Chapters Transcript Video Z-POEM (Diverticulotomy for Zenker’s diverticulum) Stavros Stavropoulos, MD, performs a Z-POEM (Diverticulotomy for Zenker’s diverticulum) on a 74 year old female patient with PMH of HTN. Well, I would like to welcome everyone. Tow our course, I hope. Seeing what? Some technical glitches this morning. So that's what we're a bit late. Um, basically, um, it's ah covered. Um oh, basically hanging by the bootstraps live transmission. Until that, of course, was canceled because friends about having text here. Mind you too, Tex. Eso We have to do it with a finding new company to do that course remotely for us thing our i t people from the hostel of boots on the ground So it's gonna be a potentially glitzy, but I guess it's free on the content. Should be good. I'm gonna todo for on this topic. Ah, they're mixed toe to lectures in there. Um, it's gonna be a busy day. Um, with four cases and lectures, this is not like a life coach from room to room. So you get this from start to finish, and you know, there's no place for me to hide anything, which is a very good, valuable experience. It's get smaller, more akin. Toa this precept er ships that I dio 123 people visit. And what's the whole case in the room? The see Everything and ask questions. And we have the briefing between Case back full day and it's very, very educational. I'll be similar. You can submit questions my advanced fellow direct will be who will be helping with the cases. Will also be monitoring your questions and passing them on for discussion. Life, um e trying to get Chris Go start to moderate remotely. He's our moderator every year. He's very, you know, good color moderator and super super experienced in discovery. Yes, it I and while you are retired is a to retire. But I'll give my own moderator on. Then we'll try to make it all work. I hope you can stick it out and get, um, some good information and maybe, you know, entertainment. The you can get 9.5 CMS. If you go to our website and do the evaluation form, it is pretty good for a free activity on, but I would like to thank our sponsors would literally, at the last minute way. Couldn't have a lot of lead time for the course because the guidelines for coverage we're changing constantly. So we did. We did the grant process, and your visual company was changed go to another one. It was all, you know, on demand, last minute arrangements. So it's it's gonna be a pretty you know, uh, prone to errors. This process. We all figure it out. It's the first time we do, of course, this way. But we hope it will work out. Now. I'm going Thio, start with the sinkers case on, then rapidly moved to a poem case and then we'll take a break. Thio. We'll take a break and then go through a lecture on poem basically focusing on guard and in comparison to Heller on, then we'll do a full thickness resection of exist. Um, that's ah notes procedure. Really? So that's probably the most exciting part of the day on. Then we'll have any SD lecture focusing on Western years deed barrettes. Call on the controversy of the diversity of Maher in this areas and I will finish with the last case which is a colony is the the way we do it at Winthrop with the Lumen suturing very, very comprehensive way to do is did that also allows sending patient home the same day, which is very cost effective. So I hope you're watching on we don't have any technical issues, and I will now move on to the bankers first, Dr. Tarek Al Ansari advanced. Ella will present the bankers case briefly. And then we'll show you the procedure through the lens of the endoscope on. Then we'll move on to the poem on a spastic type pre aca laser patient. So thank you for attending. We get registration list was up to 150 preregistered. So we're hoping to get maybe the 200 or more. Um, today it should be a fun day. Thank you. But now we'll switch Thio. We'll switch to the presentation of the case. No. Okay. We're e I need to turn off. Like that's next. Okay, Doctor is accused. Testing. Testing? Yeah, I cannot have been. People are breathing. I mean, they have what a zoo might get. Yeah, Doctor is Michael's office contribution. He's ready to go. Okay. Do you want to give a countdown for him? Okay. Yeah. Hey. Good morning, everyone. My name is Dr Sarah. I'm sorry, I'm the advanced fellow working with Dr Stavropoulos this year. So for our first case, we will be seeing a procedure done on a 74 year old woman with past medical history of hypertension. Um, she was referred for the Space Asia to solid and regurgitation of undigested food and constant globus sensation over the past five years, she was seen by N. T. And G I. Over the past few years with multiple work I've done with no revealing ideology. She even had an e g d in 2018 that was reported as un revealing. She had a super graham done in 2000 and 19 that showed a two centimeters sinkers diverticular. So today we will see a parole endoscopic my autumn me off sinkers, diverticular azi poem. And now I take you to Dr Sabah Rapolas feels mhm. Okay, I think it's more like then No. Yeah. Okay. Yeah. Uh mhm. Yeah, this is the look can all there is. Okay, so this is the stuff a er Lumen hit. Um look, stop of one man from the bankers on the other. So, uh huh. And do a true tunnel down to the septum. Got the spirit on the septum. Reported by Jaw Guy The issue was but difficult to close here. The issue in the hype of far field can be very difficult to close. This'll tunnel now, if you easier. Maybe a little trickier to enter without splitting the muscle. Um, while you're doing the the entry, tell you might you want what you got. This is a disaster. That was saying she was. Yeah, but okay, we're ahead. Yeah, but, uh, the audio, the audio Is that better? Scott? There it is. Unacceptable. It looks like a constant signal. So I think we're in better shape. Okay, so here we are now, they set up the Olympus cap. I think for this kind of application, it's best I don't like I hear my He thought I wasn't doing 40. Well, anyway, um, with the best cap to use here would be the food cab with this taper. Um, so we can We can quickly sweet it, but the food seem a lot better entry because of the paper cap. It has some disadvantages. Bit of a star peds. Sometimes you get bubbles. Um, but less visibility. But here the entry is more important than having good visibility, because things are kind of a straight shot, unlike some complex es de. So we are going to So we changed to the food. The cap you can see immediately. We have less less of ah, less of a field in terms of visibility. But it will be potentially easier toe wiggle in. Now, with bankers, you always get this kind off sideways orientation. You can by manipulating the patient's head. You can kind of center it a little, and then we're gonna go here, and it's always the endoscope is pushed to one side. So you have, um, some tight quarters to work with. Yeah, right here. We have been pushed to onto the right side, which is problem, particularly in closing this. So I'm gonna inject just a little bit of an injection, not more than a C C. Open, because if you inject too much under such close quarters, you can have ah, an issue with getting in and with orientation just one cc, right on another half. Azizi, I can't stop. So we're using the alright jail here and we're gonna use the hybrid knife because I I find for areas off straight channeling poem. The poem panel assisted the is the Z poem having a tunnel, um, creation with a knife that can inject actively is helpful. Open. He's now we're using the Vaio three and we're starting with dry cuts to enter again. I usually make a a penetration first. Then I extend on either side and some patients. You get contractions like this off the sprinter. This makes things more dangerous. It may get worse as we get close to the sphincter and in terms off having the finger jump under the knife. So this is what's going on here again? I'm expanding very slowly. The incision. I don't overdo it. We can also inject The subject goes on either side again trying not to split the muscle whole. Right? And then in order to create a tunnel, obviously you cannot do it purely with something you caza. You need at least a centimeter to put your you're begin. So So you're gonna start cutting the muscle. And the full tunnel view will not appear until we're into the my auto me a little bit that here there's also a various ways of doing it. You can dio, uh I forgot to mention underwater helps when? When you have difficulty entry in areas of tunneling, you know going underwater can facilitate displaying them you casa and entering and seeing your planes better. So what we have here is the muscles begin to appear and you see the magnified view here. Now I'm injecting on either side of the muscle again. We don't want to split it and live some muscle on. There is something because on the Zanker side here that were carefully trying toe inject and you can see the sub because are playing here. So now we're gonna use precise sect, which is a human static current with very precise measurements of tissue independence and regulation of the kind by the microprocessors. It's a current that basically works by the micro. Persons were realizing when to give less energy or more energy, depending on the teacher resistance. So it avoids, You know, zipper cutting on one hand or cooking on the other end achieves the best possible world off carton independent off how much this resistance there is if I understand it correctly, so that's precise sect, and that's what I'm using now well on injecting see the see how it's possible to split the muscle. That's why the hybrid is useful here, injecting the sub because they're clearly outlines the planes better on the food. The camp also helps. Now some people use the Caesar knife the other There's been I for the cloud scatter. Um okay, I find them a little less, um less cutting more coagulation, which can be somewhat disturbing when you start burning them. Your cousin that you're gonna clip later you might get a bigger orifice are not good at this. And it z less precise, I can imagine under such difficult orientation here trying Thio trying to put the edges of the Caesar knife in the without injuring them. You casa. Okay, so there it is. Where now? At the beginning of the tunneling here. So here I want a little more precise cutting, even on the dry cat on the precise six years and a cut here and the cat I try to cut this without injuring them. You're because of that. This lying next to it hopes propaganda. I want to stop just at the subject cars out there. The problem with the Advocate is not very human static, but here we have just pure muscle with no vessels. So it's okay. So now I found my plane again on now I can use precise SEC because I don't know if some vessel is hiding in the septum. So So I'm having some resistance here, so I get a little less contact with the knife, and then it cuts when it is coming along Well, and look out here to be more precise. Andi, I would go. So this is, um this is the sub, because on the sofa, just see. Now you can see we begin to get in tunnel mode, which makes things a lot easier because it stabilizes the endoscope. Um, same when you have a ton of a sister, the SD, that's a vessel there. So this is, um so we can try. You know, you have two ways to do it. Do it a careful way which is used the grasshopper or use precise sect and try to coagulated on. I use precise here, and it works on their inject either side. So I'm doing the tunnels in the model a same time. I said tunnels because it's the tunnel in the sub, because off the solar goods and the tunnel in the sub, because off the diverticular side. But once you get to the final phase. Obviously, things get very straightforward. You can see the muscle things out to the thickness of us off Osiel muscle. So, you know, you did the crack of firing. This has been cut because you can see how things out. This is muscularity appropriate of the sofa. So but you can. You can now go all the way to the G. Jackson, if you so desire, because it gets very easy. The scope is stable. It's in the tunnel, so it's all looking good. Now this is a two centimeters anchors. As you saw, there's no need to go crazy so you can withdraw. We just made, I think, the smallest hold we could make. And now the tricky part of which is the closure, uh, show you why it's, uh, it can be very frustrating on. Obviously, the most dreaded complication is a leak. So the closure there's a lot that rides on the closure. Now there's some bleeding that let me find out what's going the closure, the if you look at traditional bankers techniques. Open studies have reported leaks anywhere between 2% and 15% in the literature, and I think it depends on how aggressive you are, at least on the traditional technique. How far you cut down. So the traditional technique was to stop one centimeter above the funders of the bank of the diverticular. And you see the particular, um, here on the left were were close to the bottom of it. In fact, we're beyond the bottom, But with the traditional technique, you can't do that. You have to live a little space there. The problem with that is, the more careful we are, the more the more off a let you live, and then the reconnaissance rate goes up. In fact, huge studies from Europe that so at 30% 30% recurrence Ah, I would the dura well, the started in Europe that so huge cancers of 30% or 33% by two years. I think this is because of the being careful in cutting the muscle, um on. Then they have to go back and do re treatment. Now I more aggressive. So Americans rate eyes. I don't know the 1% or 2% we maybe had one or two patients in the last five years that I remember that had some pats up needs so very low recanted, but we're pretty aggressive. We take it that my autumn it down to the sofa goose with a tunnel. You can do this with more. But the tunnel I got to say it's the closer is not much easier than doing the traditional bankers, you know, you can see. So you have to use a clip that has a small stem like here. We use the door. A clip are you can use similar clips. Um, don't want a big stem and then you have tow. You have Thio. You have to be careful not toe cuts new casa, um near the wall and create a leg. So you have to sort of twist and close there on then. Sometimes you get that they're on one of the sides. That makes things even more difficult. But you see, big push to the side can be problematic. And then you Which side you start is important because you can see how much difficulty I have with all the dial's cranked up reaching the left side, The anatomy pushes me to this side to the bottom, right, as opposed to up there. So I tried to go as high as possible because you can then easily corrected. Once I deploy this clip, it's gonna be in the way to try and put one even further up there. We think, Steve, they will go. We'll have to go higher. My Billary think open a little on slide A. The It's very, very eccentric. Cannot come here of these anchors I may regret not living good enough alone will say Okay, Open. Yeah, that's as much as I can reach. Basically, sometimes doing underwater helps by deflating the Lumen A very difficult But this is the most important and most difficult part here because because, I mean, we only had two licks in 10 years. That's probably because of how obsessive compulsive were about the closure. I mean, any, these are not futures. Any amount of food could displace those clips prematurely. And then we'll have a tunnel almost going into the media Steinem open. So you have to be very careful on trying to get a good closure. Okay, but close. Very slowly close. I used a lot of the subject cause, uh there too. Okay. I think that Zatz the best I can do I can't go any higher than that way. Uh huh. Good. Do you have enough of the bottom? Let's hope forget deploy. I mean, some some of these anchors, some of these bankers open a little bit with ball hands. Okay. Some of these anchors, um, are nicely center. I've been actually ableto to shoot her two or three of them because there was nicely centered. But unfortunately, most of the times you are pushed to the side like here, and you're struggling. Thio gain position. And I have to say the Olympus scopes, we have have limited regulation capabilities. I don't understand why send them out to be restrained and re tightened. And, you know, if you do a retro flex CSD in the funders, you always find your missing 20 degrees. Okay, I'm putting that their clothes, uh, overlapping Ed's is open A little close. Okay, I think I said well, Dio, what do you think? That e fine. My stuff is more obsessive compulsive than may that wanted closer to the other clips. So I will try to oblige. Hey, uh, because usually they know what they're talking about. I tend to be influenced by the difficulty and try to cut corners sometimes, right? Yeah. I don't know what to tell you to see that. That Zoe's close as I can't get it closed. Uh, okay. I think that's the best I can do. Sorry. Okay, go. We'll deploy. Yes. Okay, I'll paddle. See, that's what I don't understand. Also, by people there. There's some European centers that these are patients like this the same day. So you have these 80 year old s sake. Last three patients with this kind of closure and then go home. And if they don't follow your liquid diet and may be trying to eat some bread that night, I mean leak. Here, you'll end up with a neck. APS is very unpleasant experience. As I said, we had to in 10 years and they particularly unpleasant. One of them had Thio treat with with a stand through the U. S. Also very unpleasant experience. A bank? No, no, no. Come on. Okay. I hope the audio works. Okay. I'm worried about Yeah, I'm hearing from I'm hearing that the doctor. Mhm. Okay, close question. If you have tried the Fugees stuff the foodie. If I have tried, the food discovers Yes, I have That's a loaded question. I do think that rep reflects, but not to mention the bl I imagine. Technology. Okay? Yeah, but this I think that z just Well, okay, I see. I see. I see what just happened. Uh, hold on. Uh, Steve, stop opening when you see that open. Okay, let's try to grab that to open a little more. A little more. Okay. A couple blocks. There you go. Okay. Close. Okay, Deploy. Okay, It's all over. Okay, let's see this one. Now, this is this is the most difficult clip, the one on the flat side of the bankers. Because best thing is not to get the whole on this wall. But as you see here, the scope was pushed to this wall. So some of the whole extended here. Now you have to catch this wall and not create a fall that will impinge on the lumens. Not idea. Ah, good. Burn it. Try to put a slat as possible. Open, which is not possible. Actually, we have to be perpendicular, so we'll try not to catch too much tissue up there. Yeah, Yeah, this is close. E got this. Looks good. Right. I gotta do it. Yeah, but you see, I mean, I shoot you. All my poems to meet this kind of closure makes me sleep less well at night. If I pull this, if I put the scope through this pretending I'm a footballers, just the stretch on the septum could rip the clips off. So I'm not gonna do that. I'd like to empty the stomach from their prevents, gagging and retching and doing things like that. But the only way to do it if you want to do it, would be an XP scope. Let me do it just to make a comfortable I mean telco to. But as I said we are. We are the obsessive compulsive side in general. So I'm gonna try to we go through with the XP, sack the stomach down to avoid any a reputation that may vibrate those clips over there. Okay, so that's that's it for the bankers. Any where's direct any other? Any questions? Any other questions? Well, I want the I want to give you access to to the questions. How was the plan? I need to talk to direct direct. Can you tell? Tell them to give access to the question. Google Shade. Did you see it? You see any other questions? I'm not. Good morning, sir. Thank you for doing this for, actually, Crystal heard everything you were saying about the audience. That's how he sounds. Fine. Yeah. Okay. Yeah. Fidel, what do you think? Okay, so now let's put the XP down. So the pediatric scope, we're gonna try toe wiggle next to the clips gently on empty the stomach. There is the clips. Uh, um, yeah. Perfect. Okay. Oh, a little bit of can you put some water on the X pay? Maybe. Maybe I'm not gonna try this. It doesn't. It's also pushed to the side here. I'm gonna use some water to try to splay the planes and lubricate. Okay, I work. So this is, um this is it here. Okay. So empty the stomach. No liquid. The nurse that make her a lot more common comfortable. So we're gonna keep her. How old this is is in her seventies com abilities wise hybrid. Done. Okay, So you may keep her 24 24 or 48 hours, so send it home tomorrow or sunday. Now, if there is any elevated CRP the white count is going the wrong way. Anything like that? Um, we may delay a day or two. And that was sent home with a typical poem protocol. Few days of liquids, a week of soft, then resumption of regular diet. Okay, so we are Thing looks good. Yes. Yeah. Okay, that's our injection. Which runs down their sofa. Greece tell. Swollen from the injection. This is the closure now? No, but this area here, hold on. No, it looks good that the clip is buried down there, Right? Yeah. Okay, that's it. Now we're gonna move to the bottom room. Published February 8, 2021 Created by Related Presenters Stavros N. Stavropoulos, MD Gastroenterology View full profile
