11 p.m. in Hyderabad and 10 30 p.m. in Milan Italy so imagine all of them opening up their endoscopy units just for ASGE and for all of you so a round of applause for all of them as we do that. Okay now if I can have Uzma Siddiqui and Mohan Kashyap who will be the panelists as we go to live endoscopy from Dusseldorf Germany. So Horst Neuhaus and Torsten Benja if you can hear us we will get started you know with you and see you on the screen. Fantastic. So welcome in San Diego it's a great pleasure and honor for us to join you and transmit from Dusseldorf. So firstly I would also like to thank our team Uter and Ralf and the anesthesiologist Miss Leuphen and Kerstin for the general anesthesia and this patient and we would like to present the first case may I have the PowerPoint file. So this is a 87 years old patient with progressive dysphagia for some months he lost 15 kilogram of body weight and in April this year he was admitted in another institution because of obviously aspiration caused pneumonia and for the first time he underwent EGD and CT scan showing a large zankerous diverticulum. Now the patient has been referred to us since then he is not able to swallow any solid food. So this is a Ducat and Bennett score of four. He can only drink liquids and we would like to perform a Z-poem. Of course this can can spend a lot of time on the differential indication for traditional poem or Z-poem. In principle the potential advantage of Z-poem is that we have a better exposure of the cricopharyngeal muscle of the septum and can estimate how deep it should cut and as I said he has a very large diverticulum. So I'm using Olympus the EZ 1500 from the new Avis X1 series and this allows us to modify also imaging. So it comes with five LEDs red, green, blue, violet and amber and amber absorbs at maximum when there are vessels or blood and I can just push here on the on the panel of this only one processor with touchpad so we can easily switch between the different settings. So now you can switch to the endoscopic image. The endoscope is equipped with a tapered cap. Seven centimeter from the tip is the length and eight millimeter in diameter. So we're in the pharynx of the patient and now I can already ask the panel what's that here in the pharynx. So this is white light endoscopy. I switched to TXI. Now TXI means texture and structure enhancements okay can better visualize vessels and differentiate red colors. So this is dedicated for detection of lesion and if you have not yet made the diagnosis, I switch to NBI and can magnify also the image. Any idea? So now approaching the upper esophageal sphincter and this large diverticulum here already clear. No wonder the patient cannot swallow. This is obviously the septum and it's not easy to expose the septum. It's a very very narrow space to the esophageal lumen. So a cap is helpful to separate the tissue and to expose the septum. So we will do a modified Z-point, not starting above the septum, but we would like to cut right on top of the septum and in principle our aim is to establish a tunnel on both sides of the muscle, esophageal side, pharyngeal side, to expose the muscle, then cutting the muscle and finally closing the mucostomy after incision. So for this procedure I'm using the Irby hybrid knife which allows to inject, to cut and to coagulate. So I have not to change the instrument and it is helpful especially in such a difficult anatomical situation but I think to make some coagulation markers on top of this bridge here because after injection it may be difficult to identify the top of the septum. So it should be in this direction. And I make a small cut into the mucosa with endocut 2-2-2. That means cutting duration and cutting interval is two. That means it will cut quite fast with less thermal injury. So I think I start from here. This is important to choose. So now we are in the submucosa. Now I use another pedal, one for flushing and just one now for injection through. Hi, good morning. Do you choose your technique for the Zankers treatment based on the size of the diverticulum? This is obviously a quite large one. Yeah, this is a good question. So we're still waiting for results of an ongoing randomized control trial. It's probably especially useful in small diverticular. But here, this narrow space, I would like to expose the muscle to have a better control how deep I cut. So now I inject. You see, we have just saline and a little bit indigo carmine. So as you see, now it's good to know that the other marker is there at 12 o'clock. So I'm cutting this direction. I open up the mucosa. And we have to see if this is already large enough. Not yet. We already see part of the muscle. And of course, your patient is intubated typically for these procedures? Yes, because of the high risk aspiration, especially in case of bleeding. So we can already see there's a very thin sub-mucosa layer. I would like to push this debris away, the good into the esophageal lobe. So this is flushing. So we have to see if this is already large enough. Probably have to cut a little bit more. I'm surprised that this is so. This is probably of the long tension here that we have. It's a very thin sub-mucosa layer. But now I would like to start with tunneling on the esophageal side. So I inject. And now we use dissection with the precise SEC mode from the Irby generator. This has a constant voltage. And cutting and dissection depends on the impedance. So when you have a very little contact to the tissue, we have high impedance, more dissection. Then we have broad contact. For example, in case of a vessel, then we have more coagulation. So this is specially dedicated for sub-mucosal endoscopy. So here you see the space is very narrow. I have very little space. But SEC, the cap allows us to keep appropriate distance from the mucosa. So the most important aim is to protect the mucosa. When we cut into the muscle layer, we shouldn't have any problem because we will cut the muscle anyway. But we have to protect the mucosa to avoid any thermal injury. So I'm pushing the cap into the space. Exposing. You're working with very little space there. Does the size of the cap matter ever? Do you switch that around too? Or is this a standard cap that you use for all Z-POEMs? Yes, we use it also for POEM. This is the SD hood. And this facilitates. Now you can see. We have TXI mode. So this is white light. And you see with TXI, we can see even better. At 12 o'clock, this is the backside of the mucosa. At six o'clock is the muscle, the septum towards the diverticulum. At 12 o'clock, we approach the mucosa of the esophageal site. And so we see some vessels here. And this is another advantage of the new generation. If I switch to ember, that means this is LED ember, maximum absorption at 600 nanometers. That means maximum absorption to identify vessels. This is particularly useful in case of bleeding. So to avoid bleeding, as I said, I go just tangential with a large contact to the vessel. So it means low impedance and use the blue pedal for coagulation and for precise act. Of course, with this new system, it helps you prevent bleeding because you're identifying the vessels more easily. But also to manage bleeding. We hope that we have not to show it, but it's very useful when you have a heavy bleeding. The more blood, the better the visualization compared to white light. So as you see, we are in the tunnel. And now I will continue injection cutting as we do. And now I would like to switch to Dr. Beiner and his team showing the next case. And later on, we could come back. So I will continue in this direction. Okay. Thank you very much, Horst. So we are still with Dusseldorf. And Torsten, we can see you. Please go ahead. Good afternoon from Dusseldorf and good morning to the West Coast in the United States. So my name is Torsten Beiner. I'm working here in the EBK Dusseldorf and I'm very happy to work together with Martina and Birgit this Sunday afternoon. And we are very much honored to participate in this ASGE life endoscopy course. So let me introduce our case that we would like to present to you. So we have here a 62 year patient of long segment barrier esophagus. And this patient underwent surveillance EGD in private practice. And the colleague found a focal lesion, took a biopsy and this biopsy proved an adenocarcinoma. And what we are going to do now is that we inspect the lesion and then do an endoscopic resection. And so now I ask my colleagues to switch to the endoscopy image. So we are working here also with an olymposcope and HQ 190. And so let's go ahead. In principle, this kind of patients, first we have to identify the landmarks of the barrier. So you can see why we are in the middle of the esophagus and we can already see some reddish surface here. So this is 20, 27 centimeters from the incisors. And then we advance the scope a little bit more. So we suck all the fluid from the lumen. And here we go. We can see something, but we go a little bit further. Here we can see the area at the top of the fold. It is the end of our Barrett segment. We are now here 38 centimeters from the incisors. So we go back as we have already found something that is located here. So first we always have to clean the surface in order to identify all focal lesions. And so we go back a little bit further. So obviously we have a very clear lesion here that is located here in the distal part of the Barrett segment. And obviously here we have really an elevated lesion that is not flat. And so we know that these kinds of lesions provide a very high risk of already harboring some parts of something called invasive cancer here. And this is why we already prepared for doing an ESD in this case. So firstly, we also go ahead with a little bit of more imaging. So what we can, you have nicely seen by Horst Neuels, what type of advanced imaging you can use like TXI or bright NBI. But what we wanted to show you here is that you can also use different forms of magnification. So here I'm going to inject a little bit of fluid. So I have to be a little bit careful here because the patient is not intubated. Okay, I inject a little bit more fluid here. So I don't use too much. It's a little bit difficult here. So I suck the air from the lumen. In a good position. So here you can nicely see a regular surface here. So in this elevated lesion, we can add narrowband imaging to have a closer look at the vessel structure. So, Torsten, your goal here with these nice imaging techniques that you are showing is to define the extent which will help you mark how much you need to resect, correct? Yes, so there's no doubt that we have a cancerous lesion here. But in the end, our aim is then also to delineate the lateral part because from a technical perspective, the resection can be successful. But if you don't succeed to delineate the lesion laterally, then you will have an incomplete resection here. So what we also wanted to show you is, despite from the advanced techniques on, we have a little bit of already bleeding here. So we prepare now for spraying some acetic acid. So, Martina, in a good position. Okay, please. We have now 2% acetic acid. Okay, that's already enough. A little bit more. Now here, a little bit more. Okay, that's enough. Now we remove the spray catheter. And what we want to show you is, we can already see here that we have very early. So firstly, we can nicely delineate the structure of the mucosa. And secondly, we wait for the loss of acetic whitening, what already is starting here. So it's less than 20 seconds after injection. So we have also some spontaneous bleeding. So while we prepare now for marking the lesion, what's really important before we move to resection, Pratik, maybe you can also give a comment. What would be your strategy for resection? So my strategy would be, because we have a high risk of submucosa invasion, of course, we did EOS and CT scan. We didn't find any submucosa. But our aim would be to achieve unblocked resection, and we would perform an ESD now. No, Torsten, I think that's absolutely correct. So just for the audience, I mean, a couple of important points before treatment. Number one is clear delineation of the lesion. So even with ESD, the R0 resection rates can be quite low if you don't resect the margins along with it, which Torsten is doing. And Torsten, to your point, I think any suggestion of submucosal invasion, which when you have sessile lesions like this, and it's not flat, not a Paris 2A or B lesion, the risk of submucosal invasion is high, and ESD is probably good. Thomas? Well, I was going to also say, if there is a risk of submucosal invasion, before we would do this procedure, we would be talking in a multidisciplinary conference, and obviously getting your surgeons and oncologists input. But I agree, ESD is the choice. And also with EOS, I think it is very difficult to tell T1A versus T1B. So your endosinography skills are excellent. But the final histology is going to be on this specimen. That's when we'll really know the depth of an invasion. Yes. So we mark here the lesion now. As you can see, this can sometimes be difficult because the ED junction is moving here. And this can be the case even in the lucky situation where you have an intubated patient, what we don't have here. So okay. I would like to place one marker here. Okay. So sometimes what we also try to do is that we can work in retroflexion, but we tested it here, so it's really difficult because it's above the junction, so we have to do this in an untreated way. So my plan is now, after marking the lesion, that we will do injection at the gastric side to elevate the submucosa here, then to do incision of the gastric margin. And then we will switch to the oral margin and do an incision there. And we don't cut the lateral edges. We will do a tunneling then until we reach a distal end and then to keep the traction, and then we would advance to complete resection. So we will use an injection type knife, but to make it a little bit easier for the distal margin, we have decided to inject with a vicious solution. We have chosen a gel, the ORISE gel from Boston Scientific, and we have here the interject needle. Okay. We have the interject needle. I put it into the submucosa. Okay. Yeah. Okay. We can nicely see the lifting here. Okay. We inject it here. We can nicely see the blood. And here. Okay. Go on, go on, go on. Go on, go on. Okay. That's enough. Okay. Nadel rein. Needle in. So we have nicely injected the distal margin here. And now we will use the knife. Okay. We have chosen, of course, we could also use a hybrid knife that Hosnaros is using in the esophagus, but here we decided to use a little knife that is a little bit, has a little bit less diameter. We have chosen to use the Microtec gold knife, the T-type gold knife. As you can see here, it has this golden active electrode. Yeah, Martina. Okay. Please out. And for the mucosal incision, we will use an endocut at our Irby generator. Okay. We will do it like this. Here. I'm going to cut out. Sorry. Okay. I just show the distal incision, and then we go back to the other room, to the ZEC poem, and then we can see you come back for the final result. Torsten, very nicely done. We were just commenting about the excessive motility there and how difficult is it to maintain the position, but very nicely done. Thank you. Yeah. See you. Thank you. I think in these cases, the cap can be very useful to try to push up against the mucosa and try to stabilize, but it was tough. Torsten, we're back with you. Okay, so I show you firstly the tunnel prepared towards the esophageal lumen side again at three o'clock backside of the mucosa nine o'clock the septum and we also started on the side of the diverticula so it's a very thick muscle a lot of fibrosis also so that means nine o'clock backside of the mucosa of the diverticulum and three o'clock the septum we have to go because this is a very large diverticulum so we have to go even deeper now the question is of course is it how deep can we cut we have to clear the field but also some vessels so it's very well mesmerized and as you see here fibrosis Horst good afternoon do you have to finish the tunnel before you start the myotomy or you can start the myotomy and then later on tunnel further as needed yeah in such a huge diverticulum we could also start with myotomy and continue tunneling but usually I prepare the tunnel down to the bottom of the diverticulum what is your suggestion yeah with this much fibrosis I think once you start cutting your landmarks will be easier to to delineate yeah so we can nicely see this layer and and as I said this is quite similar to poem so if we have such a large amount of fibrosis then it's always better to go close close to the muscle layer as shown here keep away from the mucosa because we want to protect the mucosa so now we have a bleeding and I show you the RDI mode you see the bleeding very small bleeding here I target the bleeding side the vessels inject to tamponade and it's a soft quark okay not to apply too much because of avoiding any thermal injury for the mucosa still a little bit here it's a bleeding side okay so we switch back to white light so this is TXI this is white light endoscopy so we can go out of the tunnel to check the depth we cut you see the bulging here becoming close close to the bottom but as you said we could now start with myotomy see very tight very thick muscle so I'm checking again the tunnel towards the esophageal side a lot of tension here so this is the upper edge of the muscle muscle muscle okay and the cap helps me so I'm rotating to push it away so I'm push here this is again the tunnel towards the the reticulum side very thick muscle yeah this would be is probably easier okay here we're in the back in the tunnel so and now for cutting we try to use the clutch cutter you can also do it with a knife but maybe we can catch the septum with this kind of a scissor which is the longer the one that is available with 3.5 and 5 millimeter in length I will show it to you open so it has serrated jaws and it's insulated on the outside so that you don't have thermal injury on the outside and it can be rotated show how okay to get it in a good position and we use it with the endocut endocut 222 so I try the beginning is the most difficult I try to get the proximal edge now it's clear let me see rotate so we don't want to cut we can see it but here there's a scratch here so I push this under the mucosa closed so now we have at least part of it very nicely done or such a you know tiny space to work with there so really nice okay but now we have a problem here with the correlation and of course you chose the clutch cutters just because you feel you get better approximation of the muscle to cut it more easily versus a standard knife exactly so we have a small technical problem maybe you switch back in between to torsten because so here you can see that's a real life transmission and not pre-recorded I don't know who's here torsten we are back here the current is working doesn't it so it's nice that you that you came back so obviously you can see that we have currently a little bit of bleeding okay martina close so what we have here now we can show you what we did so we opened up the the distal margin completely as you can see here and then we opened here the oral side here so we have some larger vessels here with a little bit of bleeding okay open please and we have bipolar correlation forceps by pentax okay okay and the advantage is that we have bipolar ablation here with schließen okay with less uh we have a less uh lower risk of deep thermal injury we have we have a little bit more bleeding here okay and then i show you what we what we are going to do after that i know this is okay this is okay okay and we remove this and now we take back the knife what we want to do now is that we perform a tunnel under the lesion to keep the traction so we extended our incision till here until here we keep some parts of the of the mucosa here i re-insert the knife okay we have to change the electrosurgical settings i turn around okay then i do it we go back to uh to the dissection we have it here and it's here okay okay can nicely see we also used a rice gel here okay i have a large amount of sub mucosa space here so i just open to the edges we are working here with the erby dry cut mode effect four of 100 watts and this is uzma so usually you like to use a tunnel technique regardless of size of the lesion in the esophagus yeah normally not but i anticipated a lot of movement of the et junction what would make it difficult to go really precisely below the lesion like like we have to do here and as i expect sub mucosa invasion and i cannot completely rule out that we have more than sm1 sub mucosa invasion i wanted to go as deep as possible and this is here you can see i will switch to the near focus mode what will then help us to identify the structure so we can nicely see the muscle layer we had a little bit of bleeding here and we can as you can appreciate inject through the tip of the knife what is really important advantage in this situation because i don't have to remove the knife and just can continue to to cut so i go close to the to the sub mucosa fibers okay okay so i just heard from our colleagues that we would like to go to the other room so i just give you an overview what we are going to do so you can see we opened up the aura margin here and we opened up the distant margin so we will continue to do the tunnel below and then just cut the mucosa sides here and on the other side but this is a good strategy if you want to be independent from the movement of the gi junction and keep the traction and to go tangential to the sub mucosa space okay thank you torston we'll be back with you shortly so let's see the progress that horst has made okay yes we're looking forward to so welcome back so we we use the hybrid now for septotomy there was a problem with this clutch cutter so i inserted the tip of the knife in the now in the tunnel towards the oesophageal lumen on the oesophageal side and i push it now in the direction towards the diverticulum and use endocut and now you can nicely see the muscle layer on both sides so horse here for the audience it's important to visualize the splitting of the muscle and keep track on it because you can easily miss some muscle right once it splits exactly exactly so that means here is the tunnel again towards the oesophageal lumen you see nicely the mucosa and i'm pushing the knife into the space very little space here pulling back a little bit the beginning is more difficult do you have experience with the sb knife for this indication like just another scissor type knife yeah this is also a good option this is also a good option but as you see this is a very big very very thick muscle no wonder uh no surprising that the patient couldn't swallow now it's easier so i'm now in the tunnel pushing again always keep away you see i insufflate of course it's co2 insufflation keep away from the muscle layer and pushing the knife against the septum from this side and from this side so as you can see this is the entry which will finally be closed this is the advantage that we can now continue quite deeply to the bottom because as you see this is a tunnel towards the diverticulum because we will close the space the entry so i push so this is endocut two to two it's cutting quite fast when you want to have more control then i increase the cutting interval to four so it's alternation between cutting and correlation so one is six is dark this is something in between uh so therefore it takes a little bit more time a little bit more correlation less risk of bleeding although we rarely have bleedings from the septum so again not cutting here this would be dangerous because i cause thermal injury of the mucosa but pushing the knife out pulling the septum to nine o'clock away from the mucosa cutting and vice versa so Horst how do you decide when to stop and how much muscle have you cut that you stop i will check from the outside if you see a blip finally on the on the bottom of the diverticulum you see we have a very very good control Horst do you worry in a large diverticulum after your procedure there'll be a mucosal flap that can continue to cause symptoms all right i i trust my friend Moa who wrote in a constitutorial letter he never had problems due to this because obviously i'm just kidding never is a little bit rare in medicine but i'm leading the literature and i believe my friends this may this is usually clinically irrelevant but to find if you touch a bridge then you can cut it like a weapon so so Horst as you're doing it just we have about two minutes before we start with our lectures and we will come back to you and Torsten to see the final results maybe after the first lecture oh this would be excellent yeah okay so yeah so please go ahead and do it so as you're cutting through the muscle layer we are still observing you and then what we will do is we'll start with our first state-of-the-art lecture and then we will come back to you and Torsten Horst to look at the final results so again thank you very much Horst and very difficult cases but very well done and we'll be back to you okay so this is a good time to look at the Barrett and the Sinkers for a second or for two minutes in Dusseldorf we communicated with them and they would be ready if we can sure go back so Lyle in the back if we can if do we have Dusseldorf ready to show before we go to Torsten we can see you and hear you please Torsten one one minute huh so otherwise we will be kicked out I don't know so it's uh so we did some some work in the in the meantime uh in the meantime we um did some work here so we did almost a complete tunnel relatively strong bleeding so we wanted to be ready for you but now we can go back so yeah we have to write mode again so obviously this is a good time to look at the Barrett and the Sinkers for a second and then we will be back to you and Torsten Horst to look at the Barrett and the Sinkers for a second and then we will be back to you and Torsten Horst to look at the Barrett and the Sinkers for a second and then we will be back to you and Torsten Horst to look so yeah we have to write mode again so obviously this this uh this seems to be the distal part you can nicely see that we opened here the mucosa you can see the mucosa and this is where we can see the vessels here this seems to be the most invasive part of the tumor so obviously as you can see the muscle layer is everywhere intact so I'm very confident that we are going to have a complete resection here okay we have to continue okay okay could you maybe show the luminal side for a second at the end and we just open just a little bit more about that you can see now the luminal side okay I go out of the tunnel here we have the opening we have these mucosal edges here and here to keep the traction and then we have here this is the this is a luminal side of the distal of the distal distal end we can also open up here a little bit more that will make us more easier for us to open okay here so we had a relatively strong bleeding here from from this area that took us some minutes to treat this and we got the in the end using the bipolar forceps six percent possible to treat but as always in these kind of procedures you should be prepared to uh to treat these bleedings so we will open up a little bit more here okay I'm I'm very sorry but we just come back to you very briefly I think we all understand what the tunnel is and tunnel really has made ESD from something very painful for the endoscopist to something very doable so thanks very much for showing and one minute for one minute for the sinker no oh no let's move on to uh I think before David Katzke leaves on that lesion I think he demonstrated very well that ESD was the proper procedure choice because you get a little bit deeper and down to the muscle layer compared to EMR if you want to get a negative margin so that was a great demonstration we can try going back to horse noy house once to look at the final uh part of the uh zenkers uh if that's possible at all so I'll Lyle if you're hearing us and if that's possible that would be great while we have our panelists come up so uh forced a lot of clips please tell us what's going on yeah we will call and as you can see now the the septum was here before when we started it's six o'clock and as you can see now the septum is much smaller and we can directly look into the to the esophageal lumen here and I can easily pass yeah so uh and the clips I think it's very important to close the mucosal entry and down all close to the bottom of the diverticulum but they won't probe this and finally not to cut even deeper 88 years old and I didn't want to undergo any risk of bleeding or perforation towards the mediastinum because I was very deep but as you can see now how nicely esophageal lumen is open and what you see here at uh three o'clock I cut the mucosa there was a kind of a web which was caused by clipping and I just uh cut the web so that we have even more space so I feel for the patient very comfortable because he can drink immediately there is no perforation no leakage whereas when you would have done the conventional septotomy mucosa and muscle layer and you cut so deep then it's difficult sometimes to close the large opening you have to close the mucosa and the muscle layer which would have been very difficult to close it completely but here I think it's it should be a good result for him yeah so Horst again a very difficult case and very narrow space to work in and again a masterful endoscopy demonstration from you so thank you to you and all the nurses and the team for opening the unit for us thank you very much Horst

endoscopy units

ASGE

live endoscopy

Dusseldorf

Dr. Horst Neuhaus

Dr. Torsten Benno

zankerous diverticulum

Barrett's esophagus

endoscopic resection