Welcome to ASG Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event entitled Introduction to Third Space Endoscopy. My name is Marilyn Amador, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make the session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted within two business days on GILeap ASG's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to hand over the presentation to our GI Fellow Moderator, Dr. Nicholas McDonald from the University of Minnesota. Awesome. Thank you, Marilyn. Hey, everybody. My name is Nick McDonald. I'm a Fellow at the University of Minnesota, and I have the honor of introducing our panelists tonight for our session Introduction to Third Space Endoscopy. So I'll start off with our moderator, Sunil Amin, and he's an assistant professor at the Division of Digestive and Liver Diseases at the University of Miami Miller Medical School, where he also serves as Director of Endoscopy for the Jackson Memorial Hospital and the Lenard Foundation Medical Center. He received his medical degree from the Vagalos College of Physicians and Surgeons at Columbia University in New York, and he completed a Master's of Public Health there as well. He then completed his residency in Internal Medicine and Fellowship in GI at the Picon School of Medicine at Mount Sinai. Following his general GI training, Dr. Amin returned to Columbia University to complete an additional year of training in therapeutic endoscopy. His practice encompasses all aspects of advanced endoscopy, with a special focus on tonight's topic Third Space Endoscopy, ESD, POEM, and GPOEM. Our second panelist is Dr. Ahmed Saeed, and he completed his residency in GI Fellowship at Henry Ford Hospital in Michigan, followed by his advanced endoscopy training at Fox Chase Cancer Center in Philadelphia. He started his career as an advanced endoscopist and Director of Endoscopy at the Kansas City VA Medical Center, and currently practices at the HCA Midwest Research Medical Center. He has an interest in Third Space Endoscopy, grown from his time in GI Fellowship, and completed multiple US-based courses until he became proficient in the area. He currently maintains a busy Third Space practice in Kansas City. Our third panelist is Dr. Jeffrey Moskow, and he completed MD and Bachelor's from the University of Western Ontario, followed by Internal Medicine and General GI Training at the University of Toronto. He completed his advanced endoscopy training at Beth Israel Deaconess Medical Center in Boston, and has been on staff at St. Michael's Hospital in Toronto since graduating Advanced Endoscopy Fellowship. He completed a Master's in Quality Improvement and Patient Safety at the University of Toronto, and serves as the co-director of the Advanced Endoscopy Fellowship and Annual Live Therapy Endoscopy course. He has clinical expertise in both luminal and pancreatic ovariary advanced endoscopy. And last but not least, Dr. Kwok is a native of Southern California. He pursued his medical training at Boston University's seven-year accelerated medical program in Boston, Massachusetts, and received his MD in 2004. Following this, he matriculated at the Thomas Jefferson University Hospital in Philadelphia for his internal medicine residency and graduated in 2007. From there, he went on to general and interventional GI training at Robert Wood Johnson University Hospital in New Brunswick, New Jersey, and graduated in 2011. He joined the Southern California Permanente Medical Group in 2011 and became a partner physician in 2014. From there, he was appointed as Assistant Program Director of the GI Fellowship in 2014 as well. He has both clinical and research interests in improving the quality of gastroenterology care for all patients, with particular interest in radiation safety in the GI lab and organ preserving tissue resection techniques such as EMR and ESD. So I know we're all really excited for the topic tonight, and thank you guys all for being here. And I'll turn it over to our panelists. Thanks, Nick. So welcome to the first ASG Endo Hangout session of the new academic year. We're thrilled that you guys are joining us tonight. We have a really fantastic program lined up for you with really awesome faculty, so hopefully we'll all learn a lot in the next hour and a half. My disclosure is I'm a consultant for Boston and Medtronic. So the agenda tonight's going to be our faculty introductions, which Nick's already done. I'm going to give you a little brief primer on third space endoscopy. Dr. Kwok's going to talk to you about ESD 101, some basic steps. Dr. Moskow will then talk a little bit about some best practices and some advanced ESD stuff. Dr. Seid will talk about POEM and a tailored approach in his case. And I'll talk to you a little bit about gPOEM. And we'll have a nice Q&A session. So please, we want to make this as interactive as possible and really make it the best learning experience for you. So please send your questions through the chat, and we'll try to get to them all at the end. So the learning objectives for tonight's session are to define what's meant by third space endoscopy, to understand the clinical indications and the utility of third space procedures such as ESD, POEM, and gPOEM, to describe the technical steps common to all third space endoscopy procedures, and to be able to discuss these procedures with patients, medical and surgical colleagues, and refer to advanced endoscopists when appropriate. So before we start talking about third space endoscopy, I think we need to define what we mean by that. So here's an endoscopic picture, which you're all familiar with, of a normal esophageal lumen. And that's what we'll call the first space. And on the right, you see a perforation and some mediastinal fat there. And so that's the second space. So in third space, we're talking about the wall of the GI lumen, specifically working within it in some of the layers. So the submucosa predominantly is where we perform most of our third space procedures. And obviously, we go into the muscularis layer as well for POEM and gPOEM procedures. The idea of third space endoscopy is that this opens the door to several therapeutic procedures that otherwise wouldn't really be possible because we're preserving a mucosal flap. And so we can do these all very safely. So when we're talking about third space, we're talking about the submucosa and in some cases, the muscularis layer. So in terms of the procedures that we associate with third space endoscopy, ESD is what we use for adenomas with high grade dysplasia or intramucosal cancers when we want on block resections. POEM is what we use for achalasia and gPOEM for gastroparesis. So those are the procedures we're going to focus on in tonight's session. And with that, I'm going to turn it over to Dr. Kwok, who will get our case presentations underway. Great, thank you so much for the opportunity, Dr. Amin and the entire staff and panelists at ASGE. So hopefully you can see the slides. Again, I'm very honored to be invited to be part of this panel to talk to you about ESD. And, you know, I know that this is a very large registration pool tonight. In fact, this is very exciting because you get to see the cutting edge, if you will, of our field. Full disclosure, ESD in its current form didn't even exist when I was going through fellowship or even advanced fellowship. And so it's very exciting what 10 years, what the difference 10 years makes. I have no relevant disclosures. So, again, very briefly, this was touched upon in the introductory slides, but just to give the audience, because, you know, audience members may be anywhere from a first year fellow and up, so I don't want to assume anything. What is an EMR? What is an ESD? Both are tissue resection techniques. And EMR, of course, stands for endoscopic mucosal resection. ESD stands for endoscopic submucosal dissection. Both, if you will, are considered organ preserving tissue resection techniques. Again, not that long ago, you know, there were even practice guidelines. Well, it's actually kind of a long time ago, maybe 20 years ago now, where polyps over two centimeters were felt to be too large to be safely removed and therefore surgery was recommended for those individuals. Now, we're very fortunate that we have so many options from an endoluminal point of view. And, of course, needless to say, compared to surgery and the appropriate individual, endoscopic luminal resection techniques typically offer reduced morbidity, mortality, and certainly much less inpatient or no inpatient length of stay. Now, you could ask, well, EMR sounds fantastic, you know, why don't we just resect everything in a piecemeal fashion? I mean, that's typically how EMR is performed, you know, it's in a sense like riding a bike. And I know that's not the point of tonight's talk. And so whenever I get this question on occasion, I'm reminded of this, hopefully to you as well, hilarious commercial, which helps crystallize why ESD serves a role, especially in today's practice. Have you ever worked for Dr. Francis? Oh, yeah. He's OK. Just OK? Guess who just got reinstated? Well, not officially. Nervous? Yeah. Yeah, me too. Don't worry about it. We'll figure it out. I'll see you in there. I'll see you in there. Just OK is not OK. So this actually was the whole point of this slide, you know, there are certain situations where, you know, just OK is absolutely not OK because, you know, imagine, if you will, this picture of a fried egg, OK, and this is the entire specimen. Now, EMR, again, not the point of tonight's talk, but you will learn if you don't know already, it does carry a lot of advantages. You know, it is much, you know, in expert hands. It is very fast. It is quite safe. The learning curve is acceptable and the cost of the accessories is generally lower. However, there are some serious limitations, as you briefly heard about the primary primary limitation of which is is very difficult to obtain margin status. So imagine, if you will, this lesion, this fried egg, if the yolk itself represents the portion of the lesion that has cancer, if you're able to remove it in one piece, you know exactly what's going on. You know, the margin status, you know, a lot of things. What if what if you removed it in three pieces already? You could imagine the pathologist has some issues and difficulty. What if you remove it in multiple pieces and what if you leave a tiny fragment behind? This is precisely the challenge of utilizing EMR in a situation where you need margin status, especially in early cancers where, you know, margins are absolutely critical. And so, of course, you know, this procedure, like many others in the field of gastroenterology, requires a fair amount of pre-procedure planning, the first and foremost of which is to choose the proper endoscope, you know, like professional sports players. Every sports player has their own preferred choice of glove, bat, et cetera. For me personally, I personally gravitate towards the therapeutic type of endoscope and the adult colonoscope for lesions in the lower gastrointestinal tract. For me personally, I personally like the fact that I can suction while having a device in the channel at the same time. It's a personal preference. But as long as you're cognizant of the system performance of each device that you choose. There are many, many tools used in the field of ESD in particular. These are just three of the somewhat more common tools. There are many others that won't fit into this slide vignette here. So choice of cap is critical. There are many different caps out there. I personally like the tapered cap because it allows for in certain situations the ability to tunnel. But it is not a mandatory requirement. But a distal attachment cap is highly recommended in performance of such procedures. There are many, many accessories in the field of ESD, including the conventional mucosal incision knife. There are insulated tip knives. There are even specialty knives which allow you to cut lesions that are incredibly fibrotic to safely dissect them away from the underlying musculars propria. And then, of course, there are many growing techniques in terms of the use of various lifting and traction tools, which I trust will be discussed later on in this talk. Again, bottom line is to be familiar with all these tools and techniques as you continue your journey in this process. Location matters, just like in real estate. These procedures are long compared to a conventional EMR procedure. They can be maybe two to three X length of time. And as such, you need to be cognizant of your supporting cast, such as the anesthetic choice. In some situations, depending on the room venue, if it's inherently gravitates towards the colder end, you may need to consider a warming blanket, things that you don't typically consider in a standard endoscopy, things such as positioning devices to help reduce the likelihood of pressure ulcers, et cetera. So the case I wanted to highlight in particular, it shows the power of endoscopic submucosal dissection. This was an individual that came into my practice as a referral last year. They had a sort of gray zone duodenal bulb carcinoid, non-functioning based on hormonal studies. But based on the size, typically and the latest guidelines I share here with NCCN guidelines, for non-functioning localized lesions, if endoscopic resection is feasible, it is preferred. They used to be a little bit more granular in terms of the sonometer size. But now in the latest guidelines, they just simply say that if there's no evidence of regional or distant metastases, it's non-functioning. If it's feasible, you attempt endoscopic resection. And this is precisely if you remember back to the fried egg picture earlier, this is exactly the whole point of utilizing the techniques such as ESD, because you really want to get a good margin status. Now, so the very first step prior to any ESD, well, step zero is, you know, pre-procedure planning, meeting with the patient, talking to them about informed consent, alternatives, risk benefits. So that's technically step zero. Step one is to so-called read the green. It's a golfing analogy, which is ironic. I don't play golf, but it's a great analogy, so I'll use it. I personally still believe in the power of endoscopic ultrasound to get a good view of the field, making sure it's a go, no-go type of situation, making sure that the lesion does not involve into or beyond the muscularis propria. The recent ESGE from European societies suggests probably less of a role, but I still find utility in it. I was trained in the U.S. I know how to utilize it to our advantage. Another step of step one is actually, believe it or not, the diagnostic endoscopy portion of the exam. Some practices I'm familiar with, they actually bring the patient in for a diagnostic endoscopy prior to the planned resection date, because you really need to get a very sophisticated analysis of the field. So, for example, if you have a patient who has been diagnosed with endoscopic endoscopy, you really need to get an analysis of the field. So, for example, lesions in the rectum, it's actually, like I said, real estate, location, location, location. If the lesion happens to be in the posterior wall of the rectum, in the sacral promontory, you may need to account for that in your technique, dissection technique. Similarly, in the stomach, when it's not a straight tubular structure, it could be a somewhat challenging location. I've had several cases in the pre-pyloric antrum, but along the posterior wall, that makes for a very challenging dissection, believe it or not. Similarly, in the cardiac, you need to plan accordingly and figure out ways to get the view that you need, both in forward and retroflex views. And similarly, it's important to make sure your equipment is in excellent working order. You need to make sure that the scopes that you choose have a high degree of retroflexion in order for you to achieve your objectives. So the plan. It's important to formulate the plan. There are many different techniques which will be discussed in tonight's talk, but some of the basic plans may include a tunneling approach, potentially a semilunar approach if you're in the esophagus and it's a circumferential dissection that's required. Traction is the very important addition to our armamentarium. So it's important to consider all these things up front. And similarly, use gravity as your friend. What direction is water flowing? These are it's almost like, you know, like martial arts, right? I mean, these are things you don't even think of in a standard diagnostic endoscopy, but these are absolutely critical. And these help determine that these are key elements of success. And so for marking. So when you begin the lesion, this is actually the patient in question. This is the lesion from the pylorus looking into the duodenal bulb. It's important to get an adequate lateral margin. And so you try to mark at least three millimeters all around. In this case, it's relatively straightforward, but in some situations, it can be quite challenging, especially if the lesion is flat, especially if the borders are indistinct. And so you may actually need to utilize adjunctive techniques, such as chromoendoscopy and virtual narrowband imaging, virtual chromoendoscopy, things like that. And according to the Japanese masters, marking is actually initially left to those that are very expert in the procedure. You would think that, well, anybody can mark. No, it's actually this sets the tone and tenor of the entire procedure. And so in Japanese training, usually it's the masters that help the trainee mark the lesion first prior to commencing with the dissection. And so then we, of course, after marking, move into the dissection. Again, there are some considerations here as well. If you're planning on doing tunneling technique, you do not want to do a complete circumferential cut up front. Versus if you are planning on using either gravitational pull or even traction techniques, you may want to do the circumferential dissection up front to break the mucosa. There are a lot of considerations. I mean, this is meant as an introductory talk, of course, but there are different devices do different things. And so the so-called dual knife, which you can see here in the video, is good to, how shall I say, push, if you will, if you're trying to dissect forward. Again, there's a lot more nuances. This is just meant as a broad brush strokes, a brief overview. But just keep that in mind. Each tool has a subtly different use and purpose. Again, for hemostasis, there are purpose-designed tools that will help keep this as bloodless as possible. And one tool in particular is a hemostatic forceps, which you can see here. The design is such that it funnels all the energy to the jaw and allows you to co-opt and seal the vessel right then and there. It's very precise. I know that you can, in the appropriate context, utilize your pre-existing ESD knives to achieve hemostasis, but there can be some concerns if your knife is not precisely on where the vessel is. It may not be as precise. It may potentially result in excess char and hinder visibility. And so, again, it's very important to understand every tool in your toolbox as far as how to use it, when to use it, et cetera. This is an example of a different knife. This is the insulated tip knife, where the tip is actually coated in a ceramic material. And so the energy actually disperses along the shaft of the needle, but not towards the insulated ceramic tip, which is very useful in situations where you may be potentially perpendicular to the wall. Once the dissection itself is complete, if at all possible, you should be comfortable pinning the specimen yourself because nobody knows the lesion as well as you do. In my practice, I personally walk it to pathology. I even speak to the pathology assistant. I talk to them. I help them orient. And, in fact, one extra benefit of the clip traction technique, which I know will be discussed later on this evening, is it actually helps orient the specimen further because typically we clip and traction on the side towards the mouth or the anus. And so this is just a very brief video of us putting it all together in the ascending colon. As actually Todd Baron mentioned, this is, you know, an example of 100% of all of the videos shown are successful. So this was a highly edited video. The procedure length total time was about probably an hour and a half. But suffice it to say, you'll see why in a second. This technique is such a valuable addition to our endoluminal tissue resection technique. So here we're dissecting out the lesion. We are, of course, utilizing hemostasis as needed. It's certain parts of the procedure. You can indirectly see a clue of the clip traction technique. And here we're finishing the dissection. And this is why it matters, right? This is an individual with intramucosal cancer, no lymphovascular invasion, period of resection. I think he still sends me chocolates here and there. Thank you very much for your time. And I'll turn the floor back to Dr. Ami. Thanks, Carl. That was really a fantastic overview. And I think we all learned a lot from that. So let me ask you, tell us a little bit about your journey learning ESD and how you think you can advise the fellows in terms of kind of interested in pursuing that. Is it feasible to do during the three-year fellowship? Can they do it in the fourth year? Or do you have to kind of do something afterwards? I think the answer is probably a little bit of all of the above. As I mentioned earlier, ESD in its current form didn't even exist when I was going through the training in 2011. And so I think actually this actually brings up a very good point. Thank you for reminding me. I wanted to encourage the fellows, especially those that are on this talk tonight, never stop learning. Close to two-thirds or three-quarters of my practice now in some way, shape, or form didn't exist in its current form, even in advanced fellowship. And so for us, actually many, if not all of us in the panel, we had to sort of go the extra mile, learn on our own. So I went to multiple training sessions. For example, ASGE sponsors a fantastic course. In fact, I saw it on the introductory slide deck. It's a sponsored course, co-sponsored with Japanese Gastroenterological Society. So I went through that. I went through the industry-sponsored course from Olympus. I additionally went to the course put forth by Professor Dragunov at University of Florida. And then just ongoing hands-on locally, with my local device representatives, we were able to facilitate ex vivo sessions locally. And it is a journey, right? But the saying goes, the journey of a thousand steps, the journey of a thousand miles begin with the first step, sorry. And so now in 2022, I suspect some of these may start to be incorporated potentially in advanced fellowship. And so for those that are interested, you have a greater and larger and larger company. Yeah, I think that's great. Yeah. I was telling fellows, it's a great time to learn advanced endoscopy in 2022, because gone are the days where you have to go to Japan or Europe to learn ESD. You know, there's plenty of opportunity here. And so with that, let's move over to Jeff for another ESD talk. All right. You guys see that. Yep. All right. So thanks to Neil and ASG for having me. Thanks Nick and the panel. It's always fun to collaborate. I was asked to talk a little bit about advanced ESD, but I might be the least advanced on the panel. So let me give it a shot and hopefully these guys can correct me if I take any missteps. So I'm going to preemptively talk about my ESD journey. So since you can't ask me, you know, it started around 2017 ish. I did a bunch of animal labs, like live pig labs. I met Carl at the university of Florida, Peter Dragunov's course, which is outstanding. I did some industry sponsored courses overseas, did a little bit of observation. And then I did the Olympus master's class. I was also very fortunate to have some fellows that come over and train with us from Japan. And they come to learn EOS and ERCP. And fortunate for me there, they're already very experienced ESD practitioners. So at the beginning of my practice, you know, I taught them EOS ERCP and they were helping me learn some EHD, which was fortunate. And then I sort of progressed from the stomach to the rectum, to the esophagus. And now I'm, you know, dumb enough to take on lesions kind of all over the place. And what I was going to say during Carl's talk is that there's nothing ESD 101 about ESD-ing a neuroendocrine tumor in the duodenum. That's like a Yahagi territory. So good for you. That's why you should have been giving the advanced talk. And now, you know, I'm doing tons of volume. We have a big referral practice. And so it's, it's really probably the most exciting part of my practice now, even though I still do all things advanced endoscopy. So let's start with the case. So this was a patient that was referred to me, just like, like all patients referred with what they called some nodularity at the G junction. And the biopsies they took showed low and focal high grade dysplasia. And so I bring almost all patients for diagnostic endoscopy. And my, the pendulum has sort of swung over time from when I brought everyone for resection to now almost everyone for diagnostic endoscopy because, you know, I know that random biopsies showing high-grade dysplasia or intramucosal cancer almost never exist. And when someone says they saw some nodularity, I'm expecting there to be a like impressive lesion there. So this was my like quick diagnostic examination. I'll often do EOS as part of that if appropriate. And so then I needed to decide what to do. So I don't think I can pull the audience here, but maybe I'll pull the panel so they stay awake. So how would you guys manage this lesion? There's a bit of bias on this panel, but would you repeat biopsies to show maybe that the previous biopsies were not right? Would you go right to RFA? Would you do a staging EMR? Would you do a ESD or would you send the patient for a esophagectomy? Nick, am I allowed to ask you a question? That's fine with me. Yeah. What would you do? Tough question. You know, I think I'm probably like test taking strategies, not likely to repeat biopsies. We already have biopsies that showed something. I'm probably less likely to do RFA, probably not so severe as to need a esophagectomy, especially given the focus of the talk. And so I think, you know, this is a case where maybe you could try to ESD that, make sure you get the margins and it would also kind of stage where we're at. And so then test taking, that's what we're talking about. So I'm going to go with D. Okay. Smart. Well, he's at an ESD talk, so that's, he's pretty bright. He's smarter than you said he was. Ahmed, what would you do? I completely agree with Nick. I think I would. So in this case, it looks like it's on one side of the wall of the esophagus. If it's something that's involving the entire circumference of the esophagus, I would have my doubt. I'll go to a multidisciplinary tumor board to discuss before I do any resection. But I think in this case, you can definitely do an ESD on one side of the esophagus and avoid significant complications like strictures. And with that, you can get accurate staging and a good chance of curative resection. Okay. Anyone disagree? Sunil, Carl? No. Ahmed, why do you say you would have your doubts if it was more circumferential? Because you'd be worried it was invasive or you'd be worried that it would just stricture down after you did it? Yeah. I think in that case, the chances of stricturing is high when you do a circumferential ESD. So in that case, you would have, I think, a multidisciplinary approach, review everything, make sure that the best outcome is a decision of a board, not just one person. That's the main thing I'm worried about is the stricture because the risk of stricture is high if you do a circumferential ESD or long segment circumference. Definitely. Okay. Well, let's keep going. So yeah, I mean, I agreed with you. I thought this was a more advanced lesion than advertised. You know, there's data showing that superficial biopsies are not very accurate. And I have a slide on that after. But I thought this needed on block resection. I was worried about intramucosal cancer. There was no muscular expropriate involvement on the US. And so I thought that ESD was the right approach. And so now that you guys know everything about ESD from Carl, you're seeing me mark the lesion around. I don't have a sensei or a master with me, so I just mark it myself. And then I start usually on the distal end. And so this is a Fuji zoom gastroscope. So excellent retroflexion. I mark it around. I start distally. And then I usually for a lesion in this location, dissect oral to anal to release it. And again, depending on where the defect is, you're going to kind of tailor your approach in terms of gravity. And you're left with a defect that looks like this. And just like Ahmed said, the chance of getting severe stricturing here is extremely low. And so this is a nice approach to both stage and potentially cure disease. So in spite of my optical diagnosis not being 100% sure if this was going to be T1A versus T1B, this was into the very superficial submucosa and ended up being a curative resection, which potentially we would not have achieved with EMR. And in fact, you definitely would have had to cut through an area of tumor with EMR. So EMR was just not well suited for this lesion. And I think it was perfect for ESD. Carl, would you have ESD'd off the rest of the Barrett's at the same time? It's complicated. I think you did a fantastic job, number one. I'm not just saying that because you're watching me. But it's hard because again, everything's an opportunity cost. Be careful what you wish for. You may get it. If you end up ESDing, as you see on this screenshot here, then it's more than two-thirds circumference. And that's exactly what Ahmed was alluding to. When it's more than two-thirds circumference, you're going to have a very high rate of stricturing. In fact, I've had some individuals where it was extremely refractory, despite everything that I did. Steroids, carafate, everything. And they still ended up with severe refractory strictures. I ended up having to... They failed endoscopic dilation. I had to stent them. Then they came into the ER because of excruciating chest pain because of the stenting. It was not pleasant. I feel you did the absolute right thing here. Okay, thanks. This is a case with a bit of a different story. This is a patient with long segment Barrett's who had three sessions of EMR and then five sessions of RFA for multifocal intramucosal cancer. I got involved in this intramucosal cancer. I got involved after the RFA was failing. The biopsies are showing high-grade dysplasia in multiple locations. You can see some abnormalities even under white light in the mucosa. It just doesn't look normal. There's tons of scarring from previous resections. What would you guys do here? There's no clear nodules. There's no clear cancers jumping out at you. US was totally unhelpful. It just showed some thickened walls of the esophagus. What would you do here, Ahmed? Right here, I would do a very careful look, looking for any changes on NBI that I suspect high risk. You said you biopsied it? Endoscopically, I thought there were changes of high-grade dysplasia, nothing more advanced. I took Seattle Protocol biopsies top to bottom, and there were multiple levels of high-grade dysplasia. Multiple levels of high-grade dysplasia. With that, and with your exam, and a biopsy, it's pretty much flat. There's some nodularity. In this case, I would definitely go to a tumor board, discuss the case, and suggest a circumferential ESD resection. You think that's a better option than esophagectomy? Oh, yeah. I think it's a better option. That's a really good chance. If that approach fails, or if you end up with a refractory stricture to the point that even stenting doesn't fix, then we would move to a surgical resection. In comparison to the outcomes of an esophagectomy, this is definitely a better approach. Yeah. I'm not cutting you off, but you can see that I agreed with you. I talked to the patient, the patient saw a thoracic surgeon, and discussed the option of esophagectomy. This was refractory dysplasia, and we opted for circumferential ESD. There are differing approaches to how people do this, and I more and more now will do partial ESD, like a 60% circumferential, and then completion. I know Sunil Wee spoke about this at one point. This one, I did decide to do a circumferential ESD. I did the distal incision all the way around. I did proximal incision all the way around, and then I did multiple tunnels. And so, I find that making a tunnel similar to a poem, even though I don't do poem, allows you to target the areas of the worst fibrosis, and then you create a tunnel after tunnel, and make your way down to your distal incision. Here, we encountered a little bleeding, similar to Carl, treated with coag graspers. And so, I find that this approach allows you to take off these very long segments of Barrett's, and both cure the dysplasia, so you get complete eradication of dysplasia, and complete eradication of intestinal metaplasia in one shot. And so, that's tunnel number one, and then we move to tunnel number two. And so, whoops, I'll spare you tunnel number two, and we'll skip to the fun part, which is the defect at the end. So, this is what the defect looks like at the end. Again, these patients are at risk, high risk of stricturing. And so, I use Triamcinolone, and then a combination of a course of oral prednisone, and occasionally, betasinide slurry, and I'm quite aggressive with upfront dilation in these patients, because they are definitely at high risk. But again, this specimen showed actually multifocal intramucosal cancer, but it was an R0 resection, and this patient has no dysplasia now, about a year later. So, what are you injecting? So, this is Triamcinolone, so it's steroid. So, you inject it randomly? So, I inject it into the residual submucosa, not into the muscle, because it can cause muscle injury and or fibrosis. So, I inject it right into the residual submucosa where you have it. So, I have lots more to show, but I think I'll stop there, because I feel like people are going to have lots of questions, but I'm happy to come back and show a few colon cases as well. Jeff, that was really awesome. I think a couple of questions for you. So, in the esophagus, do you ever like to use traction, whether external traction, clipline, something like that, or kind of with your circumferential ESD? I found that if I do the proximal incision all the way around, it just kind of drops down as I'm dissecting it, and without some sort of traction pulling it up, but you didn't seem to have that problem. Yeah, I have been using it. I like the clipline, and I started using... Sorry, I like the clip snare now, actually. I started using clipline, so using just some dental floss with clips, and you tie the dental floss around the clips, attach a clip to the lesion, and then your poor assistant just holds the dental floss out, or you can attach it to something. Now, I've been using more clip snare, so you put a clip through the scope, snare on the outside, grab the snare, put it down beside the scope, and you can clip multipoint with the snare. You close the snare around the clips, and then you can pull back on the snare catheter. So, I like that in the esophagus, and I've been using that more and more. I find it most effective for non-circumferential lesions when they sort of are falling down, and it's hard to make out the planes. You just lift it up towards you, and your dissection goes much quicker. In fact, in Japan, they don't let trainees use any traction because it makes it too easy for them. So, I always feel like a cop out when I do use traction, but obviously, if it makes it more efficient, if it makes it safer, it makes it better, I'm going to do it. I think we're creating our own North American style of ESD with traction kind of working a little further away from the lesion, things like that are making it safer for us to do this without having those sensei-level skills. Yes, for sure. For that case you showed, was there any thought to maybe trying some other method of mucosal ablative therapy like cryo, for example, instead of R? Yeah, we talked about that. I just thought with such a long segment and multifocal dysplasia, I didn't think that rescue cryotherapy was going to do it. I mean, we did talk about it. I offered it to the patient, but he had had enough. He's like, just get this out of me. Yeah. I mean, clearly, you made the right choice because you found some cancer in there. Yeah. All right. Well, let's move on. More discussion later on, but let's move on to Ahmed's talk on home. All right. I'd like to thank Dr. Amin and the ASG for inviting me to this great talk and discussion. I'm really honored. I'll be talking about the basics of peroral endoscopic myotomy. These are my disclosures. Our case today is about an 18-year-old male with three years history of worsening dysphagia, chest pain, weight loss. EGD was done that revealed tertiary contractions and increased tone at the lower esophageal sphincter. Barium revealed diffused esophageal spasm and manometry revealed increased IRP with a 49 and premature contractions, low distal latency, and high DCI esophageal spasm with failed peristalsis. So the findings are consistent with a type 3 akalasia. And we talked to the patient about the options of management here, which are a POM procedure versus a Heller myotomy, and they decided to go forward with a POM procedure. So in general, the basics of the diagnosis for akalasia includes the esophageal manometry, which is the gold standard. And you can see the different types of akalasia, type 1 and 2 and 3. In type 1, there's no movement in the body of the esophagus. It's a peristalsis with tightness at the lower esophageal sphincter on the barium. And you can see that correlates with that very clearly on the manometry. And type 2 would have those distinct anesophageal pressurization, a column of liquid and air in the body of the esophagus. What's distinct about type 3 is there's severe esophageal spasm with high DCI in the body of the esophagus alone with a non-relaxing lower esophageal sphincter. So this is an actual barium. The one on the left is the actual barium from our patient for the case today. So the indication for POM procedure, a new diagnosis of akalasia type 1, 2, or 3, failure or recurrence of a previous therapy like a Heller myotomy or pneumatic dilation or a previous POM procedure, chronic hypercontractile esophageal disorder that are not responding to therapy. But I would suggest definitely always to confirm that diagnosis with an esophageal motility specialist. Sometimes it gets tricky to diagnose these disorders before actually doing a POM or a Heller procedure on those patients and give them an aperistaltic esophagus. You would definitely want to confirm that diagnosis with a specialist, especially with type 3 akalasia and hypercontractile esophageal disorder. So the effectiveness of POM procedure through randomized controlled trials, it's better, it's more effective than pneumatic dilation, and it's as effective as the Heller myotomy. Heller's myotomy has an advantage in controlling GERD because the surgeon can do a partial fundoplication during the surgery, which can limit the acid reflux symptoms after the procedure. POM has the advantage of your being able to tailor how long the myotomy can be. So you can go as high as like 15 centimeters on the esophageal wall and start your myotomy while that cannot be done during a Heller procedure because the approach is typically through the abdomen. So one of the things that is at an increased risk after a POM procedure would be the risk for acid reflux, which is debatable. The current data that we have is showing a possible higher risk for acid reflux compared to Heller myotomy. But is this for a short term or is it for a long term? These are all debatable questions and we should have more data in the future about that specifically. So the tools that you need to perform a POM procedure, like most third space endoscopy like ASD or POM procedure, most patients go under general anesthesia. The patient in POM procedure would need to be in a supine position, really help you assist the landmarks and the like in a posterior, the anterior position and the esophagus, which is very crucial in creating the tunnel and the myotomy. A standard gastroscope, a distal clear cap, and low flow CO2, which is very essential, I think, for all endoscopic third space resections and myotomies. So most generators have an option to decrease CO2 flow to low, but if that's not available, you can always exchange the tubing that comes from the insufflator to a low flow CO2. But I think this is a very important and can mitigate against a lot of possible complications that can come from this procedure. Electrosurgical generator is very important. You have to be familiar with your electrosurgical generator. One common one that we typically use, typically used around the state is Irby, but there are others and you have to familiarize yourself with all the possible options in coagulation or cutting currents. The knives, so there are several knives that can be used. A T-shaped knife are available from several companies or a triangular tip knife or even an I-knife can be used for a POM procedure. The injection capabilities within the catheter of the knife or through the knife are really good for efficiency, but you can also perform the procedure without having that. So lifting solution. So for the initial incision, you will need to inject a solution or continuous lifting of the submucosa as you do the dissection. Saline with blue dye is enough, but a viscous solution, especially for the initial incision, can be very helpful and increase efficiency. Coagrasper, the one that we saw during the esophageal ESD from Mark, those are also essential to control any bleeding during the dissection or the myotomy. And at the end, clips or suturing device can be used to close the entry into the submucosa. So this is a video from, so we decided to go with POM and this is our the incision part of the procedure. So we'll start lifting with the ORIs here, which is a lifting solution. And then we're making that incision. First step after that incision is trying to open up that area of the submucosa. And by trimming or dissecting the submucosa just around the incision, which will allow that the scope to intubate that incision. This is a very important step. So the trimming part and the dissection of the submucosa widen that incision. If you looked at the initial incision, you can see only a line, but by just retracing that with the knife multiple times or by pushing gently on that incision, it can open it up just a little bit like we saw here in that video. And then you can trim that submucosa and it significantly opens that incision to allow the scope to go in. So a little bit about that part of the procedure, you would want to position the patient on their back, like we said, in that position, the six o'clock would be where the water pools. And that's exactly the posterior wall of the esophagus. So if you do the incision at the two o'clock position, that would be the anterior palm. If you do the incision in the five o'clock position, that would be the posterior palm approach. It should be three centimeter above where the myotomy is intended to allow for some flap to protect against any leakage or perforation. Typically in type one or two, you want eight to 10 centimeter above the lower esophageal sphincter. And in type three, you want to be three centimeter above where the spasticity or where you can see the spastic activity on the manometry. So you start with injecting lifting solution as we saw. There are several types of current to start the incision. What you essentially want is a cutting current with coagulation property, like endocut or dry cut. And we talked about widening that incision to allow the scope to intubate the submucosa. And I think probably getting the scope into the submucosa is one of the hard steps in the learning curve of palm procedure. So the submucosal dissection. Once you have the scope in the submucosa or in the tunnel, first thing you want to do is to get very close to the muscle layer. So you want to preserve as much submucosa as possible and continue the dissection just immediately on top of the muscle layer. And that's for like, you know, for safety purposes, you want to keep the mucosal layer intact to avoid any leakage or perforation. Any damage to that layer can lead to a delayed perforation or even immediate perforation. So that's how you do it. And to maintain that tunnel straight all the way to the G-junction or the gastric side, you want to follow the circular muscle fibers. So you keep those fibers running at 90 degrees with the scope. And that's how you keep your tunnel straight. You can always go back out of the tunnel and look how it's going as you inject and continue dissecting to make sure it's straight. And during dissection, you want to use coag current and that typically there are several options. There's spray coag, which is really high voltage non-contact coag. I would not recommend that early in the learning process, but later on you probably can entertain that. Swift, forced, precise, or endocut can be used too. I really love the precise coagulation current as it it's just it changes and adjusts based on the resistance of the tissue. So it does provide really good dissection with hemostasis. If there's any severe spasm, especially in when you're close to the lower esophageal sphincter or in type 3 akalasia, it's going to be hard. The space, the submucosal space is going to continue to be narrow on and off as the spasm passes. So you want to go slow, you want to inject more, just make smaller cuts, and like Dr. Yahagi says, go slow to finish fast. So blood vessels, so that's one of the things that you find most of the time during tunneling. And if you find a blood vessel that is small, technically smaller than the shaft of the knife, you can actually coagulate through that blood vessel with the knife and that would take care of it. If it's as big as the shaft of the knife or bigger, then you would want to pre-treat that blood vessel, then cut through it. You can pre-treat it with the knife by decreasing the wattage, for example, on a forced coag or a precise sectin until it whites out. And then you go back to the regular dissection setting with that coag current and then you can cut through it or use a coag rasper. So you want to extend your tunnel two centimeters beyond the lower esophageal sphincter. So you want to go two centimeters into the cardiac and that's when the tunnel is complete. How do I know at the lower esophageal sphincter or at the G-junction? The submucosal space becomes really tight around the lower esophageal sphincter. Once you get past that, the submucosal space opens significantly. It's really hard to miss. So you can find some landmarks, which are the spindle-shaped blood vessels on the muscular side of the tunnel. You typically see those once you're at the lower esophageal sphincter, so that's one other landmark. And measurements, so measuring the length of the scope at the incisor, so how far you are when you're in the esophagus and how far you are in the tunnel and comparing that can give you an idea on how far you need to go to reach that mark of two centimeters below the lower esophageal sphincter. And then one technique, if you have the luxury of having two processors in the room, you can pass a slim scope while you have the standard scope in the tunnel and retroflex in the stomach and look for the light, and that can guide you on how much is left to cut and even guide you on the direction of the dissection. So this is the part of the submucosal dissection. So if you notice here, we stay very close to the muscle layer and just dissect that submucosa immediately close to the muscle. That's a small blood vessel. You can cut through it. Now you'll notice that I still have left, but I lost the color, and it's re-injecting. And you see, even though you are seeing muscle layer, but by injecting, you see more submucosa that needs to be cut and I needed to get closer to the muscle. Staying away from the mucosal side is essential. So you would continue keeping the circular muscle fibers just perpendicular to at 90 degrees with the scope. So type 3 achalasia, so the tunnel here is going to be long, so I'm not going to show it all. And here's a blood vessel. So one mistake here is that I'm tapping on the current and I didn't let it cycle and burn through that blood vessel. So that's one cause of the bleeding. So another option would be sclitinizing the mucosa around the blood vessel and then cutting through it with continuous coag current that would probably control it or pre-treating it before cutting through it. So now a bleeding happens, we'll get a coag grasper to control that bleeding. So you want to maintain visualization, not remove the scope, stay in the same place. Water flush can help, but that's how it's done. You get that coag grasper in and grasp the blood vessel. An indication that you actually grasp it is the stop. Once you close it, the bleeding stops and then you pull back a little bit and use the soft coag to burn through it. So here is the bleeding is controlled and we continue the tunnel and right here you can see the spindle vessels on the muscular side of the G-junction. So here we're almost done with the tunnel and we're on the gastric side. The tunnel is complete and you can see right here as we come back, this is the tight area of the lower esophageal sphincter. It's hard to pass the scope through it and the rest is the carcass. So come back and that's the tunnel completed and we move to the next step of this procedure which is the myotomy. So typically you're going to use a cutting current with some coag property like endocut or dry cut. Percise is a coag current, but it can be used for cutting the muscle layer too or a combination of these currents. So if the area is very vascular, you can start with coag and then cut. So the initial cut will be three centimeters below the mucosal incision and then you continue straight down until you get into to the lower esophageal sphincter and one to two centimeter into the gastric side. So the first part is exposing the longitudinal muscle fibers as we'll see on the video and then that's the plane where you clip the knife between the two layers and then cut the circular fibers on. A good myotomy would be one to two centimeter into the cardia of the stomach and the idea is to stay on the cardia is because you don't want to cut the sling fibers which are an essential part of the mechanism against acid reflux in the stomach which wraps around the esophagus from the fundal side of the esophagus and are spared and not existing in the cardia side. What you have in the cardia is called the clasp fibers of the stomach and those you can cut through and extend the cut two centimeter. But the best way is to avoid the sling fibers to try to maintain the anti-acid reflux mechanism. So this is the myotomy part. So that's the initial incision trying to expose the longitudinal muscle fibers and you can see some of those being exposed at this point. So idea is getting the knife in between the two layers and the space between the two layers and then you angle it and provide very minimal tension toward the lumen of the tunnel. You have to be careful with the amount of tension you put on the knife toward the lumen of the tunnel because if there's too much tension the knife can jump toward the mucosal side and cause an injury. Even if you're not having the current the knife remains hot for some time. So a jump from the knife toward the mucosal side can cause a mucosal injury. You can definitely find that from the other side and clip it but this is the best way is to be very careful with the amount of tension and you want to go very slow early on when you do the procedure and you will learn with time how much tension with every type of current you you're using and adjust. So this is the end of the myotomy. As we come back you're gonna see the full separation of the muscles close to the lower part of the esophagus and a lot of it is preserved toward the upper portion of the esophagus. So it's very hard to preserve the longitudinal muscle fibers and most of the time even if you cut between the two layers without the intention of cutting the longitudinal fibers, those fibers would separate just from the tension of passing the scope which is not a problem. A lot of people would intentionally actually cut the fibers too and the thought is it would give you a much better outcomes in terms of relaxing the lower esophageal sphincter but it's not it's not necessarily true. I always try to preserve it but it would separate on its own. Alright so going to the closure so clips starting from the distal end of the incision and going backward and the zipper technique is typically what most people do but suturing and X-stacks suturing with overstitch or X-stack has been described and it can work very well. So this is the part where we do the closure so starting at the distal end of the cut you'll place your first clip intention is even if you go even distal to the distal end of the cut and just approximate the two ends of it it works very nice so placing one the next clip just with the two arms or jaws of the clip just on top of the other clip which function basically as a guide so one after the other just creates that zipper technique and leads to a complete closure of that incision and that's it. That case is done. So how do I take care of the patient after the procedure? Things that we do is an esophagram to make sure there's no leak outside of the wall of the esophagus. I keep patients on liquid full liquids for six days followed by three days of soft diet and go back to a regular diet. Antibiotics I do a course of antibiotics three to five days but there is literature saying that it's not necessary and it doesn't change the outcomes. An overnight stay in the hospital there's also literature saying that it's not necessary but early in the learning curve or your first few cases I would say definitely use antibiotics and do the overnight stay. PPI therapy on everybody so this is an so this is the opposite of anti reflux treatment. You're basically causing reflux after this procedure so you would definitely want to keep those patients on PPI. I would typically do another scope and a pH testing at one year to decide if I want to continue it or if I want to consider anti reflux management. So it's an actual bearing from the case that we've done prior to the procedure and after the procedure on the left. And that's the end. Ahmed that was really fantastic. You know there's so much I would love to pick your brain about you know in terms of poem anterior versus posterior kind of how long the myotomy or the tunnel needs to be you know. But I think you know for the purposes of time we're going to move on. But I think one thing you made clear is that I'd really like to underscore to the fellows is that the the tunneling approach in ESD versus poem is diametrically opposite right. In ESD you really want to preserve the muscle whereas poem you really want to work close to the muscle to preserve the mucosa. And in fact it's encouraged in poem even to nick the mucosa the muscle layer just to kind of provide yourself some sort of kind of map you know to go forward so that you're kind of always in the right direction. It's okay to injure the muscle there in fact you're going to do a myotomy anyway but the tunneling strategy really is quite different there. Okay so I'm going to present just a quick kind of five minute thing on G poem then we'll save some time for the Q&A. Well I guess to set up audience if you guys have any questions it's a great time to leave kind of questions in the Q&A section and after the presentation we'll get to some of those. So you know just for the sake of time to skip over some of these slides but you know G poem is a treatment for gastroparesis which is delayed gastric emptying in the absence of mechanical obstruction. There's lots of treatments but none of them really work well and they have their issues whether we try to do dietary modification, glycemic control, prokinetics, not well tolerated, transpilar extenting which has issues with migration and the surgical option is invasive. G poem has been around for several years now. We're starting to get some longer-term data but you know in general it seems to work about 70% of the time. We're still trying to figure out exactly which patients do the best with it whether idiopathic, diabetic, post-surgical and different series suggest kind of different groups but in general I think for all comers it's about 70% response rate in terms of objective gastric emptying GCSI which is a gastroparesis cardinal symptom index. You know we could talk forever on patient selection but I think one of the things that we've learned is that patients that are on opiates, patients that have pain predominant gastroparesis don't really do as well with the procedure. This is one of my favorite studies and I'm only going to show you this one and it shows that it was 30 patients out of Emory and it looked at ER visits and hospitalizations pre and post G poem and even if you don't see an objective improvement in the gastric emptying study or GCSI in some cases you know you have to keep in mind things like healthcare utilization and ER visits and hospitalizations are really important and they really can affect quality of life and they do seem to drop significantly after G poem. So this is a case, this is a four-year-old gentleman previously uncontrolled but now controlled diabetes. A1c was 12 and now it's 6, medically refractory, he's intolerant to metoclopramidin or erythromycin. He's had 15 ED visits and hospitalizations in the past year debilitating to his personal and professional life just in and out of the hospital. It can't hold down a job and his GCSI is 3.65 which on a scale of 5 and that's really kind of an impressive number. So I'll show you a video here of a G poem procedure and there's lots of different ways to do this you know some people do a lesser curve some people do a greater curve this is a greater curve approach. I'm making an injection 5 centimeters proximal to the pylorus previously people used to make the incision much more proximal and they would end up kind of spiraling and tunneling and so we really figured out the best way to do this is to shorten it so you can see the pylorus so in the distance there and it's pretty hard to get lost when you're just a few centimeters proximal. After the lift similar to poem we make our initial mucosal incision. The gastric mucosa is a lot thicker than the esophageal mucosa and you can kind of appreciate that here. So it really we like to use longer knives. This is a four millimeter knife the hybrid knife and that really allows us to cut through the gastric mucosa. We're starting to kind of trim and expose the sub mucosa here. You know I like to use a tapered cap like Carl mentioned and I like to use a viscous injection solution easy to kind of stack the deck in my favor. I do that for poem too and it just makes it so much easier than if you're just using saline and a cap that's not tapered. So now we're into the tunnel into the submucosa. We're just kind of dissecting along working our way to the pylorus. This is the beginning of it so once we've made our tunnel we kind of go check to see where the pylorus we come in back to the tunnel and see if we can see the pylorus on the inside of the tunnel. Here we are we don't really see it at all we just kind of see our tunnel. Dissect a little bit further see some vessels there but we still know pylorus and this point anything procedure usually just like what should I do where do I go you have to persist a little bit more you have to kind of move upwards and these are our first these are the pylorus you see that muscular ring at 12 o'clock or at 6 o'clock there and I'm just kind of exposing this a little bit more here there you can see it pretty nicely and so that's kind of what you'd expect it to look like in the tunnel. We inject a little bit to protect the duodenal mucosa which is on the backside there and then we just do the myotomy and so it's a much shorter much simpler myotomy than we do in poem traditional esophageal poem and it's just kind of like peeling back the skin of an onion. The pylorus muscle you can see the circular muscle fibers there I'm just kind of slowly making a really ginger first cut kind of retracing it over and over again until I feel like I'm down to the cirrhosis and you know a lot of times sometimes we even go through the cirrhosis and it's not a big deal and that's the whole beauty of these third space procedures because patients may have a little bit of free air but you can close it up. Here's I think I've done my myotomy here so you can see the pylorus muscles completely kind of separated we'll go under with a duodenal bulb and just make sure there's no injury anywhere the duodenal mucosa and and then we're suturing and I like to do a transverse incision and just place four stitches just kind of top left top bottom left top right bottom right and it just takes about you know three or four minutes to close and we're done. Keep the patient overnight I usually I get an upper GI series I probably don't need to when I suture it but that's what I do and and this patient did really well he had no more ED visits his GCSI dropped from three and change to I think 0.65 and he's really grateful he did the procedure and of course not everyone has this amazing outcome but you know if we can pick our patients right it really can be life-changing for them. So with that I think let's save some time for the Q&A I'll hand it back over to you Nick and let's we'll chat a little more. Wonderful wonderful well thank you guys for the talk that was excellent I know we got a lot out of it. While I get the Q&A pulled up I guess one thing you kind of hit on earlier Sneil was talking about your guys's journey to kind of proficiency and competency in these procedures. How like for us fellows when you're have these skills and your patient selection and deciding what cases and techniques to to take on how did you guys kind of start at the beginning of this as you're working towards you know where you are now? So you know we can ask everyone everyone kind of talked a little bit about their journey in terms of learning and you know for me I did an ASGE travel award and I went to Prague and I went to I learned from a Jan Martinik over in the Czech Republic who's kind of a super high-volume ESD poem guy and I spent a month for my practice and kind of learned from him and that's how I got started. One thing people haven't mentioned yet is the pig labs and I think those are also if you have access to those are a huge way to learn you know you can do multiple tunnels in a pig if you have access to a live pig that's really fantastic too and you can work on ESD that way. I think in terms of patient selection I'd love to hear what the other guys say but you know definitely you know you want to start like like Jeff said you know gastric is probably the best place to start rectum you move your way to the esophagus and you know I still I don't do colonic ESD I mostly you know do that EMR there I don't feel comfortable yet you know with where my skills are and so I think it's all a journey you know you keep going at it and just try to do it safely they're not mentors you know we're in a great place now where you can zoom people into your procedures so yeah that's kind of my thoughts on it. Carl what do you think? You know absolutely I'm going to share you know what I've come across recently and I feel like it's actually I'm gonna share with everyone in the panel as well as the the fellows so chapter one of my professional career was the first maybe eight to ten years of practice you know learning how to do things safely learning how to you know not cause harm learning new techniques. Chapter two which I'm currently in right now very excited about this chapter actually equally excited is to learn about the human psyche you know interpersonal relationships things like that and mindset actually ironically could have easily been applied to chapter one I just didn't know it at the time and so 80% of what you can and conversely cannot do boils down to mindset only on average about 20% is technical now that sounds ridiculous right we spent the entire hour talking about the techniques and devices and tools but you have to believe right eventually if you have a strong why that is the single most important reason to pursue this journey and and and and go down this pathway for me the why was to you know learn minimally invasive techniques for very early stage t1a cancers that very early in my career you know every single one of them I mean if they were beyond the size of EMR would send for a subject me and you know one day you know lightbulb moment went off and I was like my gosh there has to be a better way and so that was my why maybe I'll give like a less philosophical answer even though that was a good one you know I think that you have to start somewhere and you you know everyone talked about how they started and that's fine but you need you need wins like at the beginning and so that means you know working with a team to make decisions about how you're gonna start and how you're gonna proceed and helping each other so it's very hard to be like a lone endoscopist just like taking this on on your own need mentorship I'll be it from you know a true master or from colleagues kind of going down the same path and asking questions and picking people's brains you know going to other people's centers having people come to you to kind of mentor those first few cases so I think you can't be on this journey alone and Carly didn't understand anything else you said but but the I think you just need help like along the way and then also a little bit of insight into your own skill set right and so I was gonna ask these guys during the their talks is how do you know when one of your trainees is ready to like ready to go or ready to start getting into third space and doing parts of it like how can you tell and you know as a trainee I find that it's very hard to have insight into your own skill set where people are always asking me like where am I at or they'll come to me and say can you teach me how to do you know this like eight centimeter EMR and I'm like well you know you have a hundred and forty centimeters of scope in at the SECUM like I think we have other issues that we need to talk about first and you know tip control etc so I think you know developing a bit of insight into your own skill set and then going on the journey with others is probably the best way to go and really baby steps right get and and all of these procedures feed into each other it's all about scope control and you know making good decisions about which lesions to take on yeah I think that's so important you know needing wins at the beginning is you never want to start one of these programs off on the wrong foot and and that's really having that insight is really be humble about it you know no ego just kind of just do it the right way a lot of courses right now which are available through multiple companies and the ASG and several courses even like you know in Europe or other countries that's a really good opportunity one thing like indefinitely want to get your endoscopy skills really good during the General GI Fellowship and if you want more you can go for an extra year even if it doesn't have a that third space training you can gauge how much how good you're doing through the animal lab so you'll get some of that tip control you realize how much you're doing a lot of people actually go for these courses and then they realize that it's probably not the right thing for me or I'm not interested in it anymore but you can gauge your skills your interest whether you're ready for it or no through these courses and animal labs they ASG courses one good course to try and you'll get like you know live animal models and you would see bleeding you would get a short amount of time to try to complete in an incision around the lesion or try some dissection and then you can gauge how much you want to do after that and go for more and typically so I knew I wanted to do this I I got the why that Karl talked talked about during my General GI Fellowship I did one animal lab during advanced endoscopy fellowship and then past that point after graduating I just went for every available course back-to-back like anything that's available I would just register and go and that kind of built the experience gradually and then I just accepted once I started with a case one case in the rectum and the next case was in the esophagus and then I started doing more in the rectum and then I did a G poem then a poem case so it's just like you know it's gonna come back and back and back to back and once you start advertising about it then you'll get more and more cases but the key thing is when you start your first case you'll also realize how much you can do and how much you can take and do more so it's a gradual thing but it builds up and but if you have the interest I think you definitely would persistent you can persistence you can definitely do it awesome thank you guys for the answers there one of our other audience members asking is there other than university centers is there issues with reimbursement for lengthy procedures and do you like anticipate people having trouble getting reimbursed for this if they could maybe make more of a use in things like EGD colonoscopy things like that so so I'm currently in a private practice so I do not get a fixed or guaranteed reimbursement for procedures other than I you know for definitely for poem there's a CPT for a poem for accolades there's a CPT code you can definitely if you're interested in that even academic or non academic system you can negotiate with the hospital of fixed value for your professional fee I you say okay this procedure takes me like you know an equivalent of three colonoscopy I want what's worth of three colonoscopy as my professional fee and fix it if it works it works and sometimes it's not gonna work and if that doesn't work then you'll just end up having to negotiate with insurance and prior get a prior approval before every case and then you it's gonna be hit or miss whether you get paid or no it's a lot of what I do is not paid but the model of my practice does not 100% rely off on my productivity because we pull and share and that's how it's working for me now wonderful thank you I know we're running short on time but maybe one last time for kind of a clinical question from the audience they said pneumo-mediastinum appears pretty common adverse outcome of poem how should they differentiate a true leak versus a normal expected degree of pneumo-mediastinum and then any recommendations for management and is their role for endoscopic closure in that setting so I think you know pneumo-mediastinum is pretty is a pretty common occurrence in poem and and but a leak doesn't really happen acutely but pneumo-mediastinum does so when you're doing the procedure if you're vital you get a little hypotensive if your peak pressures go up you know you communicate with anesthesiologist about that then you can be concerned there's some air leak going on you know in which case you just have to do a needle decompression which is just normal part of the procedure you know is not really a complication at all you can even pull the needle out at the end of the procedure so you know I think that's what they're getting at but but it you know I wouldn't be too concerned about that and like Ahmed mentioned if you can turn your co2 to a very low using a low flow co2 that really mitigates against a lot of this awesome well I know we're pretty short on time and we'll turn it back over to Marilyn in a minute but before we kind of brought things up any final comments from panelists I just want to thank all of the faculty and you Nick as well for for joining us I think this is a really awesome session I learned a lot personally I know it was really fun to do this so so thanks to you guys thank you yeah thank you so much thank you guys all for being here I know that as fellows we definitely learned a lot so we really benefited from your expertise and thanks for sharing that with us I'm in Maryland we'll turn it over to you for closing comments thank you thank you again to all our moderators and panelists for tonight's presentation before we close out I just want to let the audience know to make sure to check out our upcoming ASG educational events registration is open and many of these programs are available complimentary to our ASG training members visit the ASG website to register the next ASG endo hangout session will take place on Thursday August 4th at 7 p.m. Central Time on optical diagnosis of colon polyps and magnifying endoscopy registration is now open at the conclusion of this webinar you will receive a short survey and we would appreciate your feedback your experience with these learning events is important ASGE and we want to make sure we are offering interactive sessions that fit your educational needs as a final reminder ASG membership for fellows is only $25 per year if you haven't joined yet please contact our membership team or go to our website and make sure to sign up in closing thank you again to all our panelists and moderators for this excellent presentation and thank you to our audience for making this session interactive we hope this information has been useful to you and with that I will conclude our presentation have a good night everyone thank you

endoscopic submucosal dissection

ESD

GI lesions

pre-procedure planning

instrument selection

advanced ESD

circumferential ESD

peroral endoscopic myotomy

POEM

achalasia

esophageal manometry

gastroparesis