Chapters Transcript Video Live case #2: POEM for advanced achalasia with submucosal fibrosis In the second live case, Dr. Stavros N. Stavropoulos performs a POEM for advanced achalasia with submucosal fibrosis on a 20 year old woman. I think I just uh was notified that we are ready to move to the next room. And so we'll stavros has changed this gown and he's going to go back to work for us. Uh So we'll turn it over to the introduction of the next case. Thank you. Our second cases of 20 year old female who was diagnosed with a collision and referred to us for further management. Her primary symptoms were dysplasia to solids and liquids pour pure intake, intermittent chest pain and regurgitation and four kg weight loss. Her symptoms have been going on since 2017. So for about four or five years she had been previously treated with Botox around the time she was initially diagnosed but she had some improvement but symptoms persisted. Her Eckerd score was calculated at six. She was having this feature with each meals, occasional regurgitation and chest pain and had lost less than five kg weight. And it's a fake program uh could not be obtained because she could not tolerate it. He vomited the contrast and an endoscopy. Uh There was a hyper tonic. Lawrence officials finger with mild resistance to advancement of the scope to the stomach. No, here's the end of flip picture. The sensibility at 30 balloon was .8 and at 50 was .2. Uh high resolution manama tree. The ecclesia type was diagnosed with type two. Her I. R. P. Was 21.4 and 64% swallows for panis. Official pressurization. So our plan today for this Type two Oca Lesia with prior Botox treatment and longstanding disease for four years is to do a poor oral endoscopic my ah to me the equipment that we are going to use as I type hybrid knife. The goal is to do a posterior anti reflux form. Uh will be closing with endoscopic stuttering. Will use double endoscope trans illumination technique. And we'll do endo flip post poem assessment. I'm going to move you to the room now with dr Stavropoulos. We're starting the case. Hello stavros. Well I couldn't hear the audio of the presentation. I hope the rest of you could. Um But we were very well was well presented and all the important facts. Um She has a few years of disease. So we don't expect a lot of trouble. I had had another poem that had maybe 10 or 20 years of disease and food imp actions constantly. And her sub mucosal would be one big scar Which you know, not a problem. Uh at 900 poems, I've never aborted one. so but I don't think would have been appropriate for today because the next cases that ordinarily FDR and the last one is a colony S. D. And then at five p.m. We have a you know, endoscopic Eliza stacked on me live from china etcetera. So you know uh if we have taken a lot of time on the poem uh like say 1.5 hour instead of half an hour, one hour it would have been pinched on the FDR. And maybe we wouldn't be able to show the colony as this and we have to make some decisions. Um But you know, we can review the anti reflux poem. Set it over here. So, you know, start the poem. You look at the high pressure zone, that's where the cutting has to be About 38 for the my autonomy. So I'm gonna start at whatever is a convenient place further up. She is very vascular, very vascular. So you got to be careful when you do them. You cause an incision that you don't start an edge bleed because this can be very pesky to um to stop the ones that happened from arteries that are right there in the new causal plane. So we can try to not stick a vein. And you see that that deeper veins there's a network of capitalist. And then underneath you can hardly see the deeper veins. These are the ones that keep bleeding. And you keep burning your open and trying to stop them. So We'll see so 38 there. So we're gonna start that. You know, I don't know about 30 30 4 35, 33. Some were there maybe in between these vessels here and you have to make sure you don't puncture the muscle very gentle insertion. Then you tend the mucosa. And when you're about to fall out, you inject and you need to see this translucent blood and fibrosis, you see these sort of caribbean green, opaque or sometimes if it's really bad, even white. So it lifts. But you get this white or very light green color. That means a lot of fibrosis. And you know, you could decide at that point to say forget about posterior orientation and maybe go and inject anterior early where you may get more of a translucent blob like this. Okay, so now we're on dry and precise. Again, we're gonna do dry because we have to try and get through those veins without causing a net bleed at the opening. Which is very annoying and difficult to stop. So I'm gonna make a first make a puncture to get into the proper plane. And then you can decide. So do I want to go left or right? Probably have to go left. So I want to be between four and five o'clock. I'm gonna go left but the vein is right there. So I'm gonna inject with a hybrid. Doesn't I'm gonna try see it's already trying to bleed. So I'm gonna use precise to try and go very slowly through it. That doesn't mean it's gonna succeed because these veins are very very annoying. Some people are not vascular but he's extremely vascular the whole new cause I was very well vascular arised. So we go very slowly basically I i it doesn't look pretty but you can clean it up and make it prettier like that. Um So the main thing is to have a hemostat the country. Okay, so you can inject some more. Okay, what happened to my injection? I think you should try to make the volume a little higher because I can't hear it. Let's get this scraped off. Okay. Little bit underwater. You can magnify see exactly what's going on and then some more and then a little bit of now I need to cut a little more. So I'm gonna do dry. But again, very slow to try and calculate this area. And then you have a nice um And I don't want to make the opening more than 10 or so. And you need to stay near the muscle. See the muscle down here. If you go near the mucosa, then the mucosa is not supported. Then with the in and out of the scope during the poem. You are gonna you could get a the opening could tear to a bigger opening. A particular. If you're doing a longitudinal incision, you can see now that because our vessel, they're trying to act up. So I'm gonna just try again to calculate a little bit of precise there. But this can be hard to stop and say you need something that doesn't go deep to calculate this. I'm gonna just forced Low low, low level four. So I'm gonna just stay there. Uh come on. So what do you have settings for force to 2.53. Okay. And then coagulate here and then again, I'm using very low level forced here to get rid of the vessels. Okay, so this is good. So this is our opening and now I'm going to dive in. Yeah. Give me precise again underwater. You can do near focus and see better and then you can start dissecting and it's the usual working movements here. Yeah. Greg I can I can hear dr haber. Oh, Star rose. Can you hear me now? Oh yeah, I can hear you. Yeah. No, I was just asking me for what was your setting were forced to minimize mucosal injury? Were you down around 22.5 on the bio three. For which which which current? The force. Yeah. The fourth very low. You know the japanese? I think you're naga described as very low forced to coagulate vessels. I call it F 1 10 like effect 10 10 affect 1 10. Watch like F. 1 10. Well, you know the equivalent for the via three which would be Very .7. I have 1.7. Yeah, but you can't go you can't even go lower than that. You can go 2.3 or something. Somebody love forced. So now I stay very close to the muscle again because we are protecting the mucosa. And you have to constantly make sure that your tunnel axis is perpendicular to the muscle fibers. So I expose them a little intentionally so that you can see that basically you're following perpendicular early to those. That means you're maintaining your orientation. Right? So now you're just using precise sect. That's right now I'm using dry cards or dry frankly at this part of the procedure either would work very similarly so that that was dry right now. I can use precise there's your precise little more spark similar to what you see when you use a calculation current. Okay the dry cut has much less pike. Now this he's a vein so it's not a big concern. Well then think next it could be a notary actually is another. You have an artery so that the white stretch. Very. Yeah the venue can coagulate with anything so I can use dry cut on it and it will just shrivel away like it's nothing. You see that now the artery doesn't do that even a small one. So you know can I get this one with dry? I probably can with proper technique like big knife contact and start away from it. I can probably do it. But let's not experiment. So I'm gonna do low forced again low forced right for the artery. And the vein is as you saw no concern at all. So and then you do your little force. You could you slow cook it basically. Yeah. You slow cook it with big contact you know with local and density. Big contact on the knife. See how see even a small artery has a lot of substance to its wall. Now that's another artery that penetrates there. I think we can leave it alone because the eternal will extend towards here. Right? So there's a question that came on how to keep the tunnel straight. But I think you've demonstrated that I've always used a circular muscle. As your God. You want to be perpetrated your muscle. You can't see it. You must cut through to the muscle. See there's a a thin film you can see over the muscle. And if you can't detect the direction of the fibers then you just burn into the muscle a little bit. The way stavros did leaving those bread crumbs along the trail of his entry. So you can there's another there's another way that you can use. This becomes a problem even for experienced people when you have a severely signal the sofa goose or when you have a very long my Autumn in a type three where you're trying to make a 20 centimeter tunnel. You can get a little confused. I mean for the sigmoid you can actually retro flex and start tunneling backwards. Uh Really? So what you can do, I mean in those cases I used to do for every case I have I don't know if you can zoom on the scope like right here right here where my hand is we don't we don't see it. Let's yeah, I'll go down down down down to get the camera down? Down down? Okay. To my left a little to my left. My love. What? What is this now there. Can you move the I. V. Please? Okay. There you see. I put a little tape. Okay. And you can't put where's the marker? No, Michael. What happened? I don't use this much. But normally there's here. So you can see here you can put the market after you bring them the muscle exactly what you wanted. Like this is this is the orientation we want. Right? So then you can put a mark here. Okay. This is facing the ceiling, right? If you start spiraling then let's say you spiral to the left when you bring the muscle to this exact same orientation. The line. Now it's gonna be whatever degrees to the left or the right. You deviated. So then you know, if you need to dissect you can have preferentially dissected left. All right. Then when you see that you are 30° off, you can start cheating to the right or cheating to the left to bring you back to where the line is facing the ceiling. I don't do this anymore because I never lived orientation for short tunnels. But if you have some very long my autonomy or a sigmoid patient, you know it's worthwhile. So there's another little artery here. Like it's all pale. It has those white tracks around it. Right? So that's a battery. This is a vein here. I don't care. So for the artery again let's do some forced. And this coach. Slow cook it there. Make sure who's changing your settings for you every time. Vanessa Vanessa said hello Dr Haber is asking who is changing the settings every time. So that's a perfect job. You know you're saying co ag and boom it's there. Yeah because I've become pretty fixed on the currents I use so they could do it without me saying anything. Actually. She asked me whether I wanted force before I asked for it once you saw the body. She saw the order. So the principle here that establishes demonstrating you're not using the current to cut through the vessel. You don't put pressure. You sit beside the vessel and with a very low current allows to coagulate first. So you want to make sure it's completely coagulated before you cut through it. Now. What are those fibers coming in there? What's that? What's that? Tangential fiber? Yeah. I saw somebody, my fellow shot me somebody on the twitter putting about these fibers that you find them after boat docks. Well I don't think that's the case because you see them very frequent even in people without a bottle. So these are called apparent fibers. The micro of the D. Junction. And get them at the D. Junction. And they start From some circular fiber that go to three cm down and they enter another circular fiber you can find them in the even in the middle of the sub-Mucosa. And you just cut them. So uh so yeah. So they are burned fibers. One of the one of the markers that you are reaching the D. Junction along with the spindle veins and the other the other indicators of the G. I'm sorry. Yeah, I want precise back. All right. Okay. So see look here there in the middle of the sub mucosa. These fibers. You see those are barren fibers there. I don't know if maybe I don't know if there is a listen is good enough. Yeah, very subtle. Like there's a fiber right there in the middle that you see. I just cut it. You see one is there and one is there. I just cut through it. All right. There's another fiber there. You see it now there and there's a vessel hiding And it may be a big one. Big artery. So, this one is this is where people get in trouble. Yeah. I think when you get down to the G junction, the critical thing is to be very aware and alert as the vessels and feel very slowly and now several very experienced. You can move quickly. But you want to watch out for these vessels at all times One of these blows up, it destroys your dissection plane, The blood goes all into the sudden you close. It makes it much more difficult. Okay, I think this is one of the perforating vessels. Right? I don't know. that's that's just one that's just vain. I think that both of them are vain. So I'm just gonna try to zip through them with precise sec both veins so they're just evaporated. Yeah so we haven't reached yet the dangerous, you know the penetrating arteries. These are these are truly dangerous. Oh So now but now it's getting tight and I'm I'm at 40. And from the inside it looked at the high pressure zone Actually I'm a 39. The high pressure zone from inside started at 38. So I'm in the sphincter here slowly squeezing myself through right arrived. Doesn't look too tight. No her i. r. p. was what I think 21.8. And her distance, he took her distance ability at 50 was 1.2. But you get somebody with distance abilities of .3 and an i. r. p. of like uh 30 or something. Or sometimes even higher those you need to um Sometimes you need to do a pre cut, start cutting the muscle because otherwise you're not gonna be able to enter the cardia. You do what I call a precut um As you're making your my autumn, you know to create space to allow the scope to go down the channel right down the tunnel down the tunnel. Now you've got a notary there, yep. That's another um Now so that one I'm gonna do first here but you see see it now here there may be an area of Botox because this up because I got pretty dirty with actually a muscle fibers directly between the muscle and the mucosa pulling vertical. So this is this is a little scar here. But nothing, you know nothing serious obviously. So anyway let's get the vessels right. So you skeletonized them but not too much. You don't want really the knife to be touching the vessel because even with calculation current um accidentally cut through it. So you need a little bit of a buffer basically you are stewing the vessel in its surrounding sub mucosa is what you're doing in a very low fire. Okay so we are forced and then we're gonna slow cook it in its so that was very low. Yeah. That even looks like a pretty strong force. .0.7. Yeah. Which is 14. What's so you can even go lower 2.5. You can go to, let's see Like 10 watts would be .5 right? You can you can even leave it at that. I like it a little higher because occasionally I don't bother to change back and forth. If there are a lot of vessels. And actually use force to dissect as well. I'll show you use just the tip of the knives. .7 I think it's okay. So here here is the scar now this is a scar. You know, these are not a bear and fiber. You see the muscle just splits. And if it's really severe, it could force you to take a new plane inside the muscle without realizing it. And then that's a bad poem. So, so this is not a plane. You need to clean this up and get into the plane up here near the mucosa. So let's inject here. Those fibers are so small. I don't think that would affect it. I agree. You know, he dissected a little bit, but there are enough to get you. If you're a beginner into the wrong plane. See right now, I mean the muscle like this is muscle here. This is muscle at the top and muscle at the bottom. So if you continue and then the hybrid inject so you can continue here instead of continuing here, you're getting control and it starts, it starts like a little muscle. But the digger you did, you're gonna end up missing. Crafter muscle on the roof at the near the mucosa. So even though now I'm perpendicular to them because that which is dangerous. I need to clean this up and find and get the proper plane which is up here. So, I'm going to use and a cat. I don't want any leakers of guarantee to them. You cause I'm not to be very precise with very little knife. So what are you on? Very little calculation. So It's undercut the setting is one And look at I one And a live one. So let's try to get there. So stavros. Are you able to point out the sling fibers, the perforating vessels and how you, uh, prevent or reduce the reflux by uh, preserving the sling fibers. Yeah, I don't think we're seeing them yet, but when I see them, I'll let you know. Yeah. And if you don't see them, how often do you not see them? Um, I don't see them. Maybe I know 30% of the time or something. Yeah, There's a vessel up there in the right. Yes, there is. That's why I'm tiptoeing around it because it's right on the mucosa. So I I should leave it alone. I just want to clean up the tunnel a little, but I don't want to mess with that vessel. Yeah, I might have to, I don't know. See, I I turned this. I talked the scope all the way the other way, but it's not working perfect. Yeah, there is a vessel here that I may have to sacrifice. I don't know. It's not helping me. It's a small vessel. So, I think I just can't do it with precise. I just have to protect them. You cause at first and then just do a little bit of precise. All right. Okay. Now, see now we captured the plane. We had a little bit of a problem back there, but it's disappeared. Now, that's a clear sailing here into this up because of the cardia. That's, that's from one Botox. Obviously if you get 10 Botox injections and a bunch of food imp actions causing ulcers. They can get pretty hairy. Absolutely. Okay, there we go. So now we are. Now you can see the spindle veins right here, right? A sure sign that you're getting into the car. You see that little spindle veins there? Yeah, right there. But you see nice blocks of because I heard. So it's all clear sailing now. Now you have to start thinking about the length of the cardio. My autonomy. Okay, don't want to overdo it. Mm. So we used to be very cognizant of trying to go 2-3 cm below the G junction, if you like. The. Now that's been reduced a little bit in order to reduce the reflux. Now, 1.5 to this is where they're bleak fibers are you're saying that because you saw the blood vessel or because something, the blood vessels less. I can try to expose them. So the public fibers run to the left of those vessels here. Right? No, I'm not gonna I'm not gonna bother these vessels. No, because they may bother me back. Uh I can't I know anatomically, I if I if I dissect here, you'll be able to see the uh public fibers. But obviously I don't want to do it right now. But to the left of this penetrating arteries which are pretty sizable, right? You can see, you can see it pulsating there, that's like the knife is .7 mm. So this matter is you know, and there's a brother that he has next to it. It's about at least you know, .5.6 mm. It's a real lottery. Yeah, but that those arteries and veins together. I don't think that's the diameter of the artery alone. No, no, this this is an artery here. So if the knife is .7 it's 1.5. So that area alone is .5. And I think that's also another here. This one. Let's see. Yeah. You see how shiny it is. You see that sheen on it that because of the muscularity and the intimacy of the versa. Let me show underwater travel. See they're both pulsating. So these are this is a buy for credit data from the left gas. You see how they both are pulsating and they have the shiny the shiny pulse a tile flow. So so this is what this is the real branches of the of the left gastric. So these are the landmark vessels and the oblique fibers are up there to the left. So we're gonna leave them alone and continue our my autonomy to this side. And you'll see on retro reflection by trans illumination is going to end up at 2:00 until really 2.2 and 3:00. I'll show you but that's where you want to be right. And then usually if the high pressure zone is X. You want to get at X plus four or X plus five. So 38-plus 4 is 42 or 43. You need to be at 42 or 43. So now I am at um 41 a half. So or so, almost 42. So I can do a little more and call it There's another one. Right? What? I'm sorry. On the right. Yeah, I'm gonna leave it alone. Yeah, I'm at the end here. So all I need is a little extension of the tunnel in the middle here To get my extra five. Okay. I think I'm at about 42 now. And if I'm not, we're going to see it on trans illumination and do a little more extension anyway. Right? Yes. Right. So this is it. It looks like a wide open space is definitely on the gastric side. See that vessel? I wish it wasn't there. But it is. Well, you can remove that one, wow. Yeah. Just take this and not mess with a vessel. I mean, I have enough. I have enough reach now too. Do you my autonomy night. And you know what? There is your oblique muscle coming down here. Yeah. You see it, you're talking about left to right there. It is. Hold on. You say there it is. That's the oblique muscle here. You see the singular fibers here, right? Yes. That's the black muscle right here. But but when you say you're going to try to preserve the oblique. Yeah. Well preserve it. So you're going to do my autonomy proximal to the oblique. What? Oh yeah. Right. I'm sorry. You're gonna do you're my ah to me you're not going to cut that oblique muscle there? No, I'm not. What are you cutting now? The circular next to it? Well, like right here, let me show you. Yeah, I get that. Okay, you're preserving a little bit of muscle? No, I preserve all the oblique muscles. Like if I cut these fibers, you'll see a different orientation of fibers than these cut fibers here. All right. Don't cut them. So anyways I'm doing I'm cutting them. I'm doing them. I ought to me now. Right. Yeah. So you don't feel right into the you're going right into the heart of you know. Yes, this is the sphincter here. So which is exactly at 38. So I'm gonna start a little higher Like a 36 ish. You see you see where you see where the earliest ramps up, right? It starts ramping up here, Which is actually 36. and then gets at its narrowest there and then you go into the cardio. So This ramp up I'm gonna cut like right at 36? That's all you need right there are right there right now. Are you paying any attention to preservation of the longitudinal fibers here. Um Well no, I I don't actually I intentionally cut them because I would like a complete my auto man. Right. But I don't get I don't get through the pleura or the advantages. Alright. I preserve it so we don't have any problem. Right? But when you see you want complete my ah to me that's at the level of the but if you're more proximal to you, it was really approximate. Let's say that some really spastic Ds jackhammer usually then you know, if you're in the middle of the media steinem, I think you are better off doing the circular only. Right. So I agree. But here it's a short my autonomy for a type two patients right there at the earliest. Yeah. I'm doing complete. I do. What the hell are surgeon would do? Like I got all the muscles. Sure. That's I think that's part of the reason that I have 92% success out to seven years last on the on our publication now India from last month. 610 poems. And whether at least I think 60 or 70 at six years or seven years still 92% I think part of it is we make sure we do a complete my automatic right right now. Do you bother using peak seven or eight peak to prevent circulation of co two in the media Sinem. Do I'm sorry use words pete positive and pressure The anesthetist. I'm on the beef to 7th grade. I hardly use any insulation. So there you see the public now. Yeah, bleak circular. You got it. So this is a blake. This is circular. All right. Okay. So um Uh huh. Okay. So this is good. Right. Great. So this is uh how long is this? My autumn? So the approximate land of the Mata me is at 36. Yeah. And the distal end of the Maya to me is at um hold on. 42. So 600 m model. Perfect. So let me ask you now let me show you the trans illumination again. Okay, But let me ask you a question. Yes. Do you feel looking at this now that you can extend it further or you think you've maxed out. Now? I'm 100% sure that this is the perfect poem. Okay. I would agree. Because I saw the landmarks. I all the numbers feet 38 plus 4 42. Like every every confirmatory uh, line of thinking in this patient converts is perfectly. So the trans women ation is just for show. I don't really need it. I can assure you. It's gonna be between two and three o'clock, which means exactly opposite from the pool of fluid in the funders. And it's gonna be in centimeters maybe 1.5 from the Z line. But let's see. Let's see. Maybe maybe I'll be punished for my arrogance. What I'm saying. Yeah, we won't punish you. Don't worry. We're not going to put it. Well, if I'm wrong with spanish man enough. That's right. That will be the punishment. All right. Well this girl, this girl has a pretty tight you Yes, here I'm already being punished. Oh good. Oh good. Yeah. Who's holding the other scope? Know that the scope is being held by the bed. Okay. I mean I'm very careful about it with the co axial friction of the No, but I've looked the hell out of it and steve knows to watch it. Steve is watching like a hawk. He looked at his hand and he's not even listening to what you are saying. But he understood what is going on. Unfortunately the room, they cannot hear you. The only person that can hear you in my ear is myself. Okay? But see there is his hand just in case I have some friction going. Yeah, because we don't want to be pushing the regular scope. Yeah. Put so much loop that whatever push forward is is not gonna be able to overcome the tunnel. So here I am, here I am. I'm crossing the leah's uh there you go. There you go. Wide open. Yeah. So let's see, let's read reflects. Have a look where it is. The opposite of the opposite of fluid. Right? See the fluid showed the fluid and the fund is so there it is. That scope got smeared. Okay now. Good, very good. So let's see it. Maybe 1.5 from the Z line and it's a little cutting it close there. Right? But since the 20 year old girl and I don't want her to have reflux so or have to take PPS. Hold it there. Let me let me pull back. So the Z line. Mm it's almost one centimeter from the Z line. Right? You got I'm happy I'm happy with that. I don't think you have to go further. Ah Yeah no this is a this is truly an anti reflux poem here based on orientation and length and preserving the fibers by seeing them and preserving them and all that. So yeah I'm sorry where muscle was not that sick. Her sphincter was not that sick. I don't know. Yeah you guys you guys are low. She has relatively low I. R. P. So let me see now. Um let me see where we are here. Yes so there it is. Right. There you go. Say three o'clock, three o'clock. But It's literally one cm from the Z line. Yeah but don't forget the speaker is one cm above the Z line. There you go. Look at this. So yeah The question is you that extended by say five more. You know what the other problem is the scope inside is not at the end of the my autonomy because then it will be throwing the light into the peritoneal cavity. So it's a little further back so I can push the lighter than you. Cause a so the bottom is a few millimeters more than where the light is. So I'm at about 10. It's a little on the short side. But can you show us the scope in the channel, the image of the scope in the channel in the tunnel. Um The only way would be to turn the, can you turn them? Can you turn the camera on that monitor to show what the second scope is saying? The second scope doesn't have any in circulation. I'm just using a light source. I don't care about connecting any insulation or water. So you're not gonna be able, you can see Saros a muscle and then mucosa. I don't know if you can see it. You see this arosa. Arosa is at seven o'clock, then a little strip of muscle and then the mucosa in front of the scope. So I put it back and then shoved it into the mucosa. So the actual. Mata me maybe a little more than the transformation by a few millimeters. Some about 10 10 12 mm. Yeah, because it looks like your your scope. Is that the sling fibers right? And you were well below. A little bit below that. I could I could partially cut this link fibers together, better opening. Let me look at the opening and I'll let you know. And also you know, look at the opening by eye and see if I if I like it because you know, she's young. She also wants to eat with her friends without worrying about things getting stuck. Okay, so let's see. So look here what I'm saying. So see this is the myomectomy, right? But to do a good translucent nation, you come back and you show within the mucosa. So it's another five millimeters maybe or even 10 that my autonomy compared to the trans illumination right now, let me come out and see what the opening looks like. It looks pretty good when he went down with the other scope. Uh huh. Okay. So let's see um you know, it's a good anti reflux opening and I can make it bigger. The question is should I? And that that's that's the advantage of the anti reflux poem. You can titrate it like right now if I get the sling muscle, I'm gonna get a few extra millimeters. So if somebody's at a very low risk of reflects and say they are 70 years old, You can give them the gift of eating even more even better. And you know, they can take PPE once once they or maybe even twice a day. We are 75, 80 years old. What's the big deal? So that's uh but I think it's it's a it's a it's the proper anti reflex opening and we can confirm that with the end of lip. See it's it's pretty good right? Then the flip now should be between three and four, right? Three and four is okay if it's too so to tide And if it's eight like I used to do it 8910 I used to do. Then you get then you eat like a champ. But you have to take a PPS. So All right, let's let's do end of livia. Yeah, let's have a long let's see. But at what volume? What volume that 50? I do 30 and 50. Right, I'll do 51st. I have a fixed protocol. So I do 51st than 30. So, we'll see the 50 is more important because that's the first one you do then the 30, The 30 ML has been stretched by the 50. So That by itself is not as useful because if somebody does 3050 The third, it will be a lot tighter than my protocol that does 50.30. So that's that's part of the issues with the head of lip. There's a little bit of our ability in terms of what protocol you use also at 50. I live it for 30 seconds to a query bread because if you have a good my autumn and you see it starts at like three and you can get off before and it can get to five. So when you measure it because it's slowly stretches. So so If somebody has a tight diaphragm with plateaus immediately like those 3, 3.5 boom. Plateaus. If somebody doesn't have a tight dia from they can go from 3.22, like 4.8 as you're watching. So have a fixed 32nd equal liberation period for everyone from the beginning when we're doing that. So I can basically my data at least are internally um coherent. But comparing it with other centres, maybe there may be a systemic difference in the actual numbers. That's why people that obsess about actual numbers, like it says in built two or three. I don't even understand that. Depending on the institution, that could be a plus minus half for one point uh there. So yeah. So can you show the Oh yeah, perfect. No, we have the end of blood, which is excellent. Yeah. So I'm gonna go so I'm gonna go to 50, wait 30 seconds and then uh pose it and collect the numbers. What happened? Is it too far down in the stomach? Um I don't think so. It's at 40. The end of Flip Catheter says 40, so we should be fine. Yeah. Okay. There we go. I'm at 45 miles. 47 miles. 48 49 50. Also There's a long catheter that people use for type three measures at 30 seconds. Okay, let me know when two boys. Well actually, what do you do deposit. So this is the the long catheter that people use for type three gives you higher distance ability numbers. So If you mix up long and short, you're gonna get some differences. Whenever you use the long one, you're gonna get higher distance abilities. Is it 30 seconds? So, perfection. So the distance ability is 4.7. So it's it's really the perfect the perfectly sized poem. Yeah, Fantastic, fantastic. So, this sensibility 4.7 at 50 mls and diminish 14.9. So very, very nice. Not too tight, not to lose its in the golden golden range. What do you mean? Three point was at 4.7 or 39? No, 4.7. No, I think I said the minimal diameter was 14.9. Right? The minimal that's the other useful feature, you know, 13.14.9, minimal diameter. This is. And what's the diameter here For 14.9? The diameter. You know, you know how the old studies about sats key ring said more than 13 mm. No, this rage less than 13 mm this page. So, you know, it's good to see that it's 14. It's more than 13 mm. So you should have these villages symptoms. So now forever just is there ever a discordance between the FBI and the diameter? Like could you have a D. I let's say of six and a diameter of 10. Mhm. Well, no, they tend to correlate. You can't get weird things on spastic patients. You can get a lower distance ability in them, even though the minimal diameter is good because the whole esophagus is very narrow and spastic and it squeezes the balloon. So you have high pressures which gives you high distance ability. But at l yes, you have another quit opening. But yeah, in spastic patients you can get disturbances in the measurements, but generally for type two type ones, the minimal diameter and the distance ability correlated. Yeah. Save you much. Okay, so we're done. I'm gonna shoot you now. Right. Yeah. Okay. Because the D. I. Change at 30 ml The deer. Yeah, not yet because it's at 30 it's now stretched. So what was the distance ability at 30 8.7 which is typical. Okay. You get some something around 3-4 at 50 and then you get something at 7:8 at 30 at least with my protocol. Again, If you use different animals on the balloon, if you use long cast their shortcut there, if you do 31st than 50 you're gonna have maybe 10. That's point difference in the numbers. Okay. So I'm going to now future. Okay. And I suction her mouth. Mhm. Section. Would water. Mhm. I'm gonna sexually water at the end with the therapy music. Now the top of the gastric falls was And just yeah, but Ronnie didn't need the yesterday please. Psychological manama tree. Yesterday by endoscopic placement. So so the Z line is at 41 ish. Or do you want for do you want again then? Yeah. And then final look at the final look at the tunnel. Right. Make sure there's no late bleeding nothing. So yeah, looks good, totally very good. Excellent. Yeah. Okay, let's do it. So stavros, there's always the discussion. I mean you did a transverse cut to make featuring easier as opposed to a vertical cuts for eclipse clips versus suturing, suturing versus clips. Yeah. Well, we did a retrospective look at that five years ago when I wasn't as good as Children. And we closed 70 or 80 lb with clips and 70 or 80 points with featuring my first poems to be featured. So the time it took Was nine minutes on the clips and 10 minutes we put this in a review of shoe during this table in the World Journal of Gaston, Tesla and Dusk up in 2015. So it was nine minutes versus 10 minutes. Same same time. But now I've gotten much better at tutoring. I think my time now is five minutes. But the clip time should be the same because I was very good at clipping five years ago also. So the cost is 920 for the device And and $100 for the future and the since. So it's $1 $20 to close with shuttering right? Yeah. And with clips depends on what clip you guys like you, even if you use the easy clip that's like about with a catheter and the 56 clips you use the average poem. It's six clips apparently in the meta analysis. So six Clips Times 80. It's 2 40. So it's cheaper but much less secure. Like if this girl goes home and decided to go have a hamburger, even the authority to stay on liquids for a few days. I would worry if he has clips when, when Thomas Ross, who does second look endoscopic and every poem for 24 hours later looked, I think 10% of the poems were missing clips. He says that didn't result in a league. But then you know, Do you like missing clips 24 hours later? I don't like Mr Cliff 24 hours later. And that's a problem. And If you use something like a resolution clip, it's gonna be $1200 more. So if you use the cheapest possible you may be $600 more expensive with tutoring, but it's such a secure closure. I'm just, you know, I wouldn't give it up. So here we go. So where is the, what's your thinking on this? Well, listen, I used clips. I just find simple, fast, relatively cheap. Um, and uh, you know, listen, in addition to the uh, the device itself, the future device, you have to get another scope. You have to clean the scope you get out of the cupboard. You know, my chances in my text. Have it tolerated to go at the beginning of the kind of what I'm saying when you factor in the cost, You have to factor in another $200 for scope processing. Mm Yeah, I don't know. I mean it's a little it's a little weak argument. Well, I don't know if you start you have to start counting the processing cost of a reusable Orlando's called its ability of a grasping the listen, I wasn't thinking about it until all this data is coming about mom. All right. That's how we have to think about processing. Right? But this this data may be a little inflated I think to push for disposable scopes of course, you know, two sides to the argument. Well listen, I as much as I love featuring I still clear Because we haven't had leaks. We don't have, you know, uh I haven't done as many as you but I can say with at least 350 forms. We have had uh without I can't say none. We had one leak related to the clips which resolved with conservative management but otherwise we don't see it. Mm. Uh huh. But listen, You've been married to a nutrient for so long. It's like a 50-year anniversary practically. I don't want to spoil a good marriage. Uh okay. So let's sense it. Yeah, it looks great. Okay now what what are your orders for this patient? Post paul. Um well, you know i if she does great has no paint and lives nearby. She can go home the same day. If no, no, if any of this is not met we keep them overnight and at home the next day. And then it's three days of liquids for liquids a week of soft and then regular. Right. An antibiotic antibiotic. I think we're giving obviously the in the hostel and then maybe 23 days more in the sigmoid. People with Canada and whatnot. We'll make do 5 to 7 days and includes Lou Khanna's all okay go we just give one shot of prophylactic antibiotic at the time of the procedure. We don't give post procedure animal uh generally. Are you doing this because of some experience or why I'm doing it because I don't want any experience and I still haven't had any experience. So. No. I think I'm just being uh I'm being very obsessive both in in keeping in the hostel. Lemon antibiotics. Because I don't know I'm just I'm being very obsessive also in the hospital. The patients are taken care of by my colleague dR model who is also a motility specialist and she is even more obsessive than I am. I complained to her about my poem length of stay. But see she told me that if I if I want to take care of them myself I can feel free to do so. So I just shut up. All right. You see that? See that's fantastic. I mean my low complication rate and I do some horrendous poems is probably entirely attributed to her very careful administrations of these patients in the hospital. So I have no complaints. So if she cost me, you know, half a day of length of stay but ensure that nobody will ever get leak or media stir nineties or some bad bleed or whatever. That's fine with me. I mean half a day I'm okay. So stop just before we let you go because we have a lecture coming up with professor anyway. But the question I have is with something causal fibrosis, which was the other case. I think that was potentially going to be done today. What is your approach? I mean, how do you handle it? I've had a few cases. We have to change the tunnel change where we make the tunnel go a little bit more distal or proximal. Yeah, I had a case that I couldn't I couldn't get it done. I had to abort. Well, I mean look expert centers of 1-3% of board rates for poem. But as I said, I have zero But they want to 3% results are because of fibrosis. They start a tunnel and there's nowhere to go. Um you can see one of those and they can stop. Even the experts like to Long Island lives back maybe 2019 or 2018. If you go to Winthrop endoscopy dot org. Obviously all the videos are there. You can look at the poem by Harro Hero Inui of a 9, 10 year old kid with down syndrome that had two previous pneumatic dilation at boston Children's and after three hours you could do trance luminous nation. And the light is still in the sarcophagus and he quit. Okay. So it can be horrendous. Where you know, you've given an expert cannot find their way into the cardia. But you know all these tricks. Yeah, you can check like looking for sounding for water. You can inject to inject there, find out where there is least five groceries and you get at least a somewhat translucent blob and then boom start going there. And then it's like doing a colony as D by somebody that somebody in March seven times you just have to basically use and a cat as basically as sharp account as possible and cut your way where you imagine the plane is. But the problem is with these cases the entire mu cause it turns purple because inevitably if you don't want to end up splitting the muscle, you're too close to them because and you're cutting and cutting. So you end up successful. Like that girl from a new you brought her back six months later and I succeeded in the poem but it was three hours and at the end the home because I had a purple uh color all the way down to the cardia. So I had to keep our NPR on TPN for a week. We can have to let it heal and I scoped every three days to make sure that it doesn't fall apart all separate and fall apart and then you have a leak. So yeah it's not it's just I think it's 1980% persistence and patience and 20% experience and skill I think. So if you principally basically you're doing a straight my artemis, you don't really make much of a tunnel. You have to my itemized as you go if you can't get no I always make the tunnel first because on those patients, the minute you compromise the muscle you're gonna lose your planes completely and then you're gonna leave muscle and then you did nothing. I mean you will be in the Saros. I putting yourself in the back, cutting one third of the muscle and then you go back and the opening will still be tight and it won't be a good result. Keep the muscles. So at least where there is no fibrosis. I can see the muscle level and extrapolate where it could be through the fibrosis. It's what the japanese have described for difficult. If I brought a colony, is this where you make double tunnels, 1 to 1 flank, one to the other. Now you know where your muscle is on either side of the fused area of the fibrosis and then you cut from the flu vaccine right at that imagined extrapolated plane. So I wouldn't really compromise the muscle during the tunnel because then you're gonna lose yourself into you know undefined planes. Okay. Okay. What was masterfully done? As usual? You make it look simple as always. And uh, it's clear to see why you have the great results. You do. I mean, you're very, very careful and pay a lot of attention to all the metrics that are involved in, you know, assuring, you know, good swallowing and minimal reflex. So well done. Published August 5, 2021 Created by
