All right. Hello, dear colleagues. Welcome again to the esophageal AHGE course. This is the TIF station. TIF is transoral incisionless fund duplication. I have Dr. Omar with me and Dr. Brewer. Welcome, both of you, to the station. And we're going to demonstrate the Esophix XZ device. And this is basically a device used to create a gastroesophageal plication and a fund duplication for the management of the GERD. This is truly the first endoscopic device that we have that is capable of retracting the esophageal wall to elongate it into an intra-abdominal position to increase the length of the lip valve, which we're going to demonstrate in the model. Then it allows us to create a rotational plication and a fund duplication like a wrap in a 270 manners between the esophagus and the stomach. Before we do this, let's demonstrate the component of the device and how we are able to anchor this fund duplication. Basically, this device fires in the sequence about 20 of these T fasteners. Obviously, the T fasteners are not as large. The T fasteners are hosed into this cartridge right here. And there's 20 of them. Each firing fires two of them. So you have 10 firing in the sequence for firing 20 fasteners to create the fund duplication. Now, one end of the cirrhosis fuse, this is called the cirrhosis fuse. It's made of one O-proline. One end is going to be in the esophagus. The other end is going to be in the stomach. And now it will be approximating two surfaces. One is the cirrhosis of the stomach and the other is the adventitia of the esophagus. And these cirrhosis surfaces are going to fuse. That's why these are called cirrhofuse system. And once the healing happens, it will create a durable cardio esophageal wrap, as we will demonstrate. Now, we introduce the fasteners. The fasteners come in a cartridge that's right here. And the first step is to load the cartridge into the esophagus X system, which this apparatus is referred to as the esophagus X. It's Z because it now allows us to accept a standard upper gastroscope in order to provide the visualization. And the scope port is at the posterior of the device right here. So in order to load the cartridge that will deliver these fasteners, you handle the needles by using this blue function right here. You pinch it with your index and thumb. And after you pinch it, you're pulling. And again, there's a style of how you pull this because you don't want to get tangled and you want to make your life easy. So the style is you use your index finger to anchor both ends, both of these needles and your thumb. And you're not drawing like this in one continuous motion. You're drawing in five centimeter increments. So thumb and index pinch both ends of the needles and you pull them together in five centimeter increments in order to keep them parallel for loading and unloading. And that is going to make your life much easier rather than if you start pulling like this, you could see that one will go in this panel, one is going to the other panel, and you're going to start bending the system and creating friction that you do not need to worry about during the procedure. So now once we pulled these needles, we're going to take that cartridge that hosts the serosephuse fasteners and we're going to load it with a notch up toward this notch here and we're going to click it in place. Okay. Now you're going to load each side, each needle will take one of these serosephuse fasteners. So each firing will have two of them firing at the same time. So we're going to load them by clicking one end and then clicking the other end. Now you want to hear a click. I did not hear a very clear click with that one. So if you're not hearing a click, you want to visualize that these fasteners coming through the channel and we're going to visualize them here. And Shiva will tell me, Shiva, do you see blue here? Yes, I do. And on both sides, that means if you feel the click, you're comfortable that they're loaded. If you don't feel the click, the second safety spot is to look in the clear channel. Once you hit the two mark on the needle and that will correlate and will show you if the fasteners have loaded. Now again, the motion is index, thumb, and you're pushing in five centimeter increments. And now with no friction, everything nice and straight, you click it in place. So now the second part of this esophage is this tissue mold and the tissue mold is doing a lot of the action. And the tissue mold here is activated by this knob and it's nice and controlled motion in that it's clicking motion, not continuous motion. So each click, if Shiva you could hold this upward, each click transfers to the motion as shown here. So this is tissue mold open and tissue mold close. So there after the tissue mold, which is controlled by this knob, you have this helical retractor and the helical retractor is activated by unlocking it from this blue locking system. And the helical retractor job is to come out, as you see at the tip of the tissue mold, if we could mag it up, engage the GE junction by rotating on the helix and then getting it out of its sheath in order to free it. So now it's acquiring the esophagus and the stomach into that tissue mold and pulling, locking it in place and pulling the GE junction down into the tissue mold. So the principle of anti-reflex surgery is elongation of the intra-abdominal esophagus. So you want to create length on the esophagus. That's why we're pulling the GE junction into the tissue mold. Then we want to create a high pressure system by creating the front duplication and the rotation that we will show here. But the first step is to pull the tissue into the tissue mold. Let's say that this is the tissue here. This is both ends. Shiva is going to hold it into that area. And now once we acquire that tissue, we do our rotation. We're going to lock the device in place and do our firing. So pretend this is esophagus and stomach. The firing is going to happen starting from the needles are going to carry these T fasteners from the esophagus and then deliver them into the stomach. So one end of the T fasteners are going to be sitting in the esophagus and the other end is going to be sitting in the stomach, creating the cardio esophageal plication. Now you have acquired your tissue. You did your rotation. You locked that device. The third portion, actually before you start the firing is you want to apply the invaginator. Invaginator is a suction like device, which is not going to be active here because it will not create vacuum because we're outside the patient. But you open it and these holes or perforation create a vacuum and that vacuum locks the entire configuration in place to allow you to safely fire. And also it allows you to advance the device slightly before the firing to get it off the crest of the diaphragm. So you're not getting the crest of the diaphragm into that plication. But let's say we activated the invaginator. We locked the device. Now the device is in a locked position and we're ready to fire. And what we're going to do is to fire that sequence is there is a valve or the safety valve that's preventing premature firing. So if I'm not depressing that valve, I cannot push on this. It will not allow me to activate. But once I'm ready to fire, I'm going to push on this valve and slowly but firmly apply the firing mechanism. And now this has delivered the two T fasteners from the esophagus to the stomach. And we will demonstrate that here. So now if we're going to open that tissue mold, you're going to see there is two T fasteners, one on the esophageal end and one on the gastric end. And that's what holds things together. Any questions, Shiva or Ola? So now we're going to go and try to demonstrate this with Dr. Brewer in a model of a fundoplication. And it's nice to see that model because hopefully we'll demonstrate how these cardioplications come together internally and externally as well because of that model here. So Dr. Brewer is now assisting with the scope and I'm handling that device. And you could see we're already in a coupled position. That means we're going to start the rotation by doing a posterior rotation. So we start on the posterior wall of the G-junction and or it was the posterior wall of the stomach. We do a posterior rotation, fire three sequences there, six fasteners. Then we go on the anterior end and do anterior rotation and fire three times, another six fasteners. Then do two central firing with elongations but not rotation. One is at the four o'clock position and the other one is at the seven o'clock position. Now this might be confusing you because you need to be orientated to that anatomy but let me demonstrate on the monitor right here maybe. I'm not sure if we could show that here or not what we're talking about the face of the clock. So where the device is coming in corresponds to the lesser curvature of the stomach. So that's the lesser curvature of the stomach right here. If you follow my finger and draw a line that becomes six o'clock. So that's the central portion of the flap valve that we're trying to elongate. So at this location we're just elongating. While we're rotating is we're trying to rotate at 11 o'clock which is up here. That's the posterior rotation and we're trying to rotate at the one o'clock which is right here and that's anterior rotation. Again I don't want to confuse you with this too much but just for orientation what we're going to demonstrate is we're going to demonstrate the engagement of the posterior wall of the GE junction and this posterior rotation in the sequence sorry in the sequence that we will just fire. So the first step is we want to load the T fasteners. Again you depress both ends of the blue plunger right here and we're going to pull in five centimeters increments. Again we don't need to be super aggressive. We need to keep things nice and parallel. Then I'm going to use my thumb to load one side. Click. I heard it. Then the same thumb goes to the other side and load it from the other side. Click and I heard it. I do not need to see anymore. I felt and I heard the click so I'm okay now just loading this together. I'm going to load again thumb to index five centimeter increment and lock it in place. Now we're locked and ready to load. Now we're going to get we're going to get the sequence here so Dr. Brewer we're going to follow me posteriorly and the first is to engage the lip of the GE junction. So I close the device. I'm going to get the helix out. Right there. I'm going to open the device slightly. I'm going to provide traction and I'm going to engage that lip of the GE junction as shown right here. Now once I'm engaged in that lip I want to free the helix out of its channel in order to allow me to be free to do the rotation. So now the device the helix is engaged at the GE junction and it's free out of its channel so now we could retract and do the rotation and fire. Okay so now I'm going to gently open the mold here make sure I have enough grab of that tissue with at that point we desupply the stomach slightly we lock the helix so it's when you lock you it allow you just to come without pulling and come it comes gently comes gently comes gently comes gently now I have maximum purchase that the helix is locked is going nowhere I support the tissue and now I do my rotation in that configuration right here we're doing the rotation Dr. Brewer is going to follow me posteriorly here if she can to show you the other way perfect so now you see we're rotated and now we secured it in the posterior angle with 270 rotation now I lock my device fully we apply the invaginator to lock the position I push it off the diaphragm by about a centimeter I push on the valve to allow me to fire and I simply with constant motion I'm firing the two fasteners together now I'm happy with the firing I let go invaginator goes off and I go back to a neutral position reload the device again click click push it together nice and smooth and now I'm ready to fire it two more times in that angle once I'm happy with the angle I unhook the helix from the tissue and now we're ready to exchange the rotation to the different angle that we will will show here so now we did the posterior rotation then now I'm going to go anteriorly I'm going to switch anterior and Dr. Brewer is going to go posterior and now we repeat the same thing on the uh on the anterior wall of the stomach now I'm not sure if we're going to be able to see but if you if you get the camera close up here on the exterior model and get us in zoom so you could see we created a wrap that is going posterior and this wrap is between the cardio of the stomach and the esophagus and here's the t fasteners holding the strap so it becomes just like a toupee it becomes a gastro esophageal placation with a 270 wrap creating a high pressure system so it's both elongating the intra-abdominal esophagus and creating a 270 wrap function for a for an anti-reflux procedure and again this is distributed by 20 of these t fasteners along the uh along the uh circumference of that wrap to distribute the force and allow for a durable uh placation with that we're running out of time I would thank Dr. Omar and Dr. Brewer and the ASGE team and my colleagues for uh for setting this excellent course together thank you for your kind attention and we're always happy to take any questions from you feel free to email us with any questions and good luck

Esophix XZ device

GERD management

gastroesophageal plication

fundoplication

T fasteners