Chapters Transcript Video NOTES: POEF Haruhiro Inoue, MD, PhD gives a live discussion of a recorded case, followed by a Q&A session. Thank you for joining us. How would you like to introduce your video on poet? We would we're all anxiously looking forward to it. Oh uh so so this is a case of uh if that is a part oil endoscopic complication, in other words. Uh This is the pure notes procedure. So, uh in the Antillean more we're getting some closure space and the creative tunnel. It's a like a poem procedure and then getting abdominal cavity at the very end of the subculture tunnel. So at the level of the abdominal, stop this and then so flexible endoscope uh in the abdominal cavity, Couillard cavity. We keep the up and goals. So anyway, uh this is actual video. So, uh yes. All right. This is a junction. So, before procedure looks a little bit tight. Little flecks view. You can see a relatively tight junction. So we can say that this is a collage ankle asia. So, um yeah, well, in this case, uh how are you taking the junction? Yes, very tight. Okay, well, at the moment, so, uh it looks it looks um similar skirts. We can see it around the junction anyway, not dilated. So first vehicles are incision in the middle part of these actors. Uh approximately 5-10 cm from the esophagus gastric junction. Uh We, after sudden closer injection, we are praising the Nikos Otaru miracles are incision. Then we are in a some closure space. So you can see a top half of the image. You can see the surface of the central muscle um using a T. T. Nine from the display coagulation uh 50 watt effect to uh we are dissecting Z. Or something close to five years. Then our try to uh if you stand the subsequent tunnel until the Chicago gastric junction. So now using the doubles the trees. Notes left side mics. Now you can see uh some because a tunnel already reached to the gastric cardia. We can confirm it then. So uh we are definitely in a abdominal space. So uh we are dissecting here. Sad drama. So together with a longitudinal muscle layer then um so we address it also some adipose tissue. Now open the peritoneum. You can see in front of us the arch, arch of the diaphragmatic cruise. This is a diaphragmatic cruise. Um Delhi's are somewhere uh at the post tissue so we are grasping it and then dissected. So at this moment we are trying to cut the peritoneum. Now we open the one millimeter of peritoneum. So we carefully not to tax the vessel in this earlier. Um There potentially there may be anatomically potentially there may be some branches of the uh Franny the cells. Anyway. So behind you can see a lever, a back side of the left Leader law. Now we're trying to get in the abdominal cavity. Of course our carbon dioxide gas in circulation. So a cup of the image. This is a uh abdominal war and the bottom is the surface of their stomach. Now we push their stomach are using the transformation the second scope, identify the correct position of the uh intra gastric scope. So this is a simulation of a fund application catch until the war using their some grasping forceps. And then so you can see the light in a left mitch. We pull back, you can see um Yes. So pulling up there uh until you're until the war on the stomach, I was like gradually, gradually to back bad here. Uh Ontario Ontario of the stomach toward the so far, no gas re junction. So uh life side is a mother Skopje mix then, so please note the left side. The next baby scoping. Makes you can see our on the flight station. These are uh my three creators covering. So we are through layer um gastric more cover the open hiatus. But this may avoid be a repacked zam. We insert the uh then we are trying to inside the uh surgery device that that can uh This is not over speech. This is our from a living person. Um needle holder. We catch the regular salt. Uh Such a needle with the burbs. Barbeque. Um So the gridlock that is the commercial name is a really. Then we are trying to catch the uh until the award of the stomach. Come on. So please please show me my video, please uh make it bigger. Okay. Yeah. So anyway, so now we are trying to our All right, a future. The Ontario award the stomach in a truly of fashion. Yeah. Then uh needle is coming into the stomach. Each I. E. Can confound. So we are trying to catch the big bite. We were trying big bite and the now we need do is coming out or to the colonial and we are catch the holes that need to tip again using a needle holder at the tail of the gridlock there is held so we can fix the Ontario gas week more this distorts speech then we prove the gridlock to all the uh software. Some grocery tunnel back and then after that. So now now we bring the mother scope into these copiers. Okay then uh we uh we are trying to place the second speech onto the it's a hard dash with youngsters itself or um light crews of the diaphragm uh in the sound closer to now. Mhm. So normally we place uh now we are featuring the diaphragmatic cruz uh Nobody We place uh two or three speeches anyway, so this starts torturing and the proximal structuring and them who's a threat. Then we can make a tight um approximation of both anchors then as a result of it we can make uh anti r air parcel from the application. That is a uh totally saying to our dull funding application. So this procedure is we are doing the we are doing the dough from syndication. Pure and sculpturing Using our uh Summit tunnel loot of the esophagus. So this procedure is a pure note. A round of litigation. So there was simple procedure. So everything we control the position of the structuring using the second scope monitoring into a gastric on the morning procedure. We control or the size of the lab. Buy the intrigue aspects called monetary. So like this way we can complete very mild from application. Of course this indication is not a regular hired to Hania patient. Not an indication. So this indication is a first form refract disease. So of course you know Anchorage, a patient has no princesses, no clearance of the subsidy body. So uh in a search uh Principal are so far after. Hello martini. Uh in order to avoid the post uh reflux disease, replace uh the dolphin application. That is a very mild on a plantation. He goes a patient has no subject balance. So uh anyway uh now we are trying to close the pupils are uh incision using your regular clips. So this is the one of the extension of the poem procedure. But actually we make up a flight and this is the last the moment we are checking your application using a baby school. So uh we call this procedure Paula endoscopic complication forever. So this before and after the procedure junction was opened before. But after uh thank you very much for your kind attention. Thank you very much haru. That was uh really exciting for us to see that and to see your innovation. Um And uh I guess we have a few questions for you is one of the question comes to mind if if only one out of five pollen patience is uh has a significant reflux. How do you decide which form patients to use the pull up with? Ah Yes. Thank you very much. So, indication is the most important. So, so uh like this morning. So like a doctor stavros couple of follows his live demonstration of the poem. So if we are completely preserving the color scheme bus. So it's a very uh almost zero, almost zero severe reflux disease after poem. So most of the case approaching posterity. A Canadian patients. Uh can we do support approaching the possibility for syria war and then dissecting the preserving the carousing must Or no patient becomes the severe girl. But so if we do uh 1000 patients. So we have a three or four. So percentage 0.3 or 0.4% of the poem patient becomes a severe reflux. So that means that we cannot control the reflux disease using the T. P. Or some other double rows E. P. I. So in such a case. So junction A position in a normal normal position. No thriving honey. No, no the vertical deviation of the guest detention. In such a case we can apply this technique. So just getting there uh approach. I'm Tony award for getting a peritoneal cavity and the maker. Uh golf interpretation. So if I understand correctly, you you would perform the poet. Uh Not in the same session necessarily as the poem. Yeah. Thank you so much. So our first shorty 30 30 33 33 cases so far. We did the 37. We did this procedure. So our 1st 33 cases. Yes we did uh we did it. We did it uh simultaneously. Yeah like after point procedure. We did it. But uh we conducted the the control trial. So poem only and the poem press publication. So procedure time extended to 40 minutes. So procedure time is actually doubled in the poem process group. Uh And then uh 24 hour ph study after procedure is uh statistically a little bit better with the founder precipitation blue. But clinically clinically no difference. Then. Now we decided not to do this procedure routinely. So our current our strategy for Anchorage. A patient is a poem alone. Forever alone. The if so of course the procedure is the same to a doctor. Several polos and the doctor favor. So we are trying to preserve the color string muscle. So very very very few patients. Less than 1% patient becomes the uh medicine uh resisted uh dirt. So in such a case in such a case we're trying to do this. Uh Oh of procedure. So nobody won. One year later. It's a point procedure. We do this procedure independently. Yes. And then when you do that, I presume you don't have to do much of a my autumn eu just tunnel down to the uh intra abdominal pus a vigil uh junction. And then you cut through to the parent name. There. You don't do along my ah to me just a short my ah to me to get into the peritoneal cavity. Yes. Yes. So in softer side um Just for five cm someone goes to a channel that just just proceeding. Yes. And the gastric side is a um just behind the Chicago gas gastric junction. So one centimeter will like that. Right. Right. Wonderful haru. You're going at 11 o'clock like where what where did you do? What did you do the stomach? You do it a little on the sandwich side. Right. You all right. Let's go to the left anterior part of the farm workers or 12 o'clock. Thank you very much. So uh We also think about the antonia Vegas now. So you have a milk off its best. 11. It's best then uh then we dissect the longitudinal muscle layer. So uh anatomically of course anteria Vegas snap. Uh We can we can identify during procedure So 11 o'clock direction we a brought the cyclorama Sudan after that. The wrong attitudinal we dissected. So then we can most of the case we can see a large bundle are going to the light side over image. So we have to preserve the such a big bundle. So that is that that maybe nobody knows that. Maybe maybe until elevators not big bundle. So we come to these are easily then getting up running on gravity and the makeup and fighters. So how are you with the needle technique as a surgeon? Of course, you are a very skillful with the needle driver. Uh But when do you have to, after you go through the interior wall of the stomach, You have to drop the needle and then pick it up again in the right position for your next. You have to drop the needle in the stomach and pick it up again. Yes. So, uh in the video creep, we do like that. So it's a total same, totally same movement during the uh South Dakota future. No colony, but only only one or two futures. Yes, two suitors. Uh so, uh not, not time questioning. So this is a 14 minute. Do you think a double channel gas a scope would help with the exchange of the needle with two device? Uh Yes. Yes. It's always a good idea. We may use we can use the double channel score. But of course if we use a double channel scope so we control the two forceps. So sometimes it may confuse more. And of course the outer diameter of the scope increases. So, so passing shoes or something closer to now and the keep little fraction and the movement of the scope shaft is a little bit limited. So I prefer using pcs a PCF for this procedure. Uh Sir john PCF Y. P. C. F. You want to go? You have the length to go. Uh PCF uh they had walking channel in uh Uh five or 60 clock. Yes. Yes. Are you the pleasures that you use? You are started on the villach outside the pleasure? The villach doesn't have a chance leads right. Because the loop. Do you have started ledgers on the villach future? Yes. So we we make 5,000,000 5 mm sq president health. From from what material from like like Sir disease or from what materials do you make the pleasant. Yeah, your pledge. It the pledges is a very popular in that often we are suitor the lung itself. So uh american theater. Um Yes. Um uh any place uh operating the other, you can get it, uh it fell and then you take it down. How do you make you make sure there's no no saliva go. And the pleasant. How do you get to the pleasure down to without contaminating it? Uh Yeah. Good question. Of course, contamination of saliva or some new cause. But so no problems have too small. So he's going hot old his or her own mucus or No problem. Okay. You also sing uh so established. Very important so far. No, no uh complication of this procedure. No infection after procedure. No, it's amazing. Wonderful officially. All right. How do I think again? Masterful and wonderful. The avenue of Long Island live again. I know uh, stavros has really been the pioneer and bringing all of these techniques to uh, to the Western World. An honor to have. I mean, boy is amazing. I want to start doing it soon. Right with the overseas, with the overseas. I just have to convince the high degree of N. Y. U. I don't know. We have to work on it together, work together. And then and then we have to convince them about technology, stack a smack. So, uh, okay, so now we will move to dr Gahagan dr joe Published August 5, 2021 Created by
