We will next go to a video case from the Archibald Castrology Group. So, this is a video on paroral endoscopic crurotomy by Dr. Stavros Stavropoulos. I would like to thank the ASG for giving us the opportunity to present our paroral endoscopic crurotomy technique at this ASG live event. Paroral endoscopic crurotomy, a useful poem enhancement for advanced echolasia. My disclosures, a bit of background first. The diaphragm contributes to the large of the atrial sphincter high pressure zone and functionally can be thought of as part of the sphincter. In our series of about 800 poems, we have had some patients, 2-3%, with a residual recurrent outflow obstruction, despite adequate disruption of the intrinsic atrial sphincter. This typically occurs in long-standing advanced echolasia, often after adequate prior myotomy. On barium, outflow obstruction appears to be caused by a sharp angulation of the esophagus at the EGJ, attributable to traction by the right crux. On endoscopy, the ileus orifice usually appears patchless from prior therapy, but there is a speed bump-like structure intending the left wall of the esophagus, with sharp angulation of the esophagus as it veers around this structure to join the stomach. This is a diagram of the relevant anatomy, demonstrating the right crux surrounding the esophagus and the left crux, and this is another schematic demonstrating the same anatomy. So what's the possible mechanism of obstruction here? The left arm of the right crux exerts traction on the esophagus towards the right, indebting it and creating a prominent self-angulation. This effect may be more pronounced and consequential to outflow in advanced stage patients with esophageal dilation, extending posteriorly to the left towards the left hemithorax. So our endoscopic curotomy technique proposes a partial myotomy of the left arm of the right crux as part of a posterior polon. What's the technique rationale? The diaphragmatic crura are dissected or excised by surgeons with impunity in cases, for example, of surgical resection of tumors, including the crura. In patients with outflow obstruction atributable to the right crux, the offending left arm of the right crux is routinely identifiable and easily accessible during a posterior polon. Extending the polon myotomy to the adjacent right crux would be expected to relieve outflow obstruction by creating a more obtuse angle at the AGJ. We first performed this polon technique modification in 2011, with this patient still doing well with an ECA score of zero at 10-year follow-up. We present a video of the technique and outcomes of the 19 patients that had this technique. 2.4% of 7,787 polons were performed in that period from 2009 to 2021. First, a case history before we present the video of the technique. 45-year-old man with chronic hepatitis B and long-standing akalasia for eight years. At prior treatment with Heller plus Doerr in 2012 with partial initial response, followed by gradual recurrence of dysphagia in the two years prior to presentation, 2018 to 2020. His ECA score at that time was eight when we saw him in 2020. Barium showed the esophageal dilation with a sharp angulation at AGJ and slow emptying. Endoscopy showed the patchless alias, but the sharp turn of the esophagus around the crux. Endorphin revealed a distensibility of 2.5, a bit on the low side after Heller, and a D-mean of 13.4 millimeters. We performed a salvage poem with Kru Rotome in June of 2020, and this is the edited video illustrating the technique. As we go down the esophagus, you see that the alias is relatively patchless, but there is this spit-bump-like indentation in the esophagus on the left from the left arm of the right crux. We proceed initially as a regular posterior poem by injecting 10 cc of saline, and then doing an initial mucosal entry with a hybrid knife, and then extending the tunnel towards the cardia per the usual poem fashion. And then we start the myotomy at the 7 to 8 o'clock position, where the alias overlies the crux. The initial portion is typical of a posterior poem. We dissect the lower esophageal sphincter all the way to the end of our tunnel, which is extended to 2 to 3 centimeters in the cardia. You can see this is the end of the myotomy, and this exposes the crux of the diaphragm, as you shall see here shortly. This is the crux here, covered by some fascia. After exposing the fascia, you see the typical diaphragmatic muscle that has this glistening appearance with salmon-color fibers. It's a skeletal muscle. It tends to contract when there's electrosurgical energy. Therefore, we generally use a coagulating current such as spray for the initial energy delivery, and then finish the cut with endocut, since there tend to be less contractions with coagulating currents. So we perform a partial myotomy as shown here, and intermittently we check the orifice to assess if it's adequate for improved esophageal outflow. This can be done also in a more quantitative fashion. You can see here it's more open, but not quite to our satisfaction. So we proceed with additional partial crurotomy. As I said, the orifice can be assessed with endoflip intermittently to get a more quantitative assessment about how open the orifice is. So after additional crurotomy, again it's just a partial crurotomy, we will reassess the orifice. Here it appears adequate to our eye, and obviously we'll confirm this with endoflip. So the endoflip shows a minimal diameter of 22mm now, up from 13mm, and a dissensibility of 8.9, up from 2.5. And you can see the before-after, a much easier outflow now. And we close the tunnel as our usual fashion with suturing. You can see some bleeding from the vessel, which will stop as soon as the vessel is ligated when we cinch the suture. So this is a sutured closure that completes the procedure. And you can see the barium before the procedure with a sharp angulation in the area of the diaphragm, and afterwards with very easy flow of barium and even some reflux from the stomach shown here. So procedural characteristics, 59 minutes procedure time, endoflip as I showed you dimming from 13mm to 22mm, very impressive, and dissensibility from 2.5 to 8.9. So excellent results. Long-term outcomes, as you saw in the barium rapid emptying, latest follow-up was at 2.2 years in September of 22, by phone, since the patient lives in Texas, with a NICARD score of still 0 compared to the pre-procedure score of 8. These are our data on our 19 patients that had crurotomy. This line here for patient 672 is the patient whose video I just showed. Now, looking at the summary data, very long disease duration, much longer than our usual POAM patients, 102 months, also a lot of prior treatments, 68%, particularly previous myotomy. Teller or POAM, 53%, and a lot of advanced disease, 53% end-stage or advanced, 57% sigma, and that's about double or triple of our series in general. Median NICARD score decreased from 7 to 0, with 100% clinical success, about 50% objective reflux by pH and endoscopy, a little longer length of stay by a day or two compared to our usual series. No severe adverse events, with only 3 out of 19 patients having transient mild chest pain or shortness of breath, which is similar to actually our regular POAM patients. In conclusion, parole crurotomy have a role in patients with long-standing disease, with despite adequate sphincter disruption, have residual outflow obstruction attributable to angulation caused by the crush. Our preliminary results on 19 patients demonstrate excellent feasibility and remarkable efficacy and safety. And I'll leave you with a picture of the island that my family is from, Nisyros in the Dodecanese, beautiful island. It's a volcanic island with a natural volcano that you can walk down into the crater of. Thank you.

paroral endoscopic crurotomy

outflow obstruction

achalasia

posterior POEM procedure

modified POEM technique