Chapters Transcript Video Live case #1: Z-POEM for Zenker’s Diverticulum In the first live case, Dr. Stavros N. Stavropoulos performs a Z-POEM for Zenker's Diverticulum on an 86 year old woman. well, welcome to Long Island Live. This is going to be an incredible day I think that we will be seeing advanced endoscopy like you never imagined or dreamed of by the probably the best endoscopy pissed in the world to demonstrate to us live. So this is a very special day and we have to really acknowledge dr Stavropoulos stavros, who is put this together for several years now and continues to push the envelope for advanced endoscopy. Uh, himself is a master and an innovator and he's brought together some uh, wonderful innovators from around the world. Of course, we have heroin away from Japan, Professor joe from shanghai, uh, and Professor Yeha G from Japan as well. So, uh, this, I hope that everyone is, uh, has had their coffee. They're sitting down there ready to be amazed. But also we want this to be a true learning experience. We would like everybody to submit their questions. If you look at your screen, there's a submit question button, we will try to address all the questions as we go through the day. We'll have lots of time. We also want everyone to visit the exhibit all the virtual exhibit. All this could not happen without our sponsors, who have really been tremendously supportive of our educational endeavors. So, uh, I myself, I'm looking forward to a great day. Um, I will try to help out all the questions addressed and uh, I look forward to our uh, our exciting day ahead. So I think we're going to start with dr Stavropoulos is going to begin with a Z poem and I believe we're turning over to the presentation of the case by the fellow. Thank you. Hey, good morning everyone. Um so the first case we're presenting today is a 86 year old female who has history of hypertension, hypothyroidism and good. Uh she was referred to us for management of asymptomatic bankers diverticular. Her main symptoms were severe dysplasia to solids and liquids. Uh significant problem with swallowing her pills. It's been there for a while but significantly worse over the last four months. Uh with recurrent coughing fits and choking episodes. Her Milano Zenker score was seven. Um She had a program that was done that showed a two centimeter um posterior Zanker at level of uh C five. And this is the photo from the endoscopy on the referral. So today dr Stavropoulos will be doing as e poem with endoscopic diverticular to me and my autonomy of the hypertensive cricket fringes muscle. And now we're switching to the room for dr Stavropoulos. Hello everyone. Um We are ready to inspect these anchors and see um if the Z poem is going to be the way to go. My um advanced further from last year, Dr Al Ansari is not approving of these anchors. Apparently he says it's too tight. So let's see what he means by that. Um And I would want obviously I want to thank him because he came back after a pretty intense year with me to get a little last final abuse for a day. Mhm. So let's see what it looks like. Okay. Well yeah. So that you know that's why the patient has this feature. So the septum is um is uh in pitching a little on the sofa deal side. I mean that's why you know the old timers anchors. People put a wire or all right. Um And the tube they used to put right back when they would do the direct septa to me. Of all the layers. I don't think we need to do that with a Z poem. So the poem, the way I do it is start at the apex. That's right there and then go down the apex dissecting the muscle. This is a small tankers. But you can see it's maybe two cm. So we may not even you'll see. We may not even enter the tunnel except put our nose in it as opposed to get the whole endoscope in the tunnel. I'm gonna inject a little bit first. Not a lot because it's easy to get an eccentric injection that then pushes you on one side or the other and then you may miss part of the muscle. That's part of the problem. So you need to inject just a little bit. I'm not using the hybrid night for this first injection because of the small chance that if I you have to make a little puncture and then inject that little puncture. May already start a muscle splitting and then I may lose part of its stuck on either wall that that particular wall of the vagina well and it's not gonna be as good as my autonomy. And then you could have any courage. I'm using the food, the cap which is tapered. Um May make it easier to put our nose in the tunnel and I'm gonna do a little injection maybe once you see just to open just to give a little space for the hybrid knife to do the rest of the injection safely. And I'm gonna try to stay in the middle. Not result in an eccentric injection. You don't want to go too far towards 11:00 because closure there gets difficult with eclipse. You want to stay towards the five o'clock but again, not too close to five o'clock either because you see how the septum opens up. Uh Then you can end up with the clips pinching the wall and narrowing things and then getting a stenosis which may result in the clips ripping off in a leak, et cetera. So the you know, the closure is much more tricky than the zippo. Um The closure of the zippo. Um Exactly. I find more annoying. All right. Greg Greg is moderating. I want to see what he thinks about the closure of a zippo and I find it more irritating than when we used to do all the layers, inject once you see. All right. Um The average. Absolutely right. I think uh I said to my fellow is the worst complication I ever had in the last few years of uh advanced endoscopy was a leak following clipping after a fall. So media rhinitis is a disastrous consequence in the league decision. Had that surgery and graded students, et cetera. So we're very cognizant of the problems associated with closure after the fall. And I would uh I would agree. Yeah, that's paradoxical right? Because but I mean, the poem is supposed to be safer. I had I was doing the regular septa to me further, not 10 years with no leaks. The last seven I'm doing zippo. Um and I have to leaks nothing that caused me the ester nineties. But they needed antibiotics because of a micro leak. And this both both to happen after the happening the zippo and cohort. So, I'm a little I'm a little ah intrigued by this. There is also a publication I think from a surgical group. I think like maybe Bronski marks someone like that. That also they looked at cohort direct step totally versus zippo. Um, and they found all I think they had leaks on the Z poem group as opposed to I think that was the publication. So, so you have to be careful with the poem. We are still collecting data really. And you know, the only complication that I had Star Wars is actually with a Killian Jamieson and I think uh that that particular of course, a little more interior and uh and so it's I think for absolute riskier in terms of entry into the media Sinem. So uh unfortunately the bankers causes medias tonight is too, I mean it's it's still, it still leaks downward so you can get just a night is with the bankers to yeah, so I'm trying to not go too close to the wall but not too far because I'm cognizant of how am I gonna close. That's really my main concern, the zip um is very little concern. The big concern is make a smaller hole as possible that can be closed as securely as possible. That's the problem. And you know, the ankle is a bit atrocious here. Yes. Generally I found that the smaller the bankers the more difficult it is because if you have a nice long septum um you can eventually even get the scope in the tunnel and that eliminates the angle problems. But here I have to do them. I oughta me without actually entering the tunnel just have my nose in it. But on the other hand, of course with a very small diverticular and almost bridging almost like a critical ferengi old bar with very little pocket. Your only option really is important. I mean you can't do a conventional stepped onto me with all the layers. All right. If you don't have enough of a minimum of 15 millimeter dive. Executive minimum. Right. The the yeah right here here I have enough I think to do a traditional septa to me just one centimeter 1.5. But yes, sometimes it's just a crack of our angel bar and that is even more dangerous because the closure day is even trickier. It's interesting stavros I mean I generally don't start by my ought to me. So I'm inside the tunnel uh and and and it exposed the muscle on either side and then I use an sp knife just to cut down through it. I can see that you're doing it really from outside of the closer you are doing it like with a pinhole approach. Yeah, well in this very short septum yes, if I have a three centimeter septum eventually I did get in the tunnel but because I start at the apex there is not much because I to create a tunnel before you start hitting the muscle. So I just just do them. I oughta me as I go and eventually I get in right right now the important thing is not to miss muscle on either side. So you see I inject the diverticular side constantly. Can you give me? And I'll cut a little bit, I'm using up to nob was using dry but now I need precision because I keep keep extending the whole to the left so I want to cut a little more precisely just the muscles I'm injecting to get around the muscles he constantly see there now I can see submit koza. Right? So tell us again what current are exactly are using for cutting the muscle and what current for coagulation. Um The Well my go to combination for most things with the via three is dry for mucosal entry incisions, circumferential incision in SD because you get less bleeding than end of that and then for the dissection you know you're happy. For example use a swift. I think I use the precise sect which is you know again it's a well basically the simplistic way to think about is the processor. Make sure that it gives calculation when you're at a vessel and more cutting when you are you know, clear sailing sub mucosa. So I like that. I use the precise act. So what setting of precise sect 5, 4 um Yeah, precise. Like I think it's four or five the precise act Right now I'm at 5.6. And what about dry cup. Right, What I'm using, What was I going to 500 Drug Kit. Eur 5.3 5.3. I mean I really see I don't know what these numbers mean compared to the older be until I looked at the pic vault that I cheat, you know the machine. If you go to change the setting in very little letters, it tells you what the pig vault that gets to. So then you can at least somehow correlate to the older b the direct correlation that superman a little less aggressively than the old one, even at the same pick voltage because it does more calculations and is much more precise. But at least you have some idea about where what the peak voltage gets to, right? I would say when you're not in the tunnel, it seems to me that your biggest risk is mucosal injury that you are injecting alongside the muscle. But yes. Yeah, personally see I inject here very protected here and then I inject on the other side on the sofa, the outside. And you know, I keep I keep trying to do that, you know, and I'm using and a cat which has very little escape of current. It's more likely that I'll get a bleed but it doesn't escape at all around the surrounding tissue. So are you using? And a cut instead of dry cut now for the my ah to me, yes, I'm using. And a cut. Okay. And look awry. Uh Yeah. Which one? And Okay. I also I look at you look works better in the water. Use like the water pressure technique here to keep to keep visibility and keep the whole open. C. I used the water as a as a as a pushing substance to show me where to cut it's Wajahat vehicles, water pressure, which, you know, it's very useful also in the duodenum in the colon water pressure technique is very useful in that duodenal, the third cases, that duodenal resection so we can see there. So here now now have clear sailing, see the angle improves once you get through the crack of our in june. So but now you see the muscle thinned out now. So we're definitely getting to muscularity of the so far this year and it's a small sink as I don't know. I mean you can't get as much as you want at this point because it's much easier. Now my whole noses, well half my nose is in the tunnel again, I don't want to stretch the opening too much because I'm constantly cognizant about the closure, which is annoying and dangerous as you mentioned. And as I mentioned, okay, so I think what do you think? That's that's that's about two centimetres. I don't think, I mean it's pointless to keep going. I can't go another five if I want to but I don't know what the point is here. Right. I mean I'm down there. I think you're part of that should be at the end of the bankers. Right? Yes, I'm gonna keep going. As you can see it's very easy, you can keep going but I don't think we should be carried away. Well, once the muscle thins out and you're down to muscular appropriate the asafoetida wall, I don't think there's any point in continuing. So you think that sound equipment one day you think that's adequate. Right? It is. I'm looking at trying to get a sense of the depth. Sometimes I will see the thicker the crack of our end users up here where it was thicker and then it turns out right there. So I think we're okay. Right. And then yeah, I think you're okay there. Um I got cut a little more. Okay. I guess it's so easy. It's so easy to continue. Well, I think that I mean if you look at the Italian data they get like 30% recurrences. I think it's because with the old technique, I think it's because you know with the old technique you are afraid to cut too much because you know, you're not in a tunnel. So they get like a two-year recurrence of 30%. I never get any recurrences. Uh those 15 years, I don't know if I've gotten two or three recurrences probably because I'm very aggressive with how much I cut. So anyway, I think that's it. Right? I think that's it. Um There's a question that came up about the sp knife uh that that I used in the settings that we use for the sp night. Uh In fact I I um I cannot recall right at the moment exactly the setting for the espionage. It's it's uh the Olympus has the settings with the knife with the junior and and the standard knife. So we'll try to get those settings for you where there has been a knife, john you know what the settings are for the SB knife? Well, there's been a knife. The technique is coagulate and cut, calculate and cut. So the calculation with there's been knife. So 131 end a cat is to cut like a very low coagulation effect. And a cat for the cutting for the for the coagulation. Probably some kind of forced or or soft calculation like you do with a grasshopper, you don't want to cook it enough to stick to the knife. So I think soft and then and a cat soft and then and a cat. All right. So now we can we can close. Right? And this is the this is the tricky part and obviously we need clips optimally that have a short stem, right? So they don't bulk into the firings. We tend to use a Lucado clips. The 11 millimeter Lucado clips, which have a fairly short stem. The that's the not the micro tech. Yes. Alright. Micro Text. The Newer one. The newer micro type. That's right. So, I'm going to um uh I'm gonna use the really microscopic easy clip with my having the shortest. It's the, you know, it's a low double cliff. I don't know where You see there's a show the audience there's a catheter, there's a metallic catheter that used to be non disposable 20 years ago. But now it's disposable. But you can use it for the whole case and you load the clip? So the clip comes, the clip comes in little cartridges. So why don't you put your first clip on and then show how you load the next. These are like they look like candy actually and they have different colours in europe. I love it. I put it in candy jars, right? Like the pink one, the blue one, the white one. So I don't know if you can zoom. So this is a little cartridge. You put you put the Metallica that they're right in it open, close and it picks up the clip and then you can decide which size you want. So, um so we picked a smaller, the white is really the smaller one. You see very tiny clips and they are very soft. Like if you use something like a resolution that has stiffer arms, which I like for other indications. But these ones, if you have a perforation in a muscle in an SD is less likely to tear through the muscle because you need to close the hole and keep going with your ears. Day. Obviously so much less chance it will tear through the muscle than the stiffer clips. So I'm going to use it here. I don't like that. The edges are a little swollen because this is a tiny clip but we'll see how that works. Sometimes I use a resolution in the thicker part to approximate. So I may use a resolution in the middle and then at the edges go up and left an upright with a smaller cliff. I'm thinking I don't like I don't like I'm not sure if the olympics will be able the smaller olympics will be able to approximate this from the beginning properly. Uh huh. Yeah the medium use a larger. If it doesn't work we'll start with something like a resolution in the middle and the smaller clip on the edges. Opie open. Okay. Alright. Now rotate Now. The good thing about easy clip is the rotation is very good. It's 1- one. Mhm. Let's see if your arms are long enough for this one though. Oh I'm not sure what the left are the the left arm is the problem with the left arm has got yeah, I usually start at the edge and work my way down into the middle. But yeah, it looks like you're you know which says do you start with because I've tried both sides. I wasn't happy with either. Well if I do the top which is a more dangerous one that clip turns parallel to the incision. So then it's like a bit of a pain in the ass. I don't know. This is a frustrating closure. Really. A good spot right there. Okay so I think that's good. Right, okay. Do it looks good. Okay. Okay. Open. Not too much with the opening. Yeah. Okay, that looks good. That's exactly. So let's let's have a close up with the camera to show you load this now. Let's go slowly. Well they already loaded but okay the next one the next one do it on the camera. Okay. Like like why don't you show now Vanessa? So Zuma a very easy like click click click done. It's like did you remember years ago did you use the ones from olympics that would come to the little styrofoam thing and you have to learn how to load them. Remember those uh those were a pain too loud. So the other interesting thing about Z poem to talk about stavros is that sometimes when you dissect and do your my ah to me you can see a separation of the muscular appropriate of the diverticular um And of the uh soft shell wall. So we have two plates of muscle as you cut down past the cradle fair and jails. So you may see a little separation and you have two balls of muscles that are apparent. Yeah but you didn't we didn't see it here. And no we did not. It's a bad thing when you see that that's part of the fashion in front of the spine. So I think that's one of the other problems of zippo. Um I don't like when I see the splitting of the muscles that means you are very close to the spine. Has to do with where you enter. That's why I don't want to go close to either wall. Especially the people that you know when they started doing it in china. they would do the tunnel starting in the hyper pharynx. That's when you get into that area where you are in front of the spine And then you can get really bad leaks and media stand 90s and whatnot. So yeah. I don't like when I see the two muscles that means you weird afterwards the spine. And that never happens when you do a direct septa to me. And I think that's part of the problem with the zippo and it forces you in a plane. There's an editorial somewhere that says that from an E. N. T. Person that zippo um forces you into that fashion in front of the spine. And you should be really careful because the nt people know that it's bad to be there. So I don't remember which journal but it was some editorial by an anti surgeon. Turn to the right a little. Okay so there was a question about using X. Tax too close but exact would not be suitable here because the fact is the causal closure pulling it together and the way the future threat attached to the uh screw. It's a little bit high up on the screw. So you don't get a tight closure necessarily with the X. Factor. Right? Oh. Uh huh. Yeah. Oh yeah. One issue with this clip. You have to remember. It doesn't reopen. So once you close that's it it doesn't like it's not like the resolution where you can close open close open. Close open This one. You close. It's a permanent close right? You see there's a little bit of extension of the burn little contra to over to the side wall. Usually it has no consequence but it will happen. Especially we don't have much room just when you're starting to do your mucosal incision so you can see her now that you have to gently titan to open up to spread the clip apart. Yeah and the tricky part here is obviously getting the inferior arms into the diverticular side to make sure you have a number of a grip on the mucosa of the diverticular lab and there. Okay I do it not suddenly. Not suddenly. Well you're committed. Yeah but if you suddenly it stiffens the catheter and then it changes your angle. Never close the clip suddenly. So I'm not sure about your routine for these uh stavros. Uh What is your post operative routine? Well all these people obviously are ancient with comorbidities because that's the bankers. So I keep them overnight and do a Valium the next day. If everything is perfect. If I don't like the closure maybe I hold one more night before I do the barium. I'm very conservative. What do you do? Let me get you send them home? I would agree. Generally I keep them envy. Oh the first evening we give them antibiotics during the actual procedure. Generally I used the boxes in two g. Uh for prophylactic antibiotic. And then we do a contrast study in the morning to make sure there's no leak. And then we started them on clear fluids the first day and then full fluids For about five days afterwards. Well you eat probably more like four more days. And then we let them start to eat. But you see you stavros is being very aggressive with clipping. Leaving no gap unclipped because prevention of leak is the most critical aspect of preventing complications. Okay. Okay. What do you think I like this? And can you look beyond your look to the other end now to see what's at the other top end? I think it looks good. It's hard to tell. Let me go a little. I don't know. I don't want to push with my cop too much. See if I can do water pressure. You can see that. Yeah. Um Obviously don't have a lot of space to work in here. Yeah. And I tried to start at the start on the left. What did I uh can put another one. Another one up there. Okay. That's gonna be difficult. And that will be a challenge. I tried to get the ads but when the way the clip turns, so the other thing that is sometimes you start roses. I'll change caps because the funnel tip of the fuji cap. Uh That was okay. What do you do here? No, no, no go out of the way. Okay. There you go. Well, yeah, you missed a quiet debate here. I had the other scope with a straight cup ready so I can use that for clipping. But then I decided to give this a try. It worked okay. Yeah, I tend to switch to because this interferes with the clip rotation. Okay? Um uh This will be tricky. I don't know. You may have to, it's very very difficult here to move into that spot, but you can see how it's opened up that you need it. Are here close. No. Oh okay. Yeah. Okay. Let's see. Well I'm not sure it's open there and I could try to put another one, but I think it's gonna be impossible. I don't think you can get up there. I think that's just a little sub because at the edge of the incision, I don't I don't think that uh if I tried to put another one, I could displace this one and it was impossible to play. So I'm not doing it. I don't know what no, I think I would hold tight here for sure. I mean it's I think it's hard to tell uh now on that far side, but it looks it looks good now compared to it was open before. But now I think you've got it it looks like you've got nicely. Oh yeah, that's it. But that understates how difficult this tight short ones. It's it's it's terribly difficult to close them. And that that's that's why I think zip on, you know, hasn't really proven the safety yet, wow, it's still a challenge and we have to be very, very careful with it. I mean I suppose one could, one could look at it see when you did it, you went right on top of the bustle which will make you know, as opposed to starting a little bit more approximately and tumbling down to the muscle, which makes the closure easier because the closure is easier on the right side. Um So I guess that that's an option. But then you end up with a larger opening if you have to tunnel down on top of them off just so It's six of 1/2 dozen of the other. If you go directly over the muscle, you have a much smaller hole too close. Can you hear me now? I just regained the audio. Yeah, I mean what what you're talking about is basically doing a starting a tunnel before the septum and going down to the septum. That closure is difficult for different reasons because it's firm. You know, politan tissues when you try to approximate is like closing because over bone or something. So this is the this is the longer tanner that you know that joe reported like you start to centimeters above like you're doing a poem tunnel down to the septum then cut and then then then then you are closing and opening further up, right in the hyper firings. The problem in that area. It's very the tissue underneath the mucosa is very firm. So the clips tend to stay aloof. And the other problem is that when you get what TNT Guy was saying, you end up approaching from from while writing the cervical spine and there's there's that's where you get that splitting of the muscle into that fascia and there's a vaginal muscles. So I don't know. I mean I I like to stay on the septum. Listen, I think there's a there's a happy medium if you don't have to go to centimeters up. But if you if you start more a little bit more up and then and slip underneath. I think there's two ways to go here. Two ways to go. But you know, we saw here with a very limited geography. How difficult it is to close. But right. And I've got the overstates to here because of how annoying this is. I have closed with overseas too. But anatomy was very conducive. So it's I've tried it in two or three others. The angle is just the overstates cannot cannot really manage this angle. I've talked about. I've talked about putting futures before the Z. Poem. So you have them ready there to approximate when you're done that. It's just that the ankle for the overstates is very difficult over there. Oh, extremely difficult, extremely difficult. I think clipping is definitely the way to go. I think the only disadvantage of the easy clip is the inability to open and close. So I think that as you say, once you're committed, once you close your done can't you can't release it. So I think for most of us we would prefer a clip that we can open without committee, open and close without committee and also with the other clips with the uh micro tech or with the resolution flips the resolution 3 60 you can sort of partially close if you don't have enough space to open up completely. So those are the options. So I guess we're I think we have a little bit of time now before the next case um a couple of the questions that did come up that we can address now is um which is your scope of choice. So you can see because of the limited area that we have uh in the area of the bankers, we tend to use a smaller scope to be able to make a tunnel and go into the tunnel. So I tend to use the either the fuji scope. The advantage of the fuji or the the difference between the fuji I should say and the Olympus scope is that the operating channel on the fuji gastro scope is around 5 30 where as you can see with the olympics scope, the operating channel is a little bit closer to seven o'clock. So sometimes it's a little bit easier to have that 5:30 operating channel. It gives you uh easier control to do you're cutting. So that's one potential advantage of the Fuji scope. We use a small caliber scope you can use, if you use the Olympus, you can use the HQ if you want the high definition. There's not a big difference in the overall diameter compared to the basic gastro scope without the high definition and with the fuji scope you can use the zoom or the standard. Again it's about uh half a millimeter difference. So there's not a big difference in the overall diameter. I don't tend to use the one team. The only advantage of the won t clearly is a section in spite of your accessories in the channel. So uh I you know the situation where you might have bleeding or you need to control bleeding, you won't be able to aspirate while you have a coagulation device down the channel. That might be an advantage of one team. But we don't usually start with the one T scope. Um the other question that came up is do we use a viscous solution? A start solution? Hydroxy apple starch believe in Or do you sailing for uh the Z pole which end to use sailing? We don't really need a viscous solution. Uh it may create a little bit more bubbling when you use uh coagulation current or cutting current with the viscous solutions and the starch solutions and you don't need this. We don't have to have a sustained uh guess lift with the viscous solution. Um, the other question uh in terms of uh using epinephrine in the solution or not, I think uh certainly in poem we don't use epinephrine. We don't use it necessarily here in the tunnel where you want to see the vessels where you want to coagulate. So you don't want the vessels to uh to spasm, so to speak. Um, so those are the questions um any other questions here but he wants to pose here. I think we've addressed the issue of how to approach. I think my approach is a little bit different than what you saw with stavros, stavros did a direct central mucus sodomy directly on top of the muscle and then use the hybrid night in order to be able to expand the sub mucosal plane on the both the diverticular side and this on the jail side. And by expanding the suddenly closer with the hybrid knife and the injection, he was able to isolate the muscle so that when he cut the muscle uh he avoided any kind of mucosal injury so similar to poem with the Z. Ball. They want to avoid mucosal injury which would of course cause a leak and problems later. So to avoid the mucosal injury. The advantage of the hybrid night is to be able to inject vigorously in the sub mucosal plane just prior to cut it. Um we could use obviously there are different types of vibrant knives. Uh, they're the fuji night itself. The flush knife can do the same thing. And the pro knife, which is the boston Scientific Night, also allows you to inject through the tip of the needle. So these are other options for uh, hybrid style knife. Published August 5, 2021 Created by
