these various symptoms and. GERD symptoms. Number one and number two, they are relatively insensitive to guard with half of the patients with objective good not having symptoms. Um, these are the virus studies ours just published as I said in the IA 610 patients, 20.5% had significant guard symptoms at least twice a week. About half had erosive, esophagitis and 57% had a positive ph study. Now, how does this compare to Keller and I'm not going to focus on single center retrospective studies from 30 years ago. These are prospective western data from randomized controlled trials, including the best centers for Heller in the U. S. And some in europe. So you can see the numbers and you can see the ph study was done at uh 6 to 12 months when the population is actually at its tightest. And some of them, these two compared door and to pay with finding conflicting results actually. But if you look at all of this together, the pool ph study rate in this high quality studies for surgery with an application was 30% at 6 to 12 months but may increase further with time as the final application gets looser as people gain weight. So you can see in this new England Journal study, it went from 23% at one year to 34%. Positive peer started four years. An increase of 50%. How about the randomized study of poem vs. Heller did that fair for for good. So you can see that at two years the Minister exposure is virtually identical. 5.7%. 5.4%. Even even at three months very close 7.16 point seven percent of patients with abnormal asked the exposure of three months slightly higher for poem. But at two years 30% 30%. If you look at abnormal than MR score three months two years again, initially bigger difference. But the two years, 39% 34% had abnormal than MR score. So virtually almost identical ph data at two years, Uh symptoms of heartburn at two years overall and daily, 41% vs six And 41% vs 0%. Not statistically significant. Different. They only found a statistically significant difference on early three months. Rose of esophagitis mostly mild classic. Be esophagitis 57%. 1st 10%. A huge difference compared to the very similar ph and symptoms data. So, keep that in mind. Now, if you look at two years, Um as a vaginitis that is mild. 44 verse 29 getting closer and severe esophagitis slightly higher on the heller group 6% vs 5%. So it erodes with time. This difference. But why is there such a huge difference when the ph data and symptoms data don't support it? We will leave that the problem here is that post poem arose was of anxieties may be overestimated, particularly if assessed early due to solitary ischemic ulcers at the d vascular. It's because of that overlays the tennis karate DJ. And we tend to assess this at three months when there could be an ischemic culture over the device. Lives because of the tunnel. You can see one on an anti war poem, One on the posterior poem. With no other erosions. You can have those and typical reflux erosions as in these patients. Or particularly if you evaluate and say one year or two years, you may not see an ischemic culture and you may see mostly typical Hiroshima's of agility. So, does this make a difference in terms of objective ph measured reflects, well, we found that solitary ischemic answers. Uh tunnel answers may in fact not represent pathological dick levels of acid exposure. And this is again our publication in G. I. You know, we don't believe in salami publications. This publication has been called mom of publication. It includes everything you want to know about long term outcomes of poems. So, it's in there. So, we we looked at patients at an endoscopy after poem um 438 out of the 610, we were able to bring back at the median of some four months. 197 had typical refracts erosions, but 1 19 had only a solitary chemicals, I would know typical reflux erosions. So then we look at the ph that and all of these people had ph data because we do the endoscopy and the ph bravo placement at the same session. So, a higher rate of positive ph studies was sending those with typical erosive esophagitis compared to those without 74% vs 40.7% as you would expect. Now. What happened with patients with solitary ulcers? Only if we compare them to patients with no new causal breaks at all, but basically the least risk group for For um uh reflux. 44% vs 35%. Not sense statistically significant. So again, solitary ischemic cultures maybe due to ischemia of the overlying because uh I may not represent pathologic levels of reflux. So we have to be careful when we evaluate the rate of various levels of objectives and maybe that's why the new England. I'm sorry. The study uh randomized yet. The new general randomized study of poem vs. Heller found a lot of difference in erosive esophagitis, especially earlier three months, but not much difference in ph that these are symptoms. Now, if you look at time trends as have implied so far, get may get better with poem as it gets worse with taylor with time. That could have opposite time trends with further, which further favors poem. So long term follow up after Heller plus door. They had a lot of studies out there. This is a good one because they did ph studies on the 67 patients over three decades. So you can see how reflex goes from 28% at 10 years plus 2 53% at 20 years plus massive increase on by ph study, 22% long term failures were actually due to reflex and 13% developed barrettes. Um six long three short. If you look at other studies that didn't do ph study, but I look at PP. I usage and scores and such. Um you can see here uh six years after to pay in these 51 patients range 1 to 12, 2 3rd were an acid suppression therapy. This one mean of 12 years of patients from an initial randomized trial of door versus no fund application And then they were followed. The 66% of living participants were able to be followed. You can see get symptoms 69% if you have the Hitler 57 without a fund application, 57% if you have the fund application a door. Pp I used that 77% 71% and good scores very similar. So at 12 years mean it didn't make a difference whether you had the door or not in this study. So, what happens with poem long term again? This is included in our publication but also was presented at the DW. So, um what you see here is that unlike Heller, my automate poems associated with improvement in objective guard by ph study on long term follow up at greater than two years. So let's look at that. So we looked at which patients of ours. um In addition to the original ph study at the median of five months had the same patients had the second long term study. And we do offer this option for patients Um at least three years later. So the second study was a median and 57 months or what happened between those two studies in these 21 patients The positivity of the studies decreased from 67 to 43%. The total number of reflexes decreased by a third to a third and that the mistress court decreased also significantly. So about a third of patients with abnormal study initially normalize the study probably due to remodeling of the A. D. J. That extends well beyond the five months or the media and formats that we usually do. The ph study in this is supported by and a flip measurements which are consistent with this type of remodeling. And we had a lot of data also included in our publication India. Um 500 patients are so pre op and the flip and immediately post postponement of lip. And then 302 were able to also do a seven month uh End of flip measurement At a follow up. So you can see initially the minimal diameter goes from 6.7 to 12 but then tightens up a little by seven months to 10 distance ability. Very tight. 1.5 goes to 8.5 immediately after poem but drops to 5.5 Long term. And data from northwestern and maybe 30 or 40 poems only. That's so a very that's an identical trend. So I think it's real. So this is what happens. A poem is not really the good after poem is not sad compared to Heller. That would really require that We do Heller's instead of poems based on a review of the data. Now, how do you manage post poem Guard PPS are very effective. I like to study from Mexico because they took 65 patients and they did clinical endoscopic and ph measurements of guard at one month, six months, one year, two years, three years and five years and four years. Very interesting. And you can see they allowed PP. I use as needed depending on how much reflection. And you can see at one year, two years, three years, four years on P. P. I. S. Get remained very well controlled with all these three metrics in the single digits even at four years. So the FBI has worked very well long term. Now let me show you our data on what happens long term on PPS particularly long term girls. Equalize what people are afraid of like barracks and peptic strictures or the need for fund application in these patients. And you can see that in the vast majority these were minimal. Uh you can see for fund application and we presented this at this year's G. D. W. You can also see this data for 610 patients in our publication that did the W 704 patients that had at least three months follow up. Only 1.3% opted for surgical or endoscopic fund application. All four of the surgical and three out of five of the endoscopic fund obligations which were mainly maize uh and one TIF still require PPS. Um One maze patient is PP free uh the scope of the case against in the overstates at 24 months and one third of patients PP free indictments. What about postpartum gets aquila. Again minimal at the median now of over three years, 1.6% developed. Barrettes .5% per year. All short segment without displeasure. All due to poor PP compliance by the patient. Another 1.6% developed. Um uh peptic strictures all do. And some some of these patients are the same in both groups. 1.6% peptic strictures. All due to complete PPE noncompliance. Usually all results after a median of two dilation zones 124 and PP. Resumption so on. With P. P. I. As a cornerstone of management. Not a lot of people want or need a fund application and not a lot of people develop any kind of long term sequelae and usually this is due to non compliance. So good after poem appears modest. Not much different than hell are long term and manageable with PPS. But is there anything more than we can do to lower the gate rate after poem. The endoscopic anti reflux procedures as I alluded to already. Chief being the best candidate, I would say some pain. Now let me address what some operators have advocated. Which is doing the teeth at the same session as the poem. I don't think this makes any sense. And I guess I share this with tom that mr revis dance, chris, Swanstrom And Bradley who sent this to American Journal of Gastro 2021 same session poem followed by Teeth in Malaysia. Unjustified and Risky. Basically my thinking is inhaler patients. It makes a sense to do the multiplication At the same time as the heller. Because the studies back when they were doing heller with no fund obligations showed massive reflects 80-90% probably unlike poem because they disrupt all the attachment ligaments. And the friend was a vaginal membrane during the typical heller. So the first found obligation to a letter time may spare that 10-20% of Hello patients that would not have had GERD Even without an obligation but would subject the other 80-90% to a second surgical for a in announced card and more hostile surgical field increasing the risk of vagal injury. Another complication. So it makes sense to do the kind of location at the same time as killer. But it doesn't make sense to do the teeth at the same time as a poem. Most poem patients as I showed you at least 50 to 60% will not have any significant guard on long term follow up. That's the teeth at the time of poem. Apart from carrying a high risk of adverse events in the setting of an exposed poem surgical field, it would subject this over 50 to 60% of patients that would not have had significant girl to an unnecessary additional procedure we may actually, which may actually diminish the the magnitude of their dysplasia. Relief, teeth can be easily and more safely and appropriately performed as a second endoscopic session in the patients that do have significant girl after the poem and who do not respond or do not wish to take PPS. This is such a study. Multi center from actually many centers of 12 poem patients with reflux symptoms. Nine nickel asia to Jackhammer, one DJ flo that underwent. Excuse me. Uh Chief procedure After the poem. Uh, what you can see, you know, really very unsatisfactory results. Uh, they had thief, pretty people are used in 11 out of the 12. I'm not sure why. One would do not require PPS. Pretty if endoscopy showed the savage. That is only in six out of 12 and four out of six words. Great Day. Ph study done in nine out of 12. All abnormal with the minister exposure of 16% of the Mr of 61. Okay, pretty good. Now, two patients were deemed T. Failures because they develop positive dysplasia and had lack of GERD symptoms resolution. These are a bit conflicting trends here. I mean if it's tight enough to get this phase I should have very good good symptom relief. It just it just illustrates how confusing it is to separate GERD symptoms from this page is symptoms in this article asIA patients. So they were both referred for surgical applications. So immediate 20% failure state of the but then you have 10 successful give patients at the mean follow up of 6.5 months but they know the devil's in the details. Follow up endoscopy in three only out of the six patients with erosive esophagitis. So complete healing with occasional PP. I used in one but one had no worsening from great Day two great B. And was now on B. I. D. P. P. I. One we made great day with occasional PPR used. So not very successful. Ph study was completed in 77. Out of these 10 patients, three out of the seven had normal the mistress card. But two of the patients were on Q. D. And B. I. D. P. P. I. 200 Qd. And one on the I. D. P. P. I. So I'm not sure how what how to interpret this. The Mr score decreased to 31 but again some of the patients were on PP. I. Asked the exposure decreased to 7% both still abnormal. Now, what about the PPE usage after teeth? They have data and eight patients. Three patients. Um We're on B. I. D. P. P. I. Three patients were on Q. T. P. P. I. One patient was an occasional P. P. I. And only one patient was on no P. P. I. After two. So not not great results. But I would consider this work in progress and I definitely offer tiv in selected patients. Uh Harrow innovated again with his poem Plus f you know, he showed this Long Island live in March of 2018 back in the happy pre covered days. You can see go down and get through the my autonomy that you did in the poem and grabbed the gastric funders and bend it over to the my Autumn inside. And using a loop and clips clip it there while watching from inside. What's happening with the pediatric endoscope. And you can see slowly the fund application forming that looks a little bit like a door. Very nice. And he's going to discuss this at length at five p.m. Today when we have the live portion from from Asia. He'll specifically his discussion will focus on poem and poem. So, hold your excitement and questions for this. Uh So far there is an initial publication from human endoscopic of 21 patients with 100% technical success publication maintained that two months in 20 out of 21 but no data on ph There are two studies from India. Unfortunately, they raised questions about durability because there was a visible application failure on endoscopy in 41% at three months on the Patil study of 20 patients and 18% failure at 12 months in the bap. I study of 25 patients Encouragingly patients in whom the fund application remained intact on full a PGD had normalized exposure and PH study. So very nice. And a recent modification proposed by Newey that uses the Olympus needle grasshopper with a needle and future to do featuring instead of an antelope and clips may actually improve the durability issue. So very exciting because also it it brings again to the forefront the concept of notes as a very viable and successful field. This is a dolphin obligation done purely endoscopic lee. Um Now we can modify the technique of poem to prevent or minimize GERD and this would apply to every patient as we do the ponds or we can tailor it to patients that are at higher risk for reflux. Such modifications that have been looked at in various ways is full thickness, my autonomy versus circular. My autonomy only, preserving the longitudinal layer, long versus short. My autonomy an anterior versus posterior my abdomen classical A versus full thickness. This would start dissolved from china, found that the full thickness martin was faster without significant adverse events and two studies suggested more good after full thickness than circular. Only my academy. The problem is that these are very low quality retrospective data and we would need confirmation from randomized studies to confirm these results. What about short versus long? My ottoman. This a meta analysis of studies, the most important ones being I think two randomized studies, one from china and one from India. Both studies focused on us of a zeal rather than gastric length, which I find somewhat counter intuitive. Both random. My studies favored the short monogamy but only one reached statistical significance. But on the meta analysis that was that physical significant that was reached, reached for acid exposure and erosive esophagitis. Um On this um on this meth analysis. So, you know, very you know, intriguing data Until your versus posterior was a bit of a mixed bag. There were four randomized trials hours from winter and was the largest with 250 patients. Um A meta analysis of these four studies borrowed visit this in santiago and hero hero Inui found less adverse events and faster closure posterior really. Um But unfortunately as far as God goes, similar ph study data, similar endoscopic uh erosive esophagitis and similar good symptoms. Okay, very similar percentage. So it didn't pan out as an anti reflux procedure after we finished our randomized study, we engaged into a different modification that we call the anti reflux poem technique Starting in approximately May of 2018 Who presented in the double 2020. The preliminary data with 60% or so ph tested in its group or on our case control study. Now we have close to 80% and we're preparing the manuscript for publication. So we had 116 anti reflux poems from june of 2018 to august 2020. And compared to 100 16 conventional poems from March 2016 to june 2018 match precisely for six different factors that may affect reflux, including of course, be and my gender. And set two thirds of the patients have completed ph studies when we presented this data, Bassett. Now we're at 80% and ready for publication. Much less patients with positive ph studies, 43% versus 75% dramatically lower total acid exposure, 4.1% versus 10% And far lower number of Reflux episodes. 29 versus 53 in the anti reflux poem group versus the conventional and group is a very promising technique. It consists of preserving the slick fibers while only cutting the circular using landmarks. That's the so called tanaka penetrating vessels. In conclusion, poem has matured with outstanding long term outcomes. Poem represents a first line treatment for Akhil Asia with an efficacy and safety that rivals that of heller. Based on the highest quality data, the two absolute difference in get prevalence between Helen poem is less than 20% at one year and erodes further with time due to opposing time trends. Objective assessment of good after poem includes caveats, not only in ph that the interpretation, but also an endoscopic assessment of erosive esophagitis, such as the solitary answer that we reviewed. PPS are effective and represent the cornerstone of guard management with minimal long term guards equal or the need for front application and the Skopje Fund application techniques. My whole promise for select patients with severe guard, but poem technique modifications such as the anti reflux poem, have wider applicability as the reduced guard in the entire cohort of poem patients. Thank you. Published August 5, 2021 Created by
