and we will be watching a paroral endoscopic rheotomy by Dr. Stavropoulos. Ashkwal, we can see your slides. Hello, everyone. Nice to join you. Nice to join you. My fellow Dr. Ayman Buchanan will present the case, and then I'll show you what we have endoscopically. All right, so the case presentation. Sixty-two-year-old male presented with dysphagia of two years. He has had regurgitation and coughing episodes with sputum that is tinged to the color of his previous meal. Occasional chest discomfort related to feeling full. There has been no weight loss. A CARD score of 6, dysphagia 2, regurgitation 3, chest pain 1, and weight loss 0. EGD in January of this year with findings consistent with akalasia with a tight G junction. Botox 100 units was injected. There was transient relief of only two weeks. Barium performed with finding of delayed passage of contrast into the stomach with narrowing at the G junction and mild esophageal distension, suspicious for akalasia. Manometry performed with IRP 26.6, all swallows aparistaltic, and 100% panesophageal pressurization consistent with type 2 akalasia. Diagnosis is type 2 akalasia with prior Botox injection. The plan is for an antireflux pulse. Okay, you can put it side to side. Yes. So anyway, that's the schematic of what we plan here. So the Z line is at approximately 42. In this patient, the high pressure zone and the Z line at the same spot. Usually, in most patients, the Z line is a centimeter below the high pressure zone. This guy also had Botox, so he may be a little looser than a virgin patient. There's a food impaction ulcer here, unfortunately, on the left. Then there's a diverticulum, an epiphrenic diverticulum on the right. So we're going to plot a course between the ulcer and the diverticulum at about six o'clock. Hopefully, we can demonstrate the penetrating vessels, which is the landmark for the oblique fibers. Normally, we go about four or five. Sometimes, we don't even avoid the vessels altogether. But here, as a demonstration, we would like to cut it close to the vessels. So we're going to go at six o'clock. In any case here, we couldn't go at four because of the diverticulum. Well, we could, but then it would involve a diverticulotomy as well. But I don't think this makes any difference in patient symptoms. So we're going to start approximately three centimeters above or two at 39. So entry of the tunnel at 39. As you see there, then myotomy at 40. Usually, if a high-pressure zone starts at 42, the myotomy ends at plus four or plus five, two to three centimeters for the sphincter and two centimeters in the cardiac. So we didn't go through to avoid tearing the mucosa, but it's very reliable. If the high-pressure zone starts at 42, you know your myotomy will end at 46 or 47, and so will the tunnel. So this is the plan. That's why I drew it there, 46 to 47. We have good metrics on the mouse because it's not a severely sigmoidosomal. Let's see if we can avoid the scarring from the food impaction ulcer there. Okay, so we'll start. You see some vessels. The mucosal vessel is a problem, as you saw with Chris's poem. When you enter, you may get bleeding at the entry. So you try to avoid those vessels that are barely visible and go in between them, but we may get some bleeding. Posteriorly, you got more openings. So I'm at 39. I'm going to inject between those two veins, and hopefully I don't hit the vessel on the first try. Okay, inject. It's important to avoid injecting the muscle because the Oregon group published accidentally entering the serosa or instead of the submucosa, and realizing that they did that after 50 centimeters of mediastinal tunneling. So very important to get a nice translucent blab, which confirms that you are in the submucosal space. And now I use the hybrid knife. I don't use the T-type because in certain areas where you need very precise dissection, and this guy had botox, there may be some fibrosis. I like to see exactly what I'm cutting and the disc on the T-type obscures. Can we see the full endoscopy view, please? The full endoscopy view. There you go. We got it. So now I'm going to use dry cut to enter, when I cut those veins visible there, I'm not going to get too much of a bleed. I also, for that, maybe not. I have spray though because of this reason on my blue pad though. And I always enter with a puncture because you see how easier it is to get that vessel if it has nowhere to go because you're on a round puncture, as opposed to if you had a slit. The whole slit will fill with blood and you'll be trying to figure where exactly is the bleeding. Now I'm going to move to the right very slowly. So that the dry cut has a chance to coagulate the next big vessel that you see there. That's how it does it. It's also good if the patient is not too hypertensive. That's a big vessel that I don't want to cut. Let's keep the full endoscopy view. Although we'd love to look at Stavros, but we want to see him in action. Okay, so now we have, so when you enter, it's important to enter near the muscle instead of near the mucosa. For example, when you start the ESD, you keep the dissection near the mucosa. Sorry about this. Here you want to keep it near the muscle because you need the mucosa to be nicely bolstered underneath with thick, high-strength submucosa. So the closure will take sutures as well, as you close with sutures or clips. And also, especially for anterior poem, if you denude the mucosa and it doesn't have enough submucosa, because of the angle the scope makes on an anterior poem, it could tear the opening of the poem to a much larger opening than you intended. So we want to keep a lot of submucosa under the mucosa bolstering. Now, don't make a big opening. That may be sufficient. We'll see. The technique to enter posteriorly is use a lot of irrigation as you squeeze in. If that doesn't work, especially for novices, you can actually turn the scope upside down because the olymposcopes have much higher up angulation than down angulation. And enter upside down and then turn again in the original, in the post-orientation. Here, probably a small arch. You don't have to use the quadrasper. You can use the ultra-low force. Can we do that? And slowly cook the vessel with a broad knife contact. Tavros, which settings are you using for coagulation? You said that it was dry cut for the incision, but what's this space? Here, for small arteries, I use the ultra-low force, which is on the VAIO 3, 0.6. On the old VAIO is what the Japanese call F-110, which is effect 110 watts. And you have to have the patience to slow cook it, because if you try to cut it prematurely, it's going to bleed. And what about the dissection? Which setting? For the dissection, I use the dry cut, but the precise dry cut. This is a nitric. It's that elastic wall. Okay, finally, we did it. We're losing you, not hearing you well. There's a problem with the audio. Yeah, it's coming in. Here, I'm dissecting again. It's a sort of trick where I put a... Can you focus here? Hello? Hello? Hello, Corey? Yeah, yeah, we can hear you. Focus on the... For long tunnels, I put a mark on the scope. I don't know if you can see it on the room camera. Yep, we see you. So I put a mark here with a sharpie. So basically, you keep the muscle at 6 o'clock and the mucosa at 12 o'clock. And then you put a mark here at 12 o'clock on the scope. And then after a few centimeters of tunnel, if you bring the orientation, my muscle at 6 and mucosa at 12, but your mark on the scope is, say, 30 degrees off, that means you veered off by this much in your tunnel by preferentially dissecting right or left. And then you can correct by dissecting more the other way. I've used, again, very low force there to do this triangulation. Which is very nice. Stavros, we're hearing you very well now. So can you tell us more, or again, about your settings right now for the tunneling? So the tunnel, the entry, the mucosa dry cut, to try and avoid those vessels in the entry. And then the dissection is precise sect. If there is relatively a vascular submucosa, that's an aberrant muscle fiber there that I'm going to cut. The precise sect for a vascular submucosa and maybe dry cut. Precise cut is the new Arabic current on the VIO3. And it's supposed to be a smart current. The Arabic can measure tissue impedance in the tissue 25 million times per second, and adjust the energy delivery. And in the precise sect, it actually adjusts the actual modulation of the current, turning it into a cutting current, if you have nice, pristine submucosa like here. And changing it to a coagulating current, once you encounter a vessel. We're talking about small vessels. For larger vessels. It is a sort of artificial intelligence for electrosurgery. I also like the precise sect for our module. But do you think it's a type of current that everybody can use from the beginning? I think it's a current that also beginners can be safe or not. Yes, as long as you don't think that it's going to protect you in a big vessel. It's not that smart. For example, this one. Yeah, give me the coagulator. This one was on the border of what would be doable with low force. And I tried, but it's so thick that the low force ended up injuring it before cooking it enough. So that's what happens. So generally, I mean, for beginners, close. For beginners, you should always use the coagrasper. Because judging which artery can go with force and which artery can go with coagrasper is a bit tricky. Open. That's a little on the side, but close. Close, all the way. So I'm catching a little bit of muscle, too, because that helps not leave a little penetrating stump that keeps bleeding. And again, patience. So I do a little bit by grasping it. Now, obviously, I use soft coagulation. And then when I see that, let me show you when there's still conductance in this desiccated tissue. When there's no... I let go. Open. Maybe stuck a little. Open. Close. And then I use the side, too, because it's still there, the vessel, unfortunately. So I use the side. Yeah, this is something great that you can do only with a monopolar coagulation forceps. Because if you were using a bipolar one, you can have this effect of burning around the closing device. Very nice. So now let's go back to the knife. And there's definitely more vessels, because you run into all these penetrating vessels. But there are the advantages. You can definitely do it on all the post-heller patients, which is one out of five of our patients. And you can do it when there's anterior problems. And it's faster. I think the dissection is faster, not having to do an anterior tunnel. Open. So Stavros, for the audience... Stavros, can you hear me? Yes. Okay, so for the audience, when you have a severe arterial bleed, and you have a gastroscope, and you put the coag grasper, and you can't suction anything, and you lose vision, how do you manage? It's not infrequent that you get significant bleeds during tone. Yes, and we may get to demonstrate it on this posterior poem. We're trying to avoid that. Don't make it for us, please. I see some big vessels there. We'll see. But yeah, what you do is, you know, obviously the key is tamponading with the tip of the cap, and then slowly torquing the scope so the cap stays in contact while it brings the seven o'clock channel to a point where your coag grasper can catch. And actually, for those sort of emergency situations, I tend to use the hot biopsy forceps instead of the coag grasper, because you need less precision and bigger grab. Because you don't know exactly where the bleed is, and the hot forceps just grabs everything, muscle, submucosa, and the whole bleeding area. And somewhere in there, you get the vessel. And it's not as fat as the coag grasper, so you can still suck a little bit around the hot forceps, which you can suck a lot less around the coag grasper. Yeah, Starbuzz says, Mike Vasey, well done. You know, one of the things you're highlighting is really slow methodical approach, right? So I think that's really important. Yeah, I mean, you see those big vessels. If you just march down without paying attention, also use a relatively less blue solution than others to be able to see the vessels, even through submucosa. So you can see here, these are the penetrating arteries. These are a landmark for the anti-reflux, the oblique fiber to the left of these vessels. Normally, I'm not that far over them. Unfortunately, now my tunnel is actually centered on them. That's because there was the diverticulum on the right, for one thing, and the ulcer on the left, but also because I wanted to demonstrate them. Normally, my tunnel is around here, so I may not even encounter them, or I may encounter them tangentially. Here, the way we are, we are right over them to the point where I really have to collide them to continue. If you want to show the oblique fibers, yeah. Tavros, so where do you find these? Exactly at the G-junction or one centimeter on the gastric side? Just on the gastric side of the Z-line. It's the first cluster, and then there's a cluster every centimeter or centimeter and a half. Tanaka described, initially, these vessels as a landmark of how do you know you did an adequate extension into the cardia. He said that when you see the second tuft, this is where you should stop on a posterior poem. So that was his initial publication, and then the whole thing that the landmark for the oblique fibers became much more exciting. Open, but there's every one to two. I have, on some points, I've exposed the fourth cluster. So you have one, two, three, and I have an image that I used on my anti-reflex poem. Next to where I have three clusters in a row, one centimeters apart. If you see this anatomic preparation of this, so I've used the perforations on the muscle every one to two centimeters for four, five, six clusters. Close. So I'm getting those two arteries together. Close really hard, really hard. Compress. Okay, now I'm going to stay near the muscle. Try to avoid any heat. Soft. Stavros, as you're working on this, we'll go back to Brigham, and we'll come to you in a few minutes. Stavros, don't move too fast. We're coming back. Okay. Okay. So yeah, so basically you see the oblique fibers to the left of the stanaca penetrating vessels. Like the start there, you see a cluster there. You can see them running obliquely right there. There's a second shaft there. The third, because you coagulated one. So you can see them running there. I don't know how. Let me expose them a little. You see them coursing down here? Yes. Going to the left of this penetrating vessel. I'm staying to the right. You see here, it's pure circular. I'm a little tight because, again, I started at six instead of four. So I'm crowded by those vessels to the right of them. But I'm sneaking around them, trying not to have to coagulate any more of them. Stavros, where are you right now anatomically? Well, I am at about 45-ish, 45 and a half. So by my measurements, I should need another centimeter to get to the cardia and do a two-centimeter myotomy. Now something is bleeding because it was scratched by the cap while I wasn't watching and dissecting something. I'm injecting to protect the mucosa. I'm going to try a little bit of vigorous. So I could try soft with the tip of the knife, trying to not do anything to the mucosa. Give me soft. I'm going to use the side of the knife that was soft. I don't know if it's going to work. Maybe. Yeah, I think it worked. Okay, so now here I'm staying to the right of those vessels and dissecting further. I'm at 44. I need to go to 46. And then I also will do the double-scope transillumination to first of all, assess that the orientation is correct. We should be about two, three o'clock or so. Stavros, are you keeping those vessels intact on purpose to stay to the right? Or you have a landmark and you're able to see it as circular before you shear? I mean, yeah, I know I could accidentally shear. That happens. I try to be very gentle. See, they are covered with some mucosa. I hope that doesn't affect me. There's no need to go and dissect unnecessarily. There's another cluster that's about to appear here. Right there, you see? Are you not afraid that if you leave them there, then just passing with the scope and the cap, you can stretch too much, make tension, and let them bleed? Yeah, but it's a catch-22. If I try to coagulate those, these are huge arteries. They are about two millimeters a piece, and each cluster has two of them. If I try to coagulate them, that has risks too. Not that I won't be able to do it, but it could get into a massive bleed and delay me 10 minutes and make it all very exciting. So I'm just sneaking around them for now. I mean, if I disrupt them, usually they don't start massively bleeding. They start oozing from the tear and I have time to coagulate them. So now I'm about 36 here. Again, I'm intentionally migrating to the right, trying to avoid those vessels. I'm at about 46, 47. So now let's do, we can do the second scope before the myotomy or after, because you can always extend the myotomy if you want to. So I'm just gonna start the myotomy, because having a myotomy makes it easier to, makes it easier to put the second scope to the EGJ. Do you always do this double scope method? Or just in some cases? The last three, four years, yes, because it gives me such accurate information about exactly what orientation the myotomy is in the cardiac and what the length of it is. And we use this to check various techniques and how they correlate with the reflux. Like, is it the length or is it the orientation? Things like that. So I want, like, I mean, how can you tell from inside that tunnel if you are really still at six o'clock? I mean, you'll see with a double scope. See, this is, this is, I'm below the sphincter. That's why the muscle is so thin. This is all, oh. What happened? What did I do? Did I disrupt the vessel? Ah, this doesn't look good so much. Somebody's bleeding. Interesting it's from the right side. So give me the, give me the hot forceps. Hot forceps for the thoracotomy. It's the same area that was bleeding before. There's some vessel there. So I'm just going to use the forceps. No, the forceps. Now I use the forceps because it has a broader surface. I'm not going to catch anything because it's right on the mucosa. I'm just going to close. I'm going to lie the side of the forceps there and whatever is losing. It's stopped now. No, right there. I'm on soft, right? This is a nice technique, Stavros, where you can use this or the coag grasper and just, just touch and gently coagulate instead of open grasp and coagulate. Okay, I think we're good now. So I'm going to start myotomy proximal to distal because this guy is not very tight. For super tight people, I cut from the cardiac back because if you go back in the esophagus, sometimes it's so difficult to reenter the cardiac because of how tight the aliasing. So you do a sort of pull myotomy going backwards. But here, this guy is not so tight. So I think I do the regular push myotomy starting proximally. Again, I said, based on the schematic, we are going to start around 40, which is right here, open. And then- Are you still on the precise cut? I leave it on dry. You can also use endo cut for this. Endo cut. Until I get to the longitudinal layer there, right? And then in the esophagus, I do circular only because there's no need, I think, to do full thickness. And when I get into, there's the longitudinal muscle. You can inject the hybrid to separate the two layers better. So I'm just doing circular in the esophagus. And then when we get to 42, where the high pressure zone starts, I do full thickness. So you're using dry cut now? Yeah, dry cut. I think it's nice. So I'm at 42 now. So now I'm going to go full thickness just to make sure we have a good myotomy. So I'm going to inject deep to the longitudinal to fatten up the adventitia so I don't puncture it. And then I'm going to try to hook all the layers of the muscle by going underneath like this and then do a little, switch me to spray. So the deep part of the myotomy, I do spray because there are some vessels hiding in there sometimes. So I do spray initially, and then I switch to a dry cut or endo cut for the last part of the myotomy. So now I'm full thickness here, right? You can see the fat there in the back. So again, I inject here and then it will be- So Stavros, this view here, we're sure you're at the LAS. You know, when you say double scope and stuff like that, I mean, during the myotomy, it's a very nice demonstration what you just did that you're going onto the stomach side. Right, no, it's, yeah, I know. I want to know the precise, is it one centimeter from the Z line that I did? Two, two and a half, three? I want to know for study purposes, I want to know exactly what the length of the gastric myotomy was. I think it's very important for reflex more than the esophageal length. So I just need precise numbers on that. So now I'm trying to avoid this huge vessel and I will cut this one, that will show you how we do emergent hemostasis. And that's why dry cut here is better than endocut. Endocut has the sudden pulses that even if they slightly touches the vessel, we could injure it. Dry cut doesn't go so explosively and stays where you put it. But posterior definitely has more vessels. There's no doubt about it. Okay, let's try not to avalanche this vessel. I will go into the cardiac. So this is the final part of the tunnel here, the final part of the myotomy, sorry. So in this patient, you've decided to do a full thickness only in the distal esophagus G junction area. Does that, your decision, does that depend on the type of achalasia? If you have a type three, do you tend to do full thickness or do a longer and deeper myotomy? No, for all of them, I tend to stick to partial myotomy. I used to do full thickness on the entire length. I don't think in the esophagus is necessary. And that's where all the risk is. If you do anterior nicking the pericardium, if you do posterior nicking, getting pneumothorax and things like that. So I generally do this on everybody. Tavros, can I ask you something about the crurotomy? Because I really enjoy your lecture and I have a lot of questions for you. So the first- So now, okay, one second. Let me see what the plan is here. So I have time to do the double scope, right? So as we do the double scope, yeah, I can answer the crurotomy question. Okay. So the first one is that the video you show us was very clear about anatomy, but sometimes, you know, in real life when we are not so expert about what is outside from the esophagus, can we make mistakes? So how can we really have some landmarks about which one is the crurotomy we have to cut? So maybe the contraction while cutting will help in understanding that that one is the diaphragm? Or what? These patients, and again, I've only done 19 in 12 years, so it doesn't come up frequently, have a super clearly identifiable cruise. Like literally, you're going down and boom, you fall on the cruise and you can see that. There's no way the food can go around that because it's such a prominent landmark. So if you're having trouble figuring if you're over the crura, that's probably not the patient where the crura is making a big difference in the outflow. Those people that need it, that cruise is just sticking right in front of you, blocking the scope from going down. And then once you do the posterior myotomy, you see it bulge. So it's really easy to identify. And we only cut, by my estimation, one third of it, maybe half. So there's no chance, for example, you'll run into the aorta or something, which is behind. So yeah, you just cut enough. On the video, see, I cut, I check the orifice, I cut, I check the orifice. And you can use endoscopy for that. No, you are tailoring the cutting. So you decide interpretively if you cut the crura or not. You are not going there intentionally or yes. I'm not understanding this point. Do you decide before that you would cut the crura? I decide, the final decision is during the poem. Okay, I got the point. And the distensibility is still not good. And the orifice is inadequate. And if cruce is really protruding in that way, then we undertake this. Okay. I have no air, I think. I ran out of CO2 or something, right? Hold here. What's going on? Okay, so this can be a little annoying, putting a pediatric scope around the other scope and not ending in the tunnel. There, we did it. So I'll retroflex here. Okay. Hold it there. So you can see, this is the, so this is exactly a lateral poem, really. It's at what we call three o'clock. If you run retroflex, this would be about three o'clock. Between, anterior is at the bottom, posterior is behind the scope. So this is at three o'clock or so, maybe four. You see, and it's exactly three scope widths. You can see where the Z line is and where the light is. It's about three pediatric scopes width, which is about six millimeters. So this is a 1.8 centimeter cardiomyotomy right there. And if you want to show the light better, I can change the dials on my dissecting scope there and I can see that it's right there. It's about 1.8, two centimeters in the cardia at about three o'clock position, with 12 being straight down, six being behind the scope and nine o'clock being where the pool of fluid is in the fundus. And these are numbers that refer to the numbers when you are looking unretroflexed, so we can correlate. So it's adequate myotomy. And now we're gonna do endoflip and suture. So now I'm gonna do endoflip. So the endoflip before, oh, I think I forgot to show the endoflip images before the- Yeah, we haven't seen it. I think, are they still on the picture in picture? Yeah, we saw- I'll show you, did you show them? No, if we can have the camera on you, I think we have the images. Yeah, you can show it. Can you show it there? I don't know why it's not on picture on picture. It was on picture on picture. Oh yes, here we are. So it was 1.7 and five millimeter diameter. So let's see what it is now. So on the antireflexed, on our conventional poems, we get distensibilities between six and eight. And on the antireflexed, we get distensibilities of around four or three to four. And we generally measure at 30 and 50. I know some people measure 30, 40 on the short catheter. I think that long catheter gives you a little higher distensibilities than the short catheter. That's my impression. I don't know, what do you think? Yeah, so John Pendolfino mentioned this morning that for the eight centimeter catheter, 40 cc's volume balloon is the most reliable, while on the 16 centimeter balloon, it is 50 cc's. So I use the short one and I use 40 cc's as the most reliable measurement. But what do you think about if you're using the same patient, the long and the short, I think you will get a higher distensibility on the long. Yeah, the long gives you a little bit different measurement. So I don't know if you can see it, we're inflating. We're gonna do 50 first and then 30 next. And we should have distensibilities in the four plus range. And what I have seen is, so in our publication, we discussed how if you do pH study at six months and then we had 21 patients, we did it at two or three years, one third of them normalized the pH. So it's because probably the LES remodels and tightens. And the end of flip mirrors that, because when we do the end of flip immediately after the poem, our mean for the entire 800 patients was eight because there were a lot of conventionals in there. And then at seven months on the repeat end of flip, when we do the Bravo study for pH measurements, it went down to five from eight. And the Northwestern people showed the same thing in 35 patients after poem or Heller, where the poem went to seven immediately and then five at a year, but the poem, the Heller showed no remodeling. It went from five to four and a half. So it was flat. So poem reflux may improve and the orifice may get tighter. The Heller stays kind of the same. At least that's my interpretation of things. So we are at 50 and the distensibility is at 3.1, which is acceptable. So 3.1, who's writing the numbers? So balloon pressure, 50.8, distensibility 3.1, compliance is at 76.7. The D min is 14.2, CSA is 158. Save image, postpone 50, okay. Now the 30 is gonna be the distensibility is usually higher, gonna be four to five because the 50 stretches a little. See, the thing is you also have to have a protocol about what order you do it. If you do 30 first and then 50, you're gonna get a lower distensibility at 30. If you do 50 first and then 30, you're gonna get a higher distensibility at 30 because of the stretch of the myotomy on the 50. So you got to have the same protocol, whatever it is for every patient. So now we're at 30, so let's see what the distensibility is here. So the distensibility is 4.8 at 30, compliance is 113, balloon pressure is 19.4, D min 10.8, CSA 92. Save image, postpone 30, okay, deflate. Now we'll suture foreclosure. We're gonna show how you can suture that defect pretty efficiently. On the point, any questions? So why not clip? Well, you know, in Hamburg, Thomas Ross does second look endoscopy like a day later too, and they said that in 10% of the patients that are missing clips, that's scary to me. And, you know, in Europe it makes sense because the overstitch is like $3,000 and the clips are, you know, they use the easy clips from Olympus, which are, you know, 70 bucks. But in the US, if you use resolution clip, which I see you did, I think one, that's like 200, the clip you use six, you have 1,200. The overstitch is 1,100 for the device and one suture. So the cost is similar. Once you do a lot, the time it takes me, the average time to suture now, as you see, is about four minutes. And it's a cure, it's not gonna come off. If the patient is non-compliant, goes home the next day and decides, despite what we told them to eat a hamburger, I don't have to worry as much as if they had some clips. You know, people do that. So let me suck a little the stomach, that disconnected me, okay, fine. All right, so we'll just suture, that should take average four minutes. Okay, you have six. Okay, ample time. Stavros, are you discharging your patients the same day? You know what, I'm a clingy kind of guy. I agree with, you know, what you have said, and Petros, and those people that have published on that, which is, if you have somebody without severe comorbidities, and some people think ASA-3 is okay, ASA-2 or lower, the poem went flawlessly, like similar to what we just did, and the patient is not out of state patient, then I agree that, you know, you can do it. Now, having said that, that happens to meet 10% of the time, not like 40. What percentage do you discharge same day? Probably 50%, 40%. No, no, 90%. We ask them to stay at a local hotel, you know, and the next day they can leave. How many leaks have you had in your entire career? Zero. See, that, okay, it just answered me. You know, it's an overkill to us. Zero leaks. Exactly. I had two leaks with the Zipo, when I had no leaks with the traditional Zekers techniques. I don't understand this, but I'm worried about the Zipo. But poem, we never had a leak, which begs the question about doing a barium the next day and all that. I still do it. So I will start suturing my entrance of poem from tomorrow, Stavros, I tell you, with these results. No, but in Italy, the overseas is probably 3,000, right? I know, that would be too expensive. I can't. Okay, so you're going to do one running suture and going right and left, and you get into the, yeah, and then left to right, and then you get into the defect. Right. So now I did distal left. I'm going to do proximal left. Like you said, I've made such a small hole that, you know, it's probably not too much of a deal. So that's too much tissue, let's say, like there. So that's proximal left. Now I'm going to go to the middle of the defect and do distal left first, and then proximal, like that. He's losing the air, which always happens with the overstitch. Can I have some really strong cricoid pressure here? Like really strong. Because you know that cable that runs next to the scope on the overstitch, it allows air to leak out. So I can't, you have to get cricoid pressure, squeeze as tight as you can to avoid the retching and the air escaping. We have a question. They ask, when suturing, do you just suture the mucosa or do you try to bite the muscle as well? Yeah, very important. Avoid the muscle because it doesn't have any good structural integrity anyway, compared to the submucosa, which is super tough. The muscle will split and it causes pain. So, you know, it gets ischemic and it gets pain and all that. So yeah, you try to avoid the muscle. So I'm doing the middle proximal portion, like right there. Right there. Not catching too much tissue. I mean, this is the smallest mucosal incision I've ever seen. I mean, this would have been two clips, $150 times two, $300 without changing scopes. Yeah, but what happens to the guy that you decide, the 90% you decide the same day and decides to eat a hamburger? Will it handle it? Ah, we hit a vessel. Oh, we're having... So, okay. Now the left side, then we're done. The left side, sometimes you can do both edges together. So you cheat a little there. There. So that's it. I'm gonna drop it. And when you cinch that, that vessel will get ligated. It's never a problem. Okay, here. See, Courtney has already the cinch, even as I was doing this. I forgot to mention- You guys are here to prove a point. Four minutes, right? Yeah. Very true. So Courtney and Ashley are my poem nurses. Say hello, there you go. We have to, we need to... And Dawn is our anesthetist, is also amazing, because never had any airway pressure problems or anything. I know. So anyway, so deploy. Okay, so this is it. See? So now you can go through, it doesn't matter. It's all nice and secure. And I'll just put, I'll put, I'll pull this off and suck the air out of the stomach. And then we're done. Congratulations, Stavros. An excellent job. Wonderful. Excellent job, Stavros. Thank you, thank you.

POEM procedure

dysphagia

regurgitation

Botox injections

myotomy

endoflip

distensibility

Dr. Stavropoulos