We will next go to Brigham and Women's Hospital for another poem demonstration by Dr. Chris Thompson. Thank you. Today, we're going to be operating on a 34-year-old with a past medical history of spondyloarthritis who developed dysphagia in 2021. He had an esophageal CRE dilation and did not respond. He was diagnosed with type 2A kalasia, his IRP was 35 mm, and he had 50% failed swallows, 40% panesophageal pressurizations, and 10% spastic swallows. His accurate score is currently 10 with weight loss, daily dysphagia, regurgitation, and chest pain. Dr. Thompson, we can see you. Hi there. Welcome to the Brigham. I have with me my team. This is Sherry. She's been with us forever. She's our therapeutic gnostic nurse, and Chelsea, who is our anesthesia support here for these cases. You already met Rob. He'll be coming in. Thanks for having us. This is our last broadcast from our old unit. It's over 30 years old, and in 1991, we did our first live broadcast. I was an undergraduate or something, but David Carlock did that, and it was a fellows-to-fellows broadcast where they had fellows broadcasting, other fellows watching. It's kind of exciting. Next week, we go on our new unit, so this will be the last one. We were hoping to show you the new unit, but in any case, welcome, Joe and Rob. Come on around. We're going to be using some new technology today, which is kind of fun. We have the model. We're going to be using something called the SpeedBoat, and we might be able to zoom in on our hands here. The SpeedBoat is basically a device that's bipolar, so instead of our normal monopolar devices, you don't run current through the body to a grounding pad, and it's for cutting, which is a little different, and that's really right at this kind of edge here where you see the gold and the white meeting. That's where our cutting surface is, very thin cutting surface, and then the white is microwave for hemostasis, so we'll talk about it as we do it. It does have some potential advantages, and this is kind of an early-stage device, so the newer devices are going to be a good bit better, but it's fun to use it anyway, and we'll talk about what the newer devices are going to look like and why this might be a good idea. We're also probably going to use some other new technologies as well as we go along, but we'll first start by showing an endoflip here for the patient, and what you see here is the DI for this particular patient was 1.22. The diameter is 9.8 millimeters, and the pressure is 61.9, so we can go off on that, and what we do, because this is bipolar, we're not running current through the body, we can actually advance that catheter down once it's empty, which we just did here, and we put our endoscope in. We're just going to leave the endoflip in place so we don't have to take it out and put it back down, and that has an advantage because you don't have the risk of catching your tunnel or knocking clips off if you've already closed it, so it's nice just to leave it in place, and I think that's one potential advantage there, so we're on endoscopy now, I think. Hopefully, you can see that. Perfect. Perfect, and so you've already heard an excellent demonstration so far, and Moen's demonstration as well, so we're going to, you know, there's a study that came out not too long ago, I think it was last year, that showed shorter tunnels are as good as longer ones for type 2, and this is a type 2 acrolasia patient, as you heard, so we'll do an 8 centimeter tunnel. Our LES is at about 40, so if we go 2 centimeters beyond that, you know, we'll start up here at 35, and that'll give us a long enough tunnel. And with this device, there is a needle for injection, but they're getting rid of that in the smaller device, so one issue with this device in its current form is it's quite large, so you need to use a therapeutic scope, so that does make the procedure a little more complicated because you need to, you know, count on the scope being bigger, and then your channel's a good bit bigger, and the devices tend to hover pretty low in the channel, so that's a bit of an issue, but with newer devices that are going to go down a regular diagnostic scope, we're going to solve that problem. So, yep, so we're starting with a CARLAC needle to inject. I guess I could come down here one more time and show you the LES. You see, it's nice and snug, and there's no mucosal breaks and no fungal infections or anything like that. Cool, perfect. We'll inject here. So we're using head of starch and we're able to inject head of starch through the device, which is nice. It's a foot pedal. And we use a little methylene blue, of course, norepinephrine. We don't want to devascularize the flap. Now one thing with this device is that it is not blending current, right? You don't have an element of coagulation and an element of cut. It's pure cut when you're cutting and it's pure coagulation when you're coagulating with that microwave. So you get a little more bleeding with it. They're working on that because they do have impedance technology already baked in and they're changing the algorithm. So newer devices, if you said it's not cut muscle, it won't cut muscle. So there are some advantages here, but that's not built into it quite yet. So you could see some more bleeding than you normally would. Yeah, we're almost, almost down. All right. So here it is. That's what the device looks like. So the hole over here is fully insulated and that's where the needle comes out. So you can see what that looks like. Sherry's going to advance the needle out. Not that we're going to do that right now. You can pull it back. So that's fully insulated back there. Microwave is the white, cutting surface is the junction between the white and the gold. And so we're going to do, we're going to do things different here today, just to give you other views. So we'll do, instead of a longitudinal incision, we'll do a horizontal incision. No, I mean, as far as an advantage to that goes, you know, theoretically, when you close, you don't narrow the esophagus, right? But I mean, it's harder to close with clips. So we'll see that. usually gets some bleeding with this, as I mentioned. So that is the RF. And then I'm going to use the microwave here to, and you can see what that looks like. It doesn't really char, which is nice, but it does take a little bit longer because microwave is not, it's all lower voltage. So, you know, it's lower voltage technologies. They take a little longer because they're vibrating the cells. And that's how they heat them, to desiccate, you know, to do coagulation. So it's a little bit, it's a little bit different. Let's put the needle out. We're going to inject a little bit more under in there. Okay. Now we're injecting, here we go. Needle back. So it just takes a little more time to stop bleeding with the device as well. That's not going to be as much an issue with the newer platforms. Additionally, you can't use it in a wet environment. So that's another thing to keep in mind. Microwave doesn't work in a wet environment too well. Once you're done with the mucosal incision, generally there's less bleeding. It's just really this early mucosal incision where you kind of have some bleeding, which we anticipated, so. Try to get in there. You got it right up in there, right under. I'm going to have to do more cutting first. We'll see. So we're just going to stand on it until it times out. I'm not getting the bubbles I like to see. Chris, I tried this a couple of times. It was like 20, 25 seconds of bleeding. I tried this a couple of times. It was like 20, 25 seconds of continuous coagulation to try to get an effect. I know, right? Yeah, and that's what we're getting right now. And if you try to get in, you probably will be able to tampon at it. Yeah. We can always switch to a coag grasp, but I want to try to do it with this. We might just kind of persist. I'm going to make that access point a little bit bigger because again, I'm using a therapeutic scope, right? Yeah. So we're going to have to do that and we'll continue on here. Yeah, that's good. And we'll deal with the bleeding, but it's not horrific. So we'll continue working and then we'll get after it when we have a little more opened up and we'll see. And you know, with your bigger scopes, it can be a challenge to get in, but there we go. But it works. We do it. You just got to keep going. Okay, put the needle out a little bit here. We're going to put more fluid in. The trimming is a little tricky with a bigger scope too. This is coming out at the bottom. And keep in mind, we're using cut to do trimming. We're not using the microwave. So we're actually using a cutting RF wave form. So a needle back, but that, you know, eventually we do get in here. We're going to have to stop the bleeding eventually. And we might go to a coag grasper. So I'm going to try to get after it one more time. You can see it here. We might cut a little bit more, but this is just kind of what you get with it right now. Again, the newer ones are going to take care of this. Additionally, at the end of our procedures, we're going to use Puristat. Just because you get intraprocedural bleeding more so with this. And as you mentioned earlier, with intraprocedural bleeding, you're more likely to get a bleed afterwards. Now we've never had a bleed afterwards with this device, but, you know, we're going to, we've been doing that whenever we get a bleed intraprocedurally. So we'll see. Yeah. Hello. This is Roberta Mazzelli from Italy. Sorry to be late. I was in the Congress, but I like what you are trying to do. You are trying to componate with your vessel attachment to clearly see which vessel is bleeding and then try to treat exactly the vessel. Yeah. And it's a little tricky because again, it doesn't work in a wet environment too well, but I think we have a couple here. Yeah. It's not only one. Yeah. It's not just one. It's coming from right there. That's the middle one here that's coming. You can see it right above that little branch. So normally you'd be able to, so I have to dry it before I hit the blue pedal here. And with a posterior approach, everything is spooling down on you. And I'll take this chance to welcome Roberta Mazzelli from Humanitas in Milan. Thank you for joining us. I know you were probably in Dublin. Yeah. Yeah. There's the European Congress. So I'm happy of this. You know, the European Congress all together. So I have some question about the use of this device, but I don't want to distribute right now because- Oh, you can ask. The point is to try to fix this. You can ask. It's okay. I'm comfortable dealing with bleeding with this thing, so I'm just going to get it here. Yeah. It's a little unusual, but sometimes you have everything like this one. I don't know. I'll get it. And the other, oh, yeah, maybe we're there. The other very good point to highlight is that you were using a sort of underwater to check the bleeding point because with the water, with the pressure of the water, you will be able to clearly see the point of bleeding and then to, yeah, to manage it properly as you are doing great. Okay. So we're going to resume cutting here. And normally what I'll do is I'll flip the hole over upside down once we get in the tunnel, but, you know, we have to get in there first. I'm just going to kind of do some more cutting and then we'll get in. We tried to make it big enough where I don't have to tear vessels. Sometimes you want to trim enough so you're not tearing vessels when you get in. And now we're using a therapeutic scope. So it's a little challenging to do the trimming, but we'll see. So, Lads, I'm going to back up one more time, put a little more fluid in, and then we should be able to get in there. And then it generally moves quicker once you get in. I don't know how many of you have used this device very much. When you said you tried a case, how many times have you used this and what's your experience? I have no experience for POEM. I use it only once for Zynka and sometimes for Rectal ESD, but no experience with POEM, honestly. And the fact is that till now, you're forced to work with a therapeutic gastroscope can make the difference if you usually and routinely tends to work with a standard gastroscope because it's changing the settings you are used to. Yeah. So, Chris, I tried it on a POEM once and the comments I made to the company were exactly what you're dealing with. I didn't think it was, with the current design, good for treating bleeding. That was a major issue. And you know, we can get some major bleeds. So, if we're trying to cut it down to one device, this can be an issue. And the second thing is the device is just too bulky, but I know the newer iteration will be compatible with a diagnostic gastroscope. I think we have to mute everybody, guys. We're seeing, we're hearing some noise from the background. If you can mute everybody, please, including Arbol. Arbol, please mute your mics. Muente, I thought you'd go on the main screen. That's why we're here. No, just mute yourself right now and we'll be with you shortly. Yes. Chris, this is Mike Bezzi. Can you hear me? Yeah, how you doing? Hey, do you, so you're how many centimeters above the GE junction right now? You said- So we started, yeah, so we started about 35. We're going to go two below. So, and then we know it's a one centimeter high pressure zone based on the flip. Yeah. So that gives us enough. That gives us enough. Obviously with a type three, we'd be making a very long tunnel. So- Yeah, what is, what do you like to do with the type three? How high up do you like to start with them? So I find endo flip incredibly useful in type threes, a little more injection, because sometimes you get, you know, the high pressure zone can be very extensive. We've actually seen some where it doesn't seem to avow the LES. It's above the LES, even without prior treatment. Well, at least without, you know, prior home or Heller, right, which is kind of surprising. So we let the, the flip guide us in those situations. He kneels back. And so we'll just, we'll make the tunnel as long as we need based on the high pressure. And then we will, we'll give us a couple centimeters for closure. Dr. Thompson- Yeah, I really like the targeted, I really like the targeted approach rather than just doing standard for everybody. And again, that gets to, you know, if you have a high pressure zone, you address it if you don't. So it's really nice to be able to target what you need, the length you need. So I agree. We're going to flip it over upside down now. So the hole protects the mucosa. Dr. Thompson, as you're working on this, we will show a brief video and we'll come back to you in a few minutes. Sounds good. Hey guys. So we made our tunnel two centimeters behind the LES there. And we are now starting our myotomy. The tunnel, the rest of the tunnel went well. Usually it does without substantial bleeding. Nice. And you're joining us for another spot where we might get some. So let's keep it like this, please. We like to keep it, yeah, we like to keep the hole up for the myotomy. It gives us a nice broad myotomy. We have a vessel to our right here we're trying to avoid. Dr. Thompson, can you comment on the anterior versus posterior myotomy? Is there a preference in terms of the myotomy location when using this device? Yeah, I did posterior because Maureen did anterior. I'm trying to just give a different viewpoint on everything. Anterior is nice because the fluid wouldn't be pooling with this device. And you know, it's kind of good if you're more underwater and the fluid isn't as bothersome usually. But you know, there was some suggestion as well that if you use an anterior approach and a meta-analysis, you might get less GERD. But we really don't have a lot of GERD because we tend to tailor it to the endoflip. You know, we don't go crazy with length. And we haven't had anyone that needed a TIF yet or a, you know, fundoplication. So I think that, you know, we've had a lot of people on PPIs, obviously, that can't get off, but they just haven't wanted a procedure yet. But it's no more than you'd expect, you know, from the published literature. So I think it's fine. You just don't want to hit the cruise, you know. And I think that, you know, that that is, that's something that we do. And we are quick to just remeasure. And we're going to do that right now. We leave the flip down. We're going to pull it back and we're going to get another measurement and see what it looks like. And then we're going to, you know, we're going to close. We don't go full thickness either. We try not to, unless we have to. If that flip keeps giving us a tight DI, a lower number, we'll, you know, we'll go full thickness if we have to. We tend not to. We're kind of just teasing it out at the very bottom here. We've already done really what we need to probably. And you mentioned that you made a horizontal incision to create the tunnel versus longitudinal. Is there a benefit one way or the other, or is it just kind of... So yeah, theoretically, you don't get stenosis of the esophagus at all near your closure site doing that technique. That's theoretical, I should say, because it's hard to, you usually don't get stenosis, but that's kind of, you know, from bowel surgery, that's kind of a thing that they would do, right? If you learned that in med school and whatnot. So that's probably, I'm going to be one more little cut here. That's pretty much it. It's harder to close with clips though. So you're going to see, we have to start a little before it. And that's also a fun exercise. And we do have new clips here today that are removable. So we can use these big 16s and not really worry about it because you can take them off if you need to. So what we're going to do now is just pull that balloon back. So you see our flip's already down. We're going to pull it back and get a measurement and see if we're off that 1.22 number. So I'm going to do that under visualization. Okay. And then let's go up on it. Can we, we're going to have to go to, let me, you're going to, we're just going to stay live on this monitor. I'm going to see if I can switch. Was that the roll stand? Yes. Yeah. Good. So we're just, we're just putting it up now. We'll see what we get. And what's the end point that you're hoping for in terms of flip distensibility or diameter? So it was, you know, it was 1.2. We want to get it in my mind, I like it up a couple of points, a little above three be great. I don't want a real high one because I'm just going to look endoscopically through that. That's quite high. Maybe we overshot it. Just want to make sure that's where it's supposed to be. I'm going to push it down. It's not, it's just, it came back. So we had to push it down a little bit more. There you go. That should be good now. Yeah. It looks like you've done what you need to do here. That looks pretty good. Yeah. I think we did a suction and come back a little bit. Yeah. That's wow. That's pretty centered there. Do you want to go, do you go to 30 or 40? Go to 40. Yeah. 40 is probably the most reliable. Yeah. You like 40 afterwards. You can pull back just a little to center it too, before it gets fully. There we go. Okay. Stop right there. No, not, not, not measurement wise, just I'm stopping pulling. So we can't see it. Well, well, is it saying 2.5? It's 2.5 right now, which is 2.56. 2.57 is climbing. Yeah. So we have a question from the chat. Go ahead Roberta. Yeah. We have a question from the chat that has, do you care about the diameter or do you just tailor to the distanciability index post poem? Yeah, that's a good question. I mean, the diameter has improved too. We're at 11.9, 12. I mean, we're going, we're going up here. So, I mean, the diameter is the diameter is improved. I do look at that. We, we generally rely on the 40 measurement and then you know, up around three is good. If we go higher, we tend to, again, we get reflux. So I try to tailor it to that, but we're hovering at 2.7, right? 2.8. What is that? 2.8. Yeah. 2.8 ish. I think we're probably good. I don't think I'm going to do any more right now. I'm happy with that. Yes. I would say that's slow Chris. We don't really have a lot of repeat poems with this though. And then 2.9, you know, it's, it's just about three. We could cut a little bit more. Maybe we will. 2.9, 2.92. So, I mean, it's hovering right just below it. We're going to do a little more touch up here, just a little, and then we should be okay. But 1.2 to 2.95 is not bad. And the diameter went up to 14 from 9.8. So you could stop at that. I don't want, obviously. So we'll go there. So the beauty of this is I'm just going to push it down again because it's safe to do this with bipolar. I wouldn't leave this in for monopolar so much. I could have some heat transfer along the calf, right? So that's one advantage you get to using bipolar. So we go back to endoscopy here. Okay. And you can push that in. I mean, theoretically, you could even, you could even leave that thing up while you're cutting here, but we're going to do more of it here. It's just, it's just a little bit more. Maureen, what do you go for? I mean, you, you like, you have, you have more patients that need TIF and whatnot than we do. We probably have a five to 8% redo rate, but we don't have many people that need anti-reflux procedures. Okay. I can't hear anything. Is anyone on? Hey, Chris. So what we will do, we will let you complete your myotomy and we're going to come back to see the end result. And we want to see the clip closure. You bet. Yeah. Hey guys. So we extended the myotomy just a little bit. And I think you're seeing the endo flip, right? The DI is 3.5 and the diameter is 15.40. So we were happy with that. We don't need to push that anymore. We're comfortable with it. And let's go endo. So we just left that frozen and pulled that out. And now what we're going to do is you can use some purostat in the tunnel because it was a relatively bloody procedure, right? So I don't know how many people are familiar with this, but Sherry can show you. Comes in a little 3cc syringe and it's basically a little peptide chain. It's consisting of 16 amino acids. I think if you look up on PubMed, it's like R-A-D-A 16, alanine and et cetera. And we're going to inject it through the catheter. So it's a hydrogel. So it's different than the other powders, right? You can kind of see through it. Go ahead. Yep. And it covers a six by six area from that 3cc syringe. You can see it kind of coming out and you would get it on vessels that are actively bleeding, but it also is a good preventative. And if you've had someone that's on anticoagulation, in my experience, it's good to do this. You have less likelihood of it be bleeding. You can also use it if it's been a particularly bloody procedure like this one was. And it does stop active bleeding, but this also has wound healing properties, which is unique as well. And they were able to put that in their claims. And I just fill it in here. Then when I suction down, it'll get all over the place. So that's kind of good. But we do like using this in select circumstances. I don't know how many people also use this for their ESD beds. So Chris, I use it for resections and other stuff. So here, my, again, theoretical concerns, and let me know your opinion, is that this is a gel that can trap bacteria, right? You're in the GI tract and then you only have the adventitial layer there, and then you're closing. So is that a worry? I don't think so. It's 97% water, purified water, and the peptides are also synthesized. So it's made sterile. And it does dissolve as it's mostly water, right? So it's, I think it's different than maybe spraying a powder in there or something else, where you might have more of a concern. And it does have wound healing properties. So it's similar to other things they use in laparoscopic surgery where they leave it behind, right? So I think that, I think it shouldn't be a problem, but theoretically, yeah, I mean, we'll see. It is approved for use. So now we're using also something unique. If you've seen this before, this is a Creo removable clip. So this is a 16 millimeter clip. I do like these. You can see a groove in the back of the clip right there. Rotate it a little bit. You see this groove counterclockwise. You see that groove right there? That thing allows you to remove the clip. So you just put a snare on it and you can roll it back and just rotate. It rotates just like a standard clip would rotate open. So it is removable. So if you're using a bigger clip and you're worried, say into Junum or something, or you're doing a EBT exchanges or something like that, you don't have to worry about being able to close a little and we'll see what it feels like. You don't have to worry about it staying on because sometimes they do, as you know. And again, this is kind of a different closure. Go ahead and close that fire. Because we did a longitudinal incision, or we did a horizontal incision instead of a longitudinal one. So it's a little wider here. Hence I wanted bigger clips. That's why we're using the 16. Hey Chris, it's Mike Vasey. How often do you get foreign body sensation to a point where you have to go in and do something? So when I used to put clips behind zenkers, when I finished at zenkers, I get it more commonly. With poem, I very rarely get it. I mean, if it's a long type three, normally it has to do with how proximal you have to place your clips. I'll see it sometimes. It's pretty rare though. But it's nice to have this option regardless. And every once in a while, you come back and see these clips that are not supposed to be there and they stay in place a long time. So open. So just trying to show kind of new technologies and kind of the opposite approaches of what we might normally do, such as anterior versus posterior. Go ahead and close. Uh, horizontal versus longitudinal, et cetera. Go ahead and release. So, I mean, there might be certain circumstances where you want to do this, right? But another thing that's nice is like how short those tails are. Yeah, this is really nice. Yep. Yeah. So cool. That's it guys. So we'll just continue doing this. Okay. Uh, thank you, Chris. Uh, Frankie, do we want to move back to Stavros? Yeah, it looks like Stavros is ready. So yeah, we can go back to our spot. Thank you. You bet. Thanks.

peroral endoscopic myotomy

spondyloarthritis

dysphagia

achalasia

SpeedBoat device

esophageal tissue cutting

microwave hemostasis