For the sake of time, I'm just going to present the case to you guys without the slides. This is a young female with achalasia type 2. She's treatment-naive, and she has significant dysphagia and regurgitation. Let's go directly to the end of view, please. Okay, good. So, this is her esophagus, and you see here some stasis changes. We see a tight, lower esophageal sphincter, and we always like to retroflex to make sure that there is no tumor there causing a pseudo-achalasia. So, in terms of how I do this, so I measure the LAS here, the G-junction is at 40 centimeters, and I want to do 6 to 7 centimeter myotomy on the esophageal side, 2 to 3 centimeter myotomy on the gastric side, and the incision has to be 2 to 3 centimeters above the myotomy. So, this will lead us to starting our incision here at 30 centimeters. Before I do that, I'm going to do quick end-to-flip measurements of the sphincter to look at the distensibility, and this here is, can we zoom in on the balloon, please? So, this is the end-to-flip balloon. I'm using the 8 centimeter balloon, and later on, the 16 centimeter balloon with esophageal topography will be demonstrated. So, here I'm just going to insert it next to the scope, and back to the end of view now, please. So, you're going to see it coming directly towards the, so you're going to see towards the LAS, and this is now the balloon in the stomach. We're going to back it up, and let's get, usually, I get measurements at 30 and 40 centimeters, and we'll look at the distensibility. After finishing the myotomy, we re-look at the distensibility and make sure we have adequate response. From our data, we think adequate response is increased by three points, increase of the distensibility index by three points. So, we'll see what is it here to start with. So, let's go to just 40 for the sake of time. So, if any of the moderators have a question, please let me know, and I'm hoping you are hearing me well. Yes, we can hear you very well, Moin. Please go ahead. Excellent. So, here the distensibility is 1.4 at 40 cc balloon. So, we'll look at the end of the myotomy. What's the distensibility? So, I'll get the incision and the injection. So, I'm going to do anterior myotomy, and later on you'll see other examples of posterior myotomy. When the esophagus is very dilated, you'll see this impingement of this spine on the esophagus. When it's not dilated, what I do is I inject some fluid here. We see where it's spooling, and it tools posteriorly. That helps you make sure you're going where you need to go. So, here I'm looking at the 12 o'clock position, and needle out. This is just saline and methylene blue. Let's inject. Hold on. Inject. So, we'll inject 10 cc of saline and methylene blue while letting the balloon deflate. Okay, and do the back. So, now we'll go with the incision. So, I'm using now the triangular tip knife, not the T to J, the standard one. I inject through the scope, and you'll see that in a minute. So, we're gonna remove the balloon, please. Let's remove the balloon, and we'll do it, we'll repeat it at, we'll repeat the flip measurements at the end. So, knife out. So, here we're gonna do the incision with endocottic cue current. We're gonna endocottic cue 311, about a centimeter and a half incision, probably enough there. And then I'm gonna switch to spray coag here. This step is called trimming. So, we're gonna just trim the submucosa to allow my scope to get in. I'm gonna make sure we don't hit any muscle here. We don't want any early myotomy. And then we'll just use the cap to squeeze our scope in the tunnel. Good. So, here, I'm not pushing. I'm just doing a little bit more trimming to create more space. And then gently push in. Okay. And now we are in. So, we're gonna keep the muscle here at 12 o'clock. And here, we're gonna see like this, we can just inject through the scope. So, we have a bottle of saline and methylene blue. And that will stay in the submucosa very well. And here, the importance, the important point is, please make sure everybody is muted at other hospitals. I'm hearing their noise. Can I try that? Moin, there's a question in the chat box. So, I can help with this. This is Joan Chen. I'm one of the moderators. Is this a good time to ask a question, Moin? I know you're in the middle of creating your tunnel there. So, in the Q&A section, somebody asked a really good question about myotomy length into the esophagus. Do you use, based on your patient being type 2, do you have a rationale for the longer myotomy versus shorter myotomy? Yeah. Thank you, Joan. Can you still hear me well? Yes. Yeah. Sorry, because of the delay, we didn't introduce you guys. So, apologies for that. Dr. Joan Chen from University of Michigan, motility expert. We really appreciate you joining us. And as soon as we are done here, Venkat will introduce the entire course faculty. But thank you for the question. There is some data that for type 1 and 2, if you do a short myotomy, it's fine. I don't think, and I would just try to replicate the literature on Heller myotomy. They do a six centimeter myotomy. The only difference between short and long myotomy was the procedure time. But the procedure, as you'll see, it just takes us, now the whole thing takes less than 30 minutes. So, plus minus one, two minutes, I don't think it's an issue. The important question is on gastric myotomy. There is some data, and we believe that a long aggressive gastric myotomy is associated with increased risk of reflux. So, we try to limit that. So, here we see the lumen, the submucosal tunnel is narrowing. So, we are at the LES, and we look at the scope, and it is at 40 centimeters. So, that will confirm. And here we are still tunneling at the surface of the muscle. And you see, very careful, we push the scope down. We always look up. We use the large wheel to look up towards the muscle side to avoid any mucosal injury. And then we continue. Once we pass this tight area, it means we are on the stomach side. So, this is, now we are on the stomach side. So, here through, I'm just injecting with the paddle through the scope, and you see it stains and expands the submucosal tunnel very beautifully. So, I don't use a, I don't inject through the needle, and I don't use an injection, sorry, through the knife, or I don't inject through a needle, just through the scope. Makes it easy, cheap, and also pretty efficient. Here on the stomach side, you can see large vessels. So, you want to be careful with your, so that you don't hit one of these branches of the left gastric artery that can cause a significant bleeding and will stain your submucosal fibers. Red becomes hard to see and hard to complete. So, here sometimes you can figure out after tunneling that the gastric tunnel is too long. So, the anatomy does not have to reach the end. But I think here we have adequate tunnel. And if we look at the scope, we're at 45 centimeter. I'm going to look back here. Any oozing we like to treat. If it's too much, sometimes you can just leave it until. So, here this is good that this happened. This is the mucosal side. So, this is the muscle. This is the mucosal side. So, what you can do is just tampon at it for a minute or so and see if it works. If not, what I do is I do, I just spray it with a split of a second. So, you can't really be aggressive with these because you can hit the mucosa right away. But this is a little bleeder that is. So, here very careful. That's it. So, you don't want to cause injury to the mucosa. And I always like to look at the blood pressure. What's just asking here, our CRNA, Kevin, what's the blood pressure of the patient? Okay. I hear a little elevated. So, I could tell that because we have bleeding. So, we keep the pressure on the low side because when you're tunneling, basically you are removing any compression on the vessel. So, increased intravascular pressure can be associated with bleeding. Give me the coag grasper, please. So, we're going to use the five millimeter coag grasper with soft coagulation mode, and then we will proceed with the model. Any questions from the panel or the audience? It's John. Hi. Hi. Hi. How are you, Mohan? Hi, John. Hey. For these types of bleeds, do you ever use a spray in this situation? Spray coagulation, you mean? Yeah. Yeah. Yeah. If it's just a little oozing, I just spray it. Correct. Close. Yeah. So, when I treated this vessel here on the mucosal side, this was a split of a second treatment with the spray coagulation. But you got to be very careful because spray coagulation is a very strong current with very high voltage. Open. Close. So, you want to be careful with that. Open. Close. Okay. So, let me now come out of the tunnel to show you the end of view here. And that's retroflexing. And we see here the bluish discoloration of the gastric cardia. So, that tells us also that we crossed the LES. This is a main thing, right? So, the most cases that fail POEM are due to incomplete gastric myotomy. So, you want to look at the fundus by retroflexion. Also, I find that the most useful here, and go back into the tunnel, look, and this is the LES. So, the LES, and it will correspond at my scope to 40, the we know, and just look through. So, this is the cardia tunnel or the gastric tunnel. It's about two centimeters. So, this is perfect. So, you want to double check on that to ensure that you're going to have adequate. Let me just clean my lens here quickly. Can we suction them out, please? So, let me know if there's any question here. So, quickly, do you usually start with, in a naive patient, with an anterior approach as opposed to posterior? Is it easier technically, or is there another rationale for doing anterior myotomy? Yeah. No, I mean, I don't think anybody can tell you there is a strong rationale. We started all doing anterior. Some people changed to posterior after Professor Inouye found a few bleeds anteriorly, but we did a randomized trial, and others completed a randomized trial, and everything was equivalent from procedure time, reflux rate, success rate. Everything was equivalent. If you want to use the technique guided by the two penetrating vessels that Stavros will show later to maybe decrease the risk of post-poem reflux, that's only posterior, but Stavros will be showing you. But anybody who does poem should be able to do both because, you know, in sigmoid, esophagus, post-telar, open, we will be doing posterior. So, I'm here a few centimeters below the incision. I'm still using the same knife. I'm still using a spray coag. So, we're going to do one, two, three, four, and we're going to grab the muscle and cut. And you're going to see here quickly that we have the, let me pause. So, we can see the longitudinal muscle layers, the muscle fibers, and we see the circular. So, here I like to use select, do a selective myotomy at the beginning. And the reason for that, we have the heart on the other side. So, it's good to protect them with this spinal organ. However, you know, this has been studied and the selective myotomy, the main difference is really, if you do a full thickness, it just makes the procedure faster. But here, important thing is I'm keeping the longitudinal muscle fibers and I'm just using the tip of the knife. The reason for that is the tip, it has a very high current density. So, although I'm using a spray coag, you don't see much, you don't see much charring. You're using a high current density and the knife is moving. So, while cutting, you want to move the knife so that we don't cause charring. If you see a lot of charring, you move to endocut Q, but endocut Q, you're going to see a little bit more bleeding. There are some vessels usually between the muscle fibers. So, here I'm getting closer to the LES, as you can see there. So, we're going to switch here to a full thickness myotomy. And we're going to take all the fibers here, like that. You want to leave that advantageous tissue, that's important. So, you see I'm using the tip of the knife. And that's continuing along the same. So, here very important is when we're cutting this, you don't want to be cut too fast and drop your needle on the mucosa. So, what you want to do is try, slow down a little bit while cutting. And you can do also the, instead of up down, like the direction, do down up when the muscle is very close to the mucosa. So very important, again, is to this layer here, we have to protect it because we're cutting the muscle, we're cutting the submucosa, so if we cut the mucosa, then that's a full thickness perforation. Here we see a lot of charting. And so you see, I like to stain here blue so that we can see the vessels. So you can have very large vessels here on the gastric side, outside the muscle. So here, I'm gonna just do a little bit of endocut view because I have a lot of charting. You see, it just cuts very exquisitely, yeah? And then here, the myotomy is done. So we see, then we look, this is full thickness here, complete. We come back, and these are some of the genital fibers. And now we have intact muscle here, just under the incision that will be part of the flap closure. So this is done now. The next step is to go ahead. And so we check, you wanna look for a mucosal injury, and then we will check with endoflip. So the distensibility was 1.4, before the myotomy. And I would like this to be above 4.4. So the same balloon, I just put it next to the scope. So, and we go down. That's when the balloon is going down, just to make sure it's not gonna go into the tunnel. We've had this happen a couple of times. And let's go to 40 again. So I like to decompress the stomach, so that this doesn't affect the distensibility. We pull back. We estimate that at the center of the LES, and then we look at endoflip. So let me know if there are any questions while we are insufflating the balloon to 40 CCs. Can I ask you a real quick question? So you're doing this really fast. I mean, the myotomy, it looks so smooth. Can you speak on the experience of somebody that has had Botox injections previously, perhaps multiple Botox injections, you know, fibrosis scarring from that? How much more difficult does it make? Yeah, so the literature supports that prior treatment doesn't affect the outcome of POEM in terms of clinical success. But our personal experience, if somebody has had a lot of injections, you can see more fibrosis, can make the dissection of the LES a little slower, more difficult, but not to the extent that this fails. The most common reason for failure is end-stage achalasia, where there is effacement, complete effacement of the submucosal layer. So this is, in my opinion, the most common reason to fail and not prior treatment. Can we go to endoflip view? Can you enlarge the endoflip view, please? Okay. So we can see here, I hope you guys can see it, the distanceability, if it's clear to you. Now it is at 4.7. So that is up by three points from where we started. So I'm very happy with that. If I feel it didn't go, it's like now 3.5, I'll go back, extend the anatomy by like five millimeters. And we've done this where even a few millimeters on the gastric side can actually alter distanceability. It's that accurate. But with this, I'm happy. It's not overly distensible, it's adequate. So we're going to deflate and we are going to close. Here, we're not showing you the patient. Patient was on our back. Every now and then, I just touch the belly a little bit, make sure it's not getting distended. We look at the peak airway pressure. You know, when patients have capnopertinium, the peak airway pressure can go up, especially if you're starting to do POEM, you want to expose the belly, look at the peak airway pressure and decompress the abdomen if you have a lot of capnopertinium. The first thing that happens is increase in peak airway pressure. And then the tidal volumes are going to start going down and you don't want to reach that point. So just get comfortable with a varus needle or an angiocatheter where you can decompress the abdomen right away. So we're going to remove now the balloon and we are going to close. So we're using a standard rotatable 11 millimeter clips. With other faculty today, you're going to see also suturing of the mucosal incision. We want to show you a different variations of technique. So here is the incision. So here's how I like to do this. And just to show you here, you see the, here we have, so we see the cautery marks and we see a few millimeters of shearing. That's minimal shearing, but just to let you know how you can quantify the shearing. This is just from pushing against the mucosal. So the way I like to do this is I, so this is with the scope in neutral position. I like to align the incision with the channel of the scope, which is at seven o'clock and to make the incision closure symmetric and easier. So open the clip, please. So I didn't introduce my team because again, of the technical issues, we have Kevin, we have Dr. T here, Tanya, we have Denise and we have Tina. So this is my excellent team. They, we do this almost on a daily basis. So everybody is comfortable doing it. Close. Okay, let's take that. Open. Good. Martin, is your patient under general anesthesia? Do you ever do this without intubating a patient? Not in the esophagus. We put a lot of fluid and you never know when the esophagus is full of stuff. So we definitely intubate them. Close. And we even, open, sorry, open. We even place a ET tube with subglottic suction. You guys can't see it, but we have a special ET tube with subglottic suction in patients who retain a lot of fluid in the esophagus. We had one issue with aspiration pneumonia and, open please. We eliminated that with the use of this ET tube. Close. Take it. All right. So just a couple more clips. And in terms of post-op management, so now I'll tell my anesthesiologist, I'll be done in five minutes. They'll start waking the patient up. And everything the patient is on right now is short acting. We try to move efficiently so intubation doesn't slow us down. In recovery, patients stay about two hours open. We will give them, if the procedure goes well, patient is relatively healthy, no intra-op complications, and we close with high confidence. Close. Take it. Then we allow the patient in couple of hours to have some liquids, clear liquids. If that's good, they go home. We send them home on a pain medicine, nausea medicine, antibiotics just for a couple of days and a PPI. And we call them the next day. If they're doing well, we ask them to advance to a soft diet. Open. The soft diet, they'll be on for, close, for seven days. Close. Take it, take it. For seven days. And then they will, give me one more, please. One last one. And then after seven days, they will advance to a normal diet. For PPI, we tell them take it twice a day for one month, go to once a day for one month, and then stop and take it as needed. At one year, we study them with a pH testing due to high risk of reflux after pull. So this is the last plan. I didn't hear antifungal on the list of medications you mentioned. There's a question about that. Do you ever give antifungals? Yeah. So only to, so here the incision is done. So only to patients, if we do the EGD, we see candida esophagitis, or if somebody else has done prior EGD or the patient has history of candida esophagitis, then we give it. If somebody has had an EGD two years ago and they had candida, then we assume the patient has that and we give it. Otherwise we don't. How many times, if you follow this, you will abort the procedure because you find unexpected candida esophagitis very, very, very rarely. So it's just based on the history. If somebody has sigmoid esophagus, you may to consider also giving fluconazole for a couple of weeks before the procedure. So the way we give it is 200 milligrams once and then 100 milligram for a day, for two weeks prior to the procedure. Great. So I'm gonna get the scope out and if you just focus the camera on the room view, please, and turn the lights on, I'm happy to answer any questions. So there's another question regarding the tunneling or the anterior approach. Is there a speed difference, do you think, or is it based on personal comfort, the endoscopist comfort in terms of anterior versus posterior myotomy? Yeah, so if you look at the entire procedure time, when we started this, it's equivalent. Getting into the tunnel can be faster anteriorly, closure can be faster posteriorly. But in terms of tunneling and myotomy, they are pretty equivalent. I think we all have to be comfortable with both approaches. Sometimes the anatomy is difficult enough where you have to, you go, the anatomy will decide where you go, you really don't have an option. So patients with sigmoid achalasia and stage achalasia, a lot of fibrosis, a lot of times you're gonna go in and you're gonna go into multiple places and try to tunnel in multiple places and you're not gonna be successful and change into the other direction. So I just had this earlier this week where I tried four or five different spots. And at the end, we found a spot just three centimeter above the junction posteriorly. This is where I had lifting and I was able to get it. Could you also speak a little bit on the learning curve? You know, you're obviously high volume, you've done a ton of these. What do you, where do you feel like the learning curve is achieved for somebody that's starting? Yeah, we've published on this a long time ago and Stavros, who you will see soon, has published probably the best data on this. I think you get consistent at it, which means procedure time is low, no complications. You're able to be thoughtful about processing information during the, and making decisions during the procedure at 40 cases and you become an expert at a hundred. So it really is easier seeing the procedure. When you see it, you think it's easy, but when you get to do it, it's not that easy. This has been my experience with training fellows in this for the last 10 years, but definitely fun to train them. Fellows can become really good at it, but due diligence. You start with easy cases. First, actually, you look at experts, you learn from them, you go to the animal lab, you get explants, you get comfortable with the knives and et cetera, and then you choose easy cases, you get proctored. So slow progression towards being expert in poll. Which patients, Bowen, do you not send home the same day? I know that's an area of controversy across the country, but do you think it's safe for everyone to go home the same day, or are there some people that you always keep? Yeah. First, it's an endoscopist preference, which is comfort level, right? So we did this for the longest period of time and never really had leaks. So there's no, and we got esophograms on like 1500 patients, right? And we never see a leak. So that gave us some comfort in discharging them. And we were forced to do that during COVID because we just didn't have beds. So this one, we started collecting data on this approach, but we were calling patients the same day, the day after, keeping very, very close eye on them. So generally, our goal is to discharge patients, but patients who are sick, they have a lot of cardiac issues, transplant patients, pulmonary issues, complications during the procedure. If somebody has intraprocedural bleed that you stopped, we all know intraprocedural bleed, like in colonoscopy, polypectomy, EMR, EST, is a predictor for delayed bleeding. We keep those patients. Also in patients who have difficult closure, you know, the closure can be difficult at times where you have just a lot of submucosal fibrosis, the mucosa is edematous, the closure can be difficult. So if your closure is not complete with high confidence, so I say complete, incomplete, low confidence, high confidence. So if it is complete, high confidence, complete, then you're good to go. The chance these patients will have a leak is very, very, very, very low. So there is a judgment call there, but I mean, we've been doing this now for three years with great outcomes. And that goal of FLIP with the DI of 4.4, is that an absolute goal or is that based upon what the starting goal is? Yeah, so we looked at our own data. We published a large study on the best predictor for clinical success looking at endoFLIP data. It wasn't an absolute number, it was the delta. So we're used to, because you know, some patients start with a DI of 0.3, some patients start with a DI of 1.5. So what I like to see a delta increase of three. So this patient's DI before the procedure was 1.4, at increased to 4.7 after the procedure. So as long as it's more than three, I feel good about it. And this is paired our own data. Do you have a baseline FLIP going in that makes you abort the poem? And the baseline is, let's say it's 2.8 or something. Yeah. Do you stop at that point or once you're into it? Yeah, yeah. So that's a good question. If somebody is treatment naive and they have like a DI of three, I will say that's not a collision. So if somebody is treated before and they have symptoms, it can be partially treated, right? So incomplete response. So a DI of two or 2.5 is okay. And we will abort. If somebody has like this example that you mentioned, 2.8, I'm really not sure. I don't want to give them reflux. So I do pneumatic dilation in this gray zone patients. Not very common to get those patients, but of course, if you were on a busy ecological service, you're going to get to those. And I just do pneumatic dilation that can be very effective with minimal risk of reflux. I'll go with that route. Thank you, Venkat. Great demonstration and in a record time. So now we'll do some quick introductions. Thank you, Venkat. Thank you everyone. Okay.

POEM procedure

achalasia type 2

dysphagia

lower esophageal sphincter

myotomy

submucosal tunnel

distensibility measurement

endoflip