So I'm going to just show you more on the technical side some issues we run into. So this was actually published. This was a case of a patient with really kind of end-stage achalasia who had a very severe sigmoid esophagus, and the issue that we dealt with was bleeding. Okay, so this is the linear vertical incision that you've been seeing. This is a T-type hybrid knife that you used. This is creating the tunnel, and I do the similar thing that Norio just described, kind of turning it into a vertical orientation, so you can do up-down deflection for the dissection, and as I mentioned, I kept it quite wide that you can see here. And here's the sort of spinous process, and then I do a retrograde myotomy. That's a little different from what we've been teaching and talking about. It's not regularly practiced. Here you can see the longitudinal fibers and circumferential fibers. One of the problems with this technique is that it is a little blind and can run into issues with bleeding. So here I can see that I went full thickness, and then I got this bleeder. Techniques to initially try here are a tamponade with the cap of the scope, as well as coag graspers. Unfortunately, we realized when I asked for the coag graspers that I only had the small coag graspers and not the large coag graspers, and as you can see, they're really not going to be sufficient to grab any vessels, and here I'm tamponading and then releasing to try to see if I can see the site. I have poor visualization, and most likely this is a large bleeder that I'm not going to be able to get with these small coag graspers. We lost... We had quite a bit of bleeding and developed a clot, so in a bit of a desperate attempt, after also calling in my surgical colleague, I decided because the tunnel was so big that I would use a CRE balloon for just some tamponade temporarily. So this is up to 15 on the balloon. This is sped up, but it allowed for a sort of temporary cessation. We were able to visualize a little bit more. Even though I don't see bleeding right now, I do know that the bleeding is still continuing, so we did a little bit more cautery along the edges, and then the idea was to actually do some more myotomy to expose the vessels to be able to actually see where the feeder was and ultimately control it. Now this is a problem you can encounter when you're doing even the tunneling and you have a vessel that you think you co-opted, but it recedes back behind the muscle layer and it continues to bleed. And the only way to actually control it sometimes is to actually perform a little bit of a myotomy right there again so you can expose the vessel. So we had stopped the bleeding. I could have stopped right there and then, but, you know, my surgical colleague, who actually asked me to do the procedure in the first place, was in the room and said he didn't want to really take him to the OR for esophagectomy yet. He'd stopped bleeding, so we should continue. We did continue, but one thing I did here was I was concerned that we wouldn't – he might have continued bleeding, and so – and I have to send the patient for IR. So the clip that I placed within the tunnel was sort of just a marker as to where the bleeder was. And this patient actually did very well, didn't even require transfusions, had no further bleeding, and the esophagram showed no leak, and he went on. Unfortunately, he did have sigmoid esophagus, so he did not have complete resolution of his symptoms. However, he was still refusing surgery, so he kind of continues on living with his achalasia, but just an extreme case of bleeding. Any questions? Yeah. I actually haven't done that. I've seen other reports of it. I don't know if other faculty can comment on their thoughts about clipping in the tunnel when you need to. Sure. And just to clarify, it was not clipping a vessel closed. It was just clipping – As a mark. As a marker? Yeah. Any thoughts from anyone else? I haven't done it. My concern, or I guess question, is have you guys ever – because if you leave this object within the tunnel, could it potentially erode through the thin mucosal layer? Is that a potential risk? This is a fairly capacious tunnel, so balloon dilation and so forth is not, I guess, that problematic. If you have a very tight tunnel and you expand the balloon within the tunnel, you risk causing damage to the mucosa, which sometimes even just from urine sufflation, you can start thinning out that mucosal layer. Yeah. I mean, others can comment, but just to sort of emphasize, I only thought to do that because of how wide I had made the tunnel specifically for a sigmoid esophagus. So you really need to see orientation on the sigmoid esophagus. And the surgeon's theory about that particular bleeder was that this is the point at which it starts to kind of ride along in a horizontal fashion, and it may be a vertebral vessel that was coming off that we would normally encounter, would not normally encounter. If this had been a smaller esophagus, a less dilated esophagus and a straighter esophagus, I would have done the balloon dilation in the esophageal lumen, which you can also do to help tamponade in that situation. Interestingly enough, the initial original tunneling STIR procedures and third note procedures that Guest out described was dilating the submucosal space with a balloon in order to create that tunnel. So it's an interesting concept. But any other thoughts on the foreign body or balloon dilation? Well, I try not to put any foreign body inside the tunnel because you don't have access in the future. You gave antibiotics a bleed, right? Of course. I think it's going to be okay. The concern about the genesis is valid, but typically it kind of flattens out, so it doesn't kind of push it towards the lumen, but I don't think a mucosal injury would be a problem. In the future, if you don't like it, you can just try to find it, the mucosal incision, and we can probably pull it out. Yeah. Everything's healed. And if you think about it, the new procedures that are being described, POEM-F, they are leaving foreign bodies and they use clips to tack the endoloop up along onto the muscle layer itself, so it's sort of like a version of this. Certainly using a shorter arm clip might be better because you could have some damage and erosion, but hopefully if it were that delayed, there would not be an underlying muscle injury, so it wouldn't cause a problem, maybe just an ulceration. But also, they did X-TAC actually inside the tunnel to close a defect. Also, that might be a special scenario that I probably wouldn't suggest, but another technique where they're leaving foreign objects within the tunnel. The POEM-F X-TAC, that's a permanent helix. And sometimes you don't know what you're grabbing or what you're helixing into. If you get the adventitia of the aorta, you can potentially have a big issue later on. That was a POEM-Post Heller case that they X-TAC'd in, so they had the fundo that was creating issues and they couldn't identify the mucosal side of the perforation when they did it. The one thing I've done when I've had a mucosotomy that I couldn't identify from the lumen is put a jaguar through it, leave the jaguar in place, and actually clip from the lumen, just clip onto the jaguar essentially, and then I know it's in the right place when I have a really hard time getting the jaguar out. Do you have a question? If it's bleeding like that and then we are afraid to put a foreign object in there, would hemo spray possibly be a consideration? Yeah, that's a great question. I did, again, you know, this is an extreme situation. Like Kyra was saying, that was his worst blader. This has absolutely been my worst blader in my life, and I did call my thoracic surgeon in who stood by my side and was like, please take care of this because I don't want to deal with this patient in the ER. We talked about hemo spray. So my concern about hemo spray in an open cavity, because I have had experience with it in, for example, a walled off necrosis, is that the pressure required is so extreme that it, you know, I think that could create more of a problem in this case. And where this looks like it's almost an arterial bleed, I don't know that the hemo spray would actually stop it. So that's why we didn't use it in this case, yeah. Tunnel is disaster. We always want to prevent that. If it happens, you have to be able to just cope with it right away. So you have to have a co-grasper on the side. You don't have to open it, but nurse have to have access right away. The bleeding site, immediate bleeding is the time to stop. Once your blood pools, there's nothing you can do. So the bleeding, you have to call for co-grasper, and hemostasis should be achieved relatively smooth. Then you're going to trouble like that. One question I had, you did use a colon-sized co-grasper, and that has a very limited capacity to grasp tissue, and you could have probably used regular or gastric size. That may have stopped much. That was a mistake that was discovered after the package was open, and it was handed to me. That's why I commented that we realized that we actually did not have the larger size. We have some issues. It's very good to make sure that when you start POEM, that you have your POEM tower or supply closet or whatnot regularly checked, and that everyone familiar who does these procedures with you on the team knows which one is a colon length, which one is a gastric size or upper size. So educating your team is an incredibly critical aspect of performing any form of ESD or POEM. Not also for the settings and the generator, knowing how to deal with problems that might occur in the middle of the procedure, which can include things as simple as it being connected in the wrong spot, especially with the new VIO3, there are some changes in that. But they have to know, and so educating a specific team. At some institutions, that's harder to do, to be able to have a very specific team. You need to keep that in mind when you're scheduling and setting that up, so. One more tip is our nurses sometimes forget to close the forceps, and they give me a co-grasper, and it's open. I cannot pass it, and they keep doing other connections, like, close it, close it, I'm losing the time. So you have to teach them, just hand it off, close it, otherwise you cannot just pass through. And just a few more last tips, while you're waiting for them to pass you the right instrument, use that cap, try to not only tamponade this way, but then also before you lose the initial view, you can even put the cap on there and irrigate constantly, so you're able to see where the stream of blood is coming from. Those are little tips. That'll get filled up quickly, then you need to use tamponade, and hopefully by then you've got the co-grasper sound. Those, like, co-grasper and tamponade sound like the immediate things. Have you ever used, like, EpiGist to temporize if it's a spurt, or just to get a better visualization, or it's not really in the tunnel a good idea? Like Epi in the tunnel, like if you're having a spurt, just a little Epi, just to slow it down so you can see it, or have you ever used that? We don't use Epi for colon at all. First of all, the bleeding in the esophagus is much rarer, the vessels are much smaller, so that's why we always emphasize when you're going to cardio, that's a problem, you just be careful. And if you keep using the epinephrine, it's going to affect the system, you're going to have a high blood pressure. If you have some cardiac event, you're going to be blamed for it. So I don't think epinephrine is necessary, and the main thing is to be prepared, educate, and have the right tools at the site. And you don't have to be connected, you know, co-grasper can grasp and reduce the bleeding or stop it. That's my point, you know, the nurses just keep it open and try to connect, connecting is the last thing. Just give it to me. You have to educate the staff. Yeah, I would add, you know, to that point, actually, making sure that you grab it without cautery first, making sure you stop the bleeding and only cauterize after you've stopped the bleeding, because if it's still bleeding, you should reposition it, then close it again in a different place, make sure the bleeding stops before you coagulate. Absolutely. And really spend the time, like just look at it, watch it for, you know, 30 seconds to make sure it doesn't restart, because, again, it will hinder the rest of your procedure if you have a continuous user. Can you comment on myotomy, top down versus down up? I will. So, again, it's my practice, but certainly, you know, the master is not something that's commonly taught, and so we're not going to necessarily teach that here, but I do it that way for a couple of reasons. One, posterior is my preference. You really can only do it in a posterior fashion, but I like the motion of traction on the knife and pulling this way as opposed to constantly going in like this. For me, I feel that if, first of all, if I'm going to have a full thickness myotomy, I'd prefer that it be at the, where the most, the myotomy is most important. So, if there's any reason I can't complete the procedure, at least I know that the LES has been taken care of, and it's easier also to manage, you know, pneumoperitoneum than necessarily in the thorax. But I find the hook, and then you can, I actually can do it, a fairly large segment with a single motion, and I also find that it, there's less risk of damaging the mucosa because you're not sort of flicking the knife up towards the mucosal side. There are issues. It is a bit of a blind procedure. One could argue it's the same way when you're going in for the first cut and cutting down, so I usually typically do a cautery, a tap on the cautery to get down, or a cut and then a cautery on the initial pull. And so far, this is probably the biggest issue in the case that I've had. And you have to be careful that you don't come all the way to the mucosal entry. Yeah, yeah, I constantly sort of recheck, and there are times when you, the knife's still not large enough, you don't get enough of a pull to actually get all of the fiber, so you have to do like a double layer cut. And sometimes what I will do is if I'm really, if it's a long myotomy and I'm not sure, I want to make sure about the orientation of the myotomy as well, that I'm not going towards the mucosal side, after I've done that initial bottom part, then I'll come up to the top and just start where I want it to end, and then cut down and then meet the two in the middle. All right, it's time for lunch, and then you guys will be in the lab after lunch. Thank you so much.

achalasia

bleeding

hybrid knife

retrograde myotomy

visualization