Hi, my name is John Panolfino, I'm the chief of gastroenterology and hepatology at Northwestern University in Chicago, Illinois, and I'm joined here today with Hi, I'm Shifa Omar, I'm an advanced endoscopy fellow at University of Chicago, excited to join everyone virtually. And today we're going to be focusing on endoflip and wireless pH monitoring using the Bravo system. And a couple of things as we start is I think it's nice to actually look at both of these technologies together, to begin with, because they're very similar in terms of the delivery and placement. So when you actually look at the Bravo wireless capsule here, you can see this hood, and you can see the capsule is under here, I'm going to pull this guy off here for a second. So that'll just start the recording in essence, but you can see the Bravo capsule is kind of protected under this hood here. And this hood bends so that when you're actually placing this, and actually placing this, it bends. So when it's in the back of the pharynx, it'll actually slide all the way down into the back of the throat and into the esophagus. Now, if you feel that feel stiff, that is, it's, it's actually pretty flexible right here. This area is a bit more stiff. Yeah, so it's really important to remember when you're placing this, this should really glide down. If you start to feel resistance, what I typically do is I bring it back, it'll get caught in the oral pharynx, sometimes it'll bend back like this. And that can be actually a little bit painful, because there's a little sharp here. So you don't want to really push it too hard. And occasionally can get caught in the piriform sinus. So if you're ever getting any resistance here, I tend to kind of pull it back, sometimes I'll actually put the scope down. And I'll actually deflect it so that I'll actually go into the esophagus. Is there any role of lubricating it at all? Yeah, so when you lubricate this, and we will get to that in a second, but I don't I tend to not use a lot of lubrication with the Bravo. And usually I'll just put the lubrication on this top part here. And it'll be a very little bit of mouth. Because right here, there's a well and it might be hard to see this here. There's a small little well there, right there where my finger is. And you might be able to see it there. You don't want there to be lubricant in there, because that'll clog up the suction. Because it's the suction that drags the mucosa into that well, and a small pin is fired so that it attaches it. Now I'm going to just show you the endoflip here. Because the endoflip has a very similar delivery. If you can place a wireless Bravo, you can actually place an endoflip. And it's actually much easier. Now feel the endoflip a little bit here. Yeah, it's pretty soft. Yeah. And then the tip. Very flexible. Yeah. Yeah. So, so this guy's a little less, less, you know, at least in my mind, dangerous. When you start to press this through, you know, it bends very easily. In fact, it'll probably bend and come backwards instead of injuring the oral pharynx and the esophagus. Occasionally, it'll actually bend this way. So it'll bend back on itself and go right through the upper esophageal sphincter and traverse through the entire esophagus that way and just kind of pop open once you get in the stomach. But very little trauma with this and a lot easier to place. So once again, you shouldn't feel too much resistance. So a couple of quick things with the Bravo placement. Now we're not going to really look too much, but if you want to pass the scope here a little bit while we've got this in place, I'm getting a biopsy gap from my school. Yeah. There we go. You kind of see it there a little bit. So you can see the system here. I'm going to pull it back, push it over here a little bit and you can see it delivered. Now I will tell you that I don't, I don't look at this while I'm placing it. For the most part, and that's a little remnant of the previous procedure. That's not something I've done, but you can see the capsule there a little bit and you can see the workings, the battery and everything there. So there are some people that like to actually go down and do the endoscopy and visualize it in place and then pull it back a little bit. I tend to do them blind in this respect. So you can pull the scope back out. And usually what I do is once I place it and I feel comfortable that it's in the esophagus, I just put the scope down. I make sure it's in the right place. It's not in the lung. It's not curled up in the oral pharynx, that it's in the esophagus. And once that starts, and once, once I'm ready to start, I typically hold it right where the bite block is. So I'll put my hand, I'll pretend that this is the bite block. I position myself very steady. So I usually do both parts. I do the plunge and I also hold the catheter. So I'll keep very steady. I'll put this, I don't do this. I don't talk to my nurse. I don't move around because when you do that, you tend to pull this off. So you can look at the capsule here. When I do this, you can see I move it. And when you're trying to suction and attach it, you don't want that to move. So if I'm talking to my students, I'm talking to my nurse, the anesthesiologist, you know, you want to be very, very tight. So I usually put it in, I'm going to do it out here just so you can see what happens. I'm usually pretty steady. I don't move and I don't turn around. Once I've suctioned for at least 30 seconds, I usually do about 30 seconds. The pressure's stabilized. I pop this off very easily, just like that. I plunge down. I hold that. And you can hear a little bit of air go. I take my finger off and I just pop it like that. And then if this is only halfway down, I'll actually make sure I put my finger underneath it and I'll pull it up. And then once I've done that, it's most likely deployed appropriately. I'll shake this a little bit and it'll come off and I'll show you what it looked like. This is what it looks like here in my hand, but there is a little, I want to show you the pin that pops out so you can see that little pin. So you want to make sure that that pin is back here. And that's why I pull this up because if that pin doesn't come out, the capsule will stay in the hood and you'll pull everything out together. So just an important thing. So this is pretty easy to place. You can do most of these in probably, you know, 60 seconds. Once the suction is done, I always go down and check and make sure that it has attached appropriately. I don't necessarily watch it. As I mentioned, I make sure it's in the right position with the scope. And then after I'm done, I go down and I document that it's in the right position so that I can get confident monitoring of their pH over four hours. Any questions? No, thank you so much. All right. So we're going to move on to the endo flip. So pull this over here. Thank you very much. So now the endo flip, as we talked about, has a very similar delivery hood or delivery tip. It bends very easily. It's very pliable, goes down very nice and easy. And it's just like a manometry catheter. So just like you're not very worried about perforations with a manometry catheter, really what you're worried most about is nasal trauma. So with this, you're really not very worried about anything in terms of that because it slides down nice and easy. And you can see this is the bag, the tip, and these are the impedance sensors. So essentially, there's an electrical current that is flowing from the top here to the bottom. And the resistance of flow, which is governed by what's in the bag, whether it's air or liquid, and you want to get all the air out. So if it's liquid, you can actually extrapolate from Ohm's law and measure cross-sectional area. And we'll see some examples of that. And it's very easy to place. And as I mentioned, it can be placed in FOS with the tip down like this, but if the tip bends, it's still going to go through very easily. So I'm moving a little fast here, sorry. So it can be bent like this. I'm going to show it here and go down, or it could be in FOS. So what I'm going to do here is I'm going to take a little bit of lube. Now, in this person too, I will probably just use a little bit of lube. And most of the time, it flies down pretty easy, but these models can get a little bit dry. So I want you to place this and you can feel it. And what I want you to do is place it just how you typically would. Okay. So I'm going to push it down and we're going to cheat her a little bit because I don't have an endoscopic measurement, but you can see that that's the EGJ. And we know that it's probably further down. So now what we're going to do is we place that with the bag empty, and then we're going to start to fill it. And it says inflate there, but it's actually filling liquid. So it's not really inflating air, it's filling or infusing liquid. That's where we hit for an inflate. Yeah. So, and then it's telling you how much is going in right now. So right now we've got about 15 mLs and we usually inflate it until around 30 so that we can identify the high pressure zone or the low diameter zone. So I'm going to stop it. And this is where you can see that it's... Yep. So you can see it, and then you can also see it up here. So here you can see, you probably have this a little bit so we can play around with it. Now, if you move it up and down, it's a little bit tight in there. So I'm going to empty it out a little bit. So this... Take this out here a little bit, since you probably need a little bit more lube. Put that paper clip on a little bit tighter than we did the other one. Mm-hmm. So let's put a little bit more lube here. So now it's got still about 17. Normally you would do an upper endoscopy and measure the G-junction. Yeah, so normally I'd have an EGJ measurement. Mm-hmm. You know, so I can see right here, I'm pressing it. Now I know I'm through. All right. So now I've put this all the way up here and now you can see this, and I just want to accentuate that little area, that high pressure zone. So now that high pressure zone, which is the low diameter zone, you can pretty much identify that pretty well. So usually what we do, and I'm just doing this for our benefit here of actually, showing the patterns here. I'm gonna do this. It's all the way down here. Keep this guy here. Let's see if I can elicit some of these pressure changes. All right. So now usually when you're doing this, the esophagus is gonna start to react and contract and you'll be able to kind of see that. Obviously, I'm gonna have to do that myself here. So we'll just pretend we're doing this. So now it's placed appropriately. So now that I've documented at 30 mLs filled, it's a little bit of a narrowing here that you can see. I'm gonna accentuate it a little bit here with just my fingers. You can kind of see it there. Now you can see that if I play around with this and push it in, it's a little bit tight there. And now that I have that there, I'm gonna go all the way up. Now, when I hit 40, we're just gonna pretend here that maybe we start to see some contractions. I'm gonna see my hand roll down this guy here, trying to simulate a contraction. See it right there. See it right there. Brachialis. Yeah, so that's what a peristaltic sequence would look like artificially with my hand. It looks a lot cooler in real life than on a model like this, but it's really just a low diameter zone that's propagating down the esophagus. So typically when you see these anterograde contractions that are repetitive and occurring every six to seven seconds, that's typically a normal response, something we call RACs, repetitive anterograde contractions. If you place this, you've documented the EGJ, you've seen that pattern. And if the EGJ at 60, we're gonna inflate here to 60, if the EGJ diameters are above 16 and the DI is above two, you're pretty much in the normal range and stop it there. You can clearly see now that this is opening up a little bit and you can make that measurement. So you can identify the patterns of contractility and then the EGJ opening. So if the EGJ diameters are above 16 and the DI is above two, that's pretty much in the normal range. We like to see, you know, usually around three or four or higher. We'd also like to look at the patterns and depending on what the patterns look like, you know, this, for instance, would be something we call absent contractile response. So if you see this and you see a DI here that's gonna be very low and a maximal diameter of six, that would be non-spastic obstruction consistent with achalasia. Now the bag is moving a little bit, so we don't want to lose position here. So there are distinct patterns that you can identify. There are five different patterns, RACs, which are repetitive antegrade contractions, borderline contractions, which are just antegrade contractions. Then there's impaired disordered. And then there are the spastic reactive contractions where you might see stuff going backwards like this. And that typically is either a spastic feature or something where you might see an obstruction at the EGJ where the esophagus is actually going backwards and pushing things backwards. That's pretty abnormal. So when you combine these patterns of contractile response with EGJ opening diameters, you can actually essentially diagnose most manometric disorders. You do a really good job at normal. So RACs and normal opening versus non-spastic, obstruction, which is pretty much achalasia. And then in the middle, there's some difference between people presenting with a GERD-like flip pattern or people presenting with a spastic pattern. And in those spastic patterns, you might get a manometry. But in my practice, this is pretty much what I start with. And I work my way down from this particular process. So if I diagnose normal contractility here, I don't get a manometry. I'm pretty much done. And I'll send those people for either cognitive behavioral therapy if they have dysphagia or adequately evaluate their reflux with maybe a wireless Bravo capsule at that point. If it's achalasia, I know it's achalasia on my endoscopy and I've done this and it's correlating. I'm not gonna put the patient through another manometry. I'm gonna actually take this at face value. As this is achalasia, I'm gonna treat the patient appropriately. So a very nice screening tool gives you a high probability of achalasia and a high probability of normal. Any questions? It's a little artificial, but. And then, you know, taking it out is actually very simple. You know? Yeah, so I'm just gonna show you that typically what most people do is they pull back. And if it comes out pretty easily, they just kind of keep pulling. But most people wait till it's at least down to 30 mLs before they actually pull it out. But it'll come out pretty easily. And this is what it looks like fully distended. So that's endoflip and wireless pH capsule Bravo in a nutshell.

John Panolfino

Shifa Omar

endoflip

wireless pH monitoring

Bravo system