Hello everyone, my name is Dennis Yang, I'm the director of Third Space Endoscopy at the Center of Interventional Endoscopy Admin Health Orlando. I want to thank the course directors Aziz and Rita for inviting me today. Today we're going to be doing a hands-on live demonstration on the poem procedure so welcome everybody for joining me today. So first things first, before the procedure I'm just going to kind of go over a little bit about the setup in the room before we get started. I personally like to have the patient in the supine position for these procedures. Some physicians will prefer the patient the left lateral decubitus position. The reason I like to have the patient in the supine position is that it allows me to clearly identify what my anterior and posterior planes are going to be when we're going to be doing the poem. With the patient in the supine position I generally scope the patient from this position that you're seeing today and as such instead of normally having our monitors towards the side of the patient, I have the monitors in front of me and the team generally stands towards my left side. Another important thing before after positioning your patient is checking your equipment, making sure you have all the devices and accessories you need. Make sure that your electrosurgical unit is also set up. So we're going to get started here. The first thing I do before I start the poem procedure is I actually like to do the endoscopy to kind of assess my different landmarks and also look at if there's any food debris. Many of these achalasia patients will have residual food in their esophagus in the stomach. You want to make sure you clear this out before starting your procedure. So I'm here just inserting the scope. I generally start this process without putting the cap in first and then we go into the stomach. I document my different landmarks and so forth and then I come back out. I then like to get a sense of where my GE junction is going to be because this is going to give me an indication of how far approximately I'm going to make that initial mucosal incision for our myotomy. So here I'm just again, you know, pretending this is a patient. We're looking at the esophagus and I get a sense of where the GE junction is. In this particular case, it's exactly at 40 centimeters on my scope. And so at this point, I come back and I put the cap on my scope. There's different types of caps that you can use during these type of procedures. Currently we have this cap. This is a Fuji cap. It's a conical shaped type of cap. The advantage of this cap, for example, is the conical shape of it sometimes can facilitate entry into the semicosal space, but there's other caps available. Olympus has a more like a flat type of cap with the same profile width as the scope. That's a shorter cap as compared to the Fuji cap. One advantage of that cap is that you obtain better visibility as it does not impair your peripheral vision. I personally, a lot of times will use one of those soft RFA ablation caps that are beveled. Those caps are normally used to kind of clean the coagulum after doing ablation for bare esophagus, for example. The reason I like that cap is because it's soft and because it's beveled. I use that bevel to my advantage as I need to enter the mucosal incision. Here I'm just gently inserting the cap, putting it into position as you can see there. All right. Again, the next thing you want to make sure before you get started, as I tell all my trainees, is know exactly where your assistant is going to be, know exactly where your devices and your pedals are going to be, especially when you're using different types of knives. In this particular case, we're going to start with an Irby jet knife. You're going to have an additional pedal. So the last thing you want as you start doing the procedure is having to look down and search for your pedal because this is going to cause movement of your scope. So you want to, before you even start the procedure, know exactly where your pedals are so you can step on them without having to look down and lose vision endoscopically. All right. So. So now I'm going back into the esophagus with the cap. We're going to go again. The first thing is we go to where our G-junction is and to get a sense of where your anterior and posterior locations are. One way of doing so, particularly in the torches or kind of a sigmoid esophagus, is just putting a little bit of water into the lumen. And by doing so, you can get a sense of where the fluid is accumulating. That will give you a sense of where the posterior plane is and where the anterior plane is. So as you can see here, the fluid is pulling at the bottom of my screen. That tells me that's the posterior plane of the esophagus. So the anterior plane is above us. A lot of people ask, well, where do you choose your mucosal incision? And that really depends on how long your myotomy is going to be. In most cases nowadays, we tend to favor doing a relatively shorter myotomy, as recent data suggests that the shorter myotomy may have a similar efficacy as the standard myotomy, but perhaps be associated with less adverse events, shorter procedural time, and possibly less postpone or reflux. So in the case of patients with achalasia type 1 or type 2, I tend to favor a shorter esophageal myotomy of about 3 to 5 centimeters in length. So with that in mind, we generally, as we talked about, if my G-junction is at 40, I would come up to about 33 centimeters, which is 7 centimeters above the G-junction, make my mucosal incision, and then start myotomy approximately 2 centimeters below my mucosal incision, and then that would give me approximately my 5 centimeters of the myotomy. Now you got to remember, this is an X-Plant-PICC model. The X-Plant-PICC model is going to be a little bit more challenging when trying to do mucosal incisions and some mucosal tunneling just due to the actual model itself, but hopefully we are going to be able to at least emulate this with this model. So I have Jill with me today. She's going to be assisting me for the initial mucosal incision. We have a standard needle. The initial injection, I generally just like using saline with methylene blue or indigo carmine. The blue dye will help you identify your submucosal plant, and we're going to focus initially in doing an anterior mucosal incision. So with the needle in place, then you're going to tell your assistant to push out the needle into the patient. So right there, I try to approach the mucosa under good visualization. As I puncture in, then I ask them to inject. And you can see that it's starting to form a bleb right there. Right. So we generally try to do, I try to inject about eight cc's or so of fluid to give me a nice good bleb for my initial mucosal entry. So that's what we're going to do now. So Jill is just injecting into that bleb. Okay. So for purposes of this model, we'll probably stop here. Needle back in. Okay. So we're retrieving the needle and now we're going to switch to our dissection knife. In this particular case, we're using the Irby knife. This is an injection, water pressure injection capable knife. This Irby, the hybrid knife, the current model we have here is the I-type. There's two different types, the I-type or T-type. The I-type, as you see, when I push out the tip of the needle, if you can zoom in here, the tip of the needle is flat. So it's a straight knife. The T-type has a disc at the end of the knife. The difference is that the disc sometimes allows better hooking of the knife when you're doing cutting. But again, this is a personal preference, whether you use the smaller profile I-type or you end up using the T-type. In this case, we're going to demonstrate the use of the I-type. I'm going to put this behind me so it's not in my way. Hi, everyone. This is Amrita Sethi. Sorry I wasn't here for introduction, but I just want to remind you all that you can enter questions and Dennis will address them as they come in. So now we're going to... Thank you, Amrita. So if you guys have any questions, feel free to put them in. I'll hopefully be able to answer them in a timely manner. So let's get the knife out. So the knife is out. So you guys can see the initial hole where we made that injection. So using that as my landmark. So let's see here. The return electrode is not adequately placed on the peg, it seems. So again, just bear with us. Sometimes these X-plan models, the electrodes can move, and that can happen in your patient as well. It's important to check. Okay, okay. So again, this is... Yeah, there we go. So now we should be ready to go. Now that we've checked that the pad is ready, we're going to make that initial mucosal incision. And you don't want to go too deep with your knife initially. You just want to go deep enough where you start exposing the semicosal plane, as you can see there. And you know you're in the semicosal because you see the blue on the other side. Once you expose that, if you want to, you can start. In this case, I'm injecting with the pedal of the hybrid knife. So again, you want to slowly start dissecting down. And the idea is to make an incision that's going to be about two centimeters or a little bit less in length, just enough to get your cap in, right? So I'm still making that incision, and then we're going to talk about what are the key components in order to be able to sneak your scope in without causing major trauma. Again, in the pig, it's a little bit different because their esophagus is actually very, very thin compared to the human esophagus. So once you make that initial mucosal incision, the next thing you want to do is you want to separate the submucosal fibers that are attaching the lateral margins of that mucosal incision. You need to do this because if you don't, you're not going to open up that submucosal space, and no matter what you do in terms of trying to sneak that cap in, it's going to be held in place. So you are able to start what we call trimming of the mucosa by gently riding the knife up and down the lateral margins of that initial incision. As you can see here, we're just clearing some of that submucosa, and that's going to help you widen that initial mucosal incision. The other key component of this process is the lower lip or what I like to call the bottom edge of that incision. You need to clear that. If you guys can see where my knife is, it's very important to open this space up because that space is where you're going to start inserting your scope after the initial mucosal incision. So it looks like there's a question. The question says, are there any specific conditions which you prefer T-type over I-type? So as I was mentioning, this is a very personal decision. Some people like to use the T-type knife because it may help make your myotomy easier by having that disc, you're able to hook the muscle easier as you cut down on it. So some people, for those reasons, prefer using the T-type. The potential advantage of the I-type, as you can see from my endoscopy, is that it's a smaller caliber, smaller profile knife. So it's a little bit more precise than your T-type knife. But again, this all depends on your personal preference and what you feel more comfortable using. And you'll see from our panel of experts that that varies significantly. There's people that prefer the T-type and I-type, and some people prefer the other type. So again, now that we've made an initial mucosal incision, we've cleared some of the borders, you can see the mucosal incision is wide enough to allow you to insert your scope. So how do you do that? You first want to kind of approach it from above, and you want to get one side of your cap across the edge of that mucosal incision, and kind of test to see if it's wide enough. If it's not, if it starts lifting, then you gently are going to torque the scope immediately and sneak the bottom of your cap in. As you guys can see from this demonstration, by just sizing the cap, it looks like it's still small, so we may need to extend our myotomy, our mucosal incision a little bit more, which we're doing here. Why is it important to kind of take it step by step? It's important because you don't want to make a huge mucosal incision if you don't have to. The longer, the bigger the mucosal incision, obviously the longer the mucosotomy, the higher the chance you're exposing the luminal side to the third space, and secondly, it may, in some occasions, make closure of your initial mucosal incision more difficult. So again, that looks to be a little bit above the size of the cap, so we're going to give it another try. I'm going to approach the incision with the left side of the cap, try to open it up. As I push away the left margin, I'm gently, if you can focus on my hand, you'll be able to see that I'm gently torquing the scope counterclockwise. And now after I torque counterclockwise, I'm pushing my cap in just a little bit to get that cap starting to fit into the submucosal space. So if you guys see at this point, my cap is in the submucosal space, but I'm not stable because there's still a lot of submucosa down here that does not allow me to enter the submucosal tunnel. So we'll go back to the endo screen again. So here I'm injecting into that submucosal space, and we're just gently dissecting more of those fibers. We already know the mucosal incision is wide enough, so there's no need to make it any longer, but I do need to clear some of these submucosal fibers in order to be able to sneak and put our cap safely in there. One of the advantages, again, of using this type of knife, the hybrid knife, is that the simultaneous injection, it reduces the number of times that you're going to need to exchange your device. So, again, here you guys can see that we're, again, entering the tunnel. I'm in a tight position, so instead of using the scope, I'm just gently moving my wheels left and right to just opening up the space a little bit as I maintain the cap there. And then I'm going to gently push in the cap, and now we're in the submucosal space. If you guys look carefully, one of the key things is once you enter the submucosal space, you want to define the different landmarks in your tunnel. So if you guys can see at the 12 o'clock of my screen, you have the muscle of the esophagus. That's the circular muscle of the esophagus. In the middle where this wispy blue tissue is, this is your submucosa, okay? And you want to start clearing the submucosa in this plane, and then below us at six o'clock is your mucosa. So very importantly, as you are tunneling in POEM, you want to stay close to the muscle and avoid having your knife too close to the mucosa and cause inadvertent injury to that plane. In terms of scope movement, some people ask, often ask, well, what do you like to do? Do you like to use your wheels? Do you like to move your scope? In real life, in the pig model, the esophagus is a little bit small. It's a little bit tight. So it's difficult to truly demonstrate the movement that you would normally do. But in general, as you can see, the knife on the upper scope comes on the left side. So as it appears there, the natural movement for dissection would be to have the knife in this angle, start dissecting, and then just gently torque by moving your scope to the right and directing the knife in this way to cut the submucosa in this plane. And then once you're in this plane, you go and rotate back towards the left. Okay? Nicking of the muscle layer, it's okay, as long as you recognize it. You certainly don't want to cause, like, full thickness injuries early on because this increases the risk of capnopertinium in the patient. But again, touching the muscle fibers is okay. This particularly can be the case when you're by the G junction and we're in a very tight space and you are trying to avoid injuring the mucosa on the other side. So again, we're just here injecting to the tunnel. And what you're hearing the beeping is the Irby knife's injection, pressure injection system. So again, here we're tapping on the pedal and gently going left to right with our knife and clearing these submucosal fibers. And again, you can see the circular muscle fibers at 12 o'clock. And that's what you want to do. You want to direct the tip of your knife towards the muscle away from the mucosa. Every once in a while when you have, when you're doing these procedures, particularly in your early phases, you want to pull back out of your tunnel to make sure that your tunnel is straight. Okay. So there's a question. Yeah. So the question that came about is, are you dissecting with endocut and what settings? So I normally, I have, depending on your electrosurgical unit, this is going to change. In my particular unit, we have this Irby vial three unit. So in terms of what are the preferences that I use for the initial mucosal incision and for the myotomy, I use either an endocut Q or an endocut I mode because it has a little bit less charring for the mucosal incision for the myotomy. When I'm actually in the tunnel and dissecting, I tend to favor a precise set. It's a nice blend of coagulation that helps you with dealing with any small vessels that may come across. You can certainly use the endocut mode, but then it also risks the potential for more bleeding, less hemostasis. For the animal explant, right now, I'm using the precise cut. But again, in the explant model, the tissue can be a little bit dry, so it may not cut as well as compared to a live animal or a live human case. So I think this is the demonstration again of the tunnel in the anterior approach. Again, we talked about the initial mucosal incision, the importance of clearing those submucosal fibers along the lateral margin, along the bottom part of your mucosal incision to allow entry of your scope. We talked about keeping your tunnel straight, right? Using the circular muscles as a landmark of where you're going. The other important thing during tunneling, and this is an important issue, is that people who start doing POM, they tend to try to keep a very tight tunnel, meaning they want to get very fast towards the G-junction and they don't widen enough the tunnel. The problem with this is twofold. Number one, by having a very tight tunnel, it may increase the resistance and friction to the movement of your scope, which can inadvertently cause sharing of some small blood vessels that can then bleed and dirty your tunnel. So you want to widen the tunnel for those particular reasons. The second reason is by having a wider tunnel, you can actually, as you can see from this view, you can actually get a better idea that you're going on the right axis, right? You can better tell that the direction of your tunnel is straight, as opposed to if we kept a tunnel of only this width, it's really hard to tell if we're veering towards the right or towards the left. So with that demonstration on the anterior tunneling, we're going to go now proceed with closure of that tunnel. So we're going to get the needle back and we're going to switch to the clips. So when closing the tunnel on the anterior aspect, you have two options. Obviously, you can approach it in this manner, in which the mucosal incision is at 12 o'clock and you put the clips in this manner, or you can simply, what I like to do, is rotate my scope and my body and get that tunnel towards a six o'clock position where it's better lined up to my device. But again, either option is a reasonable choice. There's various ways of closing a mucosal incision. The most common way I think is by using the hemostatic clips, which is what we're going to be demonstrating now. But some people like to close it with suturing devices. There's multiple new devices through the scope, X-TAC suturing devices, and also new clips are coming into the market. This clip in particular, the DuraClip from Comet, it's a rotatable clip. The clip we're using for this particular case is 11 millimeters in width. I do prefer the smaller clip. I don't find it necessary to use the wider clip just because number one, your mucosal incision is not that wide and because the esophagus is tubular and somebody who doesn't have a dilated esophagus, using a smaller profile clip is actually easier to operate. So again, now that we have the mucosal incision at the bottom, we'll have our assistant open the clip and then they can even rotate the clip for us to align it to the mucosal incision. So we're going to align it at 9 and 3 o'clock. Open. Yep. So that's fairly good. You sometimes can rotate the scope if you need to, and we're going to basically grab it right there at the apex. The first clip is one of the most important clips. Close. The first clip is one of the most important clips because it helps form that little lip that's going to facilitate subsequent placement of additional clips. So you want to make sure that's relatively centered. In this case, as I lift up before I tell my assistant to deploy, it looks to be right at the middle. I'm pretty satisfied with the current position of the clip, so I'm going to ask her to fire. Fire. Okay. So now we're going to go with our second clip. It actually came to be a little bit more towards the left than what it initially looked to be, but that's okay. We are going to try to make up for it with our subsequent clips. Never underestimate not only the importance of an adequate mucosal incision closure because that's what's going to prevent any leakage, any extravasation, but also it can be sometimes quite challenging in patients who have a sigmoid esophagus or have had longstanding achalasia. The mucosa can be quite thick, and grabbing it with these clips can be challenging. And if you're experiencing these difficulties, that's when you want to be able to try your other alternatives, which may include over-the-scope suturing, through-the-scope suturing, or even under certain circumstances using over-the-scope clips. So we're going to have her open the clip again, and we're going to... That's not a bad position. We're going to rotate our scope to make sure that we're in the middle of that gap, and it looks like that's about right. We're going to ask her to gently close the clip. So you guys see it slipped off on the right side. So we're going to open again. We're going to try again here. I'm going to put a little bit more downward pressure to my scope to see if it grabs that right side that's giving us a little bit of trouble. Close there? Okay. So that's a better position. That's a better position. One of the things you want to see is as you fire that clip, it approximates both edges equally. Both lips of that mucosal incision are facing you, or what I'm saying that they're everting. So what you want to avoid is from them inverting down, and you're forming a tunnel underneath the closure. All right, so we're going to use another clip. So, again, we're going to open the clip. Sometimes when you open the clip proximal to the mucosal incision, and we're just going to, I'm just going to first ask her to rotate it to where it's kind of 9 to 3 o'clock again, and then I'm going to explain this concept. So, sometimes when you open the clip, as I am right here, and you're trying to close the mucosal incision, if you push in, due to the width of the esophagus, you may have some difficulty with the clip hitting the side of the esophagus and actually not being able to get where you need to get to. So, another way of dealing with this is actually just opening the clip, but going above the mucosal incision, lining up that clip with the clip that you already placed, and now big willing down towards the mucosal incision. As you can see there, it lines up with where we need to close. If it moves a little bit to one side, you can use your wheels, press down, suction down, and then fire the clip. And close, and we're going to fire the clip at that point. All right? So, okay, so we're, for the purposes of time, we're going to probably put one more clip for this demonstration in terms of mucosal incision closure, but then I'll move on to and demonstrate how to do a posterior mucosal entry and tunneling. Some of the other miscellaneous things to keep in mind is for when doing these type of procedures, POEM procedures, or third space endoscopy procedures, you want to use carbon dioxide for insufflation. You don't want to use air. There's plenty of data that has demonstrated that the use of air increases the risk of complications. So, and certainly post-procedural pain. So, you want to make sure you use carbon dioxide. The other important thing to remember that I do is once I'm in the submucosal tunnel, I reduce the amount of carbon dioxide that's flowing through my scope to minimize the risk of capnoperitoneum. How can you tell if the CO2 is rising or if there's too much CO2 in the abdomen? A couple things. Number one, if your nurse notices that the abdomen is getting more distended, that is certainly a sign. Your anesthesiologist, CRNA, or anesthesiologist may tell you that they're noticing that their peak airway pressures are increasing. That can be also a sign of the abdomen getting more distended. The first thing to do is to come out of your tunnel, go into the stomach, decompress as much as possible. If that doesn't take care of the problem and the abdomen is still distended, those are the situations that you may need to resort to needle decompression of the abdomen, and we can certainly talk more about that later. So, to just kind of finish this up, we're going to put one last clip. So, again, we're going to open that clip. We're going to have our assistant rotate a little bit horizontally. That is perfect. And, again, the key thing is to line up what I like to call the middle or the crotch of the clip to that mucosal incision, so you ensure that when you fire it, you have equal amounts of the clip arms on both sides. So, go ahead and fire. Perfect. So, again, in real life, I probably would put another one or two clips here, but for purpose of demonstration, I think you probably already get a sense of how to do this mucosal incision closure. So, moving on, we're just going to do another mucosal incision from the posterior approach. So, again, doing a posterior approach, mucosal incision is going to be very similar to the amputee approach. There are some nuances in terms of how to get into the tunnel. One of the disadvantages of doing a posterior approach is that that's the gravity-dependent portion. So, remember, fluid is going to pull in your plane of view. If you have any bleeding, it's also going to pull in your plane of view. From a technical perspective, one of the advantages is that because it's on the posterior approach, that tunnel is going to line up with your instruments that are coming out at 6 o'clock. So, similar to the anterior tunnel, we're going to start this mucosal incision by injection with the needle. So, I think the needle is right there, yes. So, we're just fishing through our different devices. There we've got the needle. We can certainly put a little bit more fluid there. As you guys can see, we have some saline that mixed with methylene blue. Okay, so just like before with the anterior tunnel, we're going to ask for assistance to push the needle out. And remember, some folks, the esophageal wall can be relatively thin, so you don't want to insert your needle too deep, and then realize that the tip of the needle is actually in the muscle layer and inject in the wrong plane. Similarly, in some folks, they have a very thick muscularis mucosa, and in certain situations, if your needle is very superficial, you could be injecting in the plane between the superficial mucosa and the muscularis mucosa. And the problem with this is then when you start tunneling without realizing that you're actually dissecting in the space between the superficial mucosa and the muscularis mucosa, this can increase the risk of mucositomy. One of the clues for this is that the layer between the superficial mucosa and the muscularis mucosa is very, very vascular, full of little vessels. So if you start noticing this, or you notice that the muscle layer is kind of splitting very easily, you should have a high index of suspicion that you may be in the wrong plane. So we're gonna, again, gently get that needle in and start injecting. And again, I generally like to inject anywhere from eight to 10 cc's of fluid to get a very nice lift. As you can see here, you can tip the tip of your needle slightly towards the lumen to again encourage this blep to form and rise. Okay, needle back. I generally like to find that spot where I initially made that injection because it gives me an idea of where I had found my plane and the direction of my longitudinal incision. Knife out. We're going to push the knife out. Okay, so with the knife out, with the posterior approach, you're going to basically again puncture the mucosa. So as you guys can see here, it doesn't, sometimes it doesn't cut very well in this model. Let's see, let's make sure everything seems to be connected. Okay, so again, in a live case, you generally do not have to put that much pressure to get the knife to penetrate into the semicosal plane. This is mainly because of the obviously X-plane model. Once the knife is in position, as opposed to the anterior approach, what you're going to start doing is you're going to gently pushing your scope forward to advance your knife. At the same time, you gently kind of big wheel away from you to get the knife to cut in this direction. So again, we're having a little bit difficulty cutting, but here we go. I had to switch to precise cut mode for it to open up this dry mucosa, but as you can see here, and that's the reason why there's a little bit more charm. So just like, just like the posterior, the anterior approach, the key thing is you want to dissect the lateral margins again of the tissue, which we're trying to do here again. It is burning quite slow because of the model, but the key thing is, again, you need to splay open those lateral margins. And again, the advantage of this knife is that it allows you to immediately cut as you're going and injecting. So similar to before, you want to engage your cap to kind of get a sense of the size if you've adequately dissected the edges. And as you can see there, it's still kind of tight. One of the lateral margins is not adequately split and we may need to do a little bit more tunneling on the edge. So we're going to try to see if we need to make any adjustment to the pad. since we're not getting as uh good electro cutting with with this posterior tunnel as okay that seems a little bit better so again just by adjusting the pad on the on the model you guys can probably tell the difference now on the cutting and again what I'm doing is we're just gently opening those submucosal fibers that are attaching our cap And you want to open the semi-closer right underneath this space again. So again, we're going to try to gently torque our scope to see if we can sneak the cap into that space. Still a little bit tight, but I think we're right there. Okay, so now we're slowly entering the space. Again, this is the area where you're not stable, and you just got to gently adjust your scope. We're pushing away just barely. We're barely into the tunnel. As you guys can see, the muscle layer is at the bottom, right? As I mentioned again, sometimes nicking the muscle is going to be inevitable as long as you're aware of that, and you want to avoid a full thickness injury at this particular junction because this is the site where you're entering with your scope. Okay, so we have a question. Yeah, it says, can you comment on how muscular mycosis is thicker in mucosa that shows signs of esophagitis that needs to be cut deeper? So yeah, so as I mentioned earlier, before we started this posterior tunnel, you can oftentimes see a very thick muscularis mucosa. This can be quite common in patients with longstanding achalasia that have developed esophagitis as a result of food stasis and whatnot, and the muscularis mucosa can literally just look like muscle fibers, and a lot of it is just going slowly. If you see a very thick white band right underneath your superficial mucosa, that's probably going to be the thick muscularis mucosa, and you have to get beyond it in order to get into the actual submucosal plane. So again, as you guys see here, I'm already in the tunnel. So as opposed to our previous tunnel, the muscle layer is at the bottom, right? So we have the muscle layer at 6 o'clock. Well, right now it's at 9 o'clock, but as I gently torque my scope, you can see that the muscle layer is at 6 o'clock, and the superficial mucosa in the luminal side is at 12 o'clock. So for purpose of demonstration, we're going to switch our knife here. I'm going to demonstrate one of the other commonly used knives for POEM. The knife I just demonstrated was a hybrid knife. The advantage of the hybrid knife is that it allows water pressure injection. One of the other commonly used knives is the Olympus triangular tip knife. So first things first, we're going to exit our program, and we're going to pick a different program for this particular knife. Okay, so we're going to give it a shot, see if this setting is going to allow us to cut adequately in this explant model. Yes. Okay, so now we got the knife in. So if I can get the camera towards us, it may be a little bit difficult. Let me see if we have the package of that knife. Yeah, here's the package. If you guys can see, this is a triangular tip knife, and as the name implies, the tip of the knife is in a triangular shape. And then this knife is called the Triangle Tip Knife J, J for injection. So as you can see, you can inject through this knife through, currently it's connected to the water port, so I can connect it to a water pedal and inject through this knife. The profile of this knife is smaller than our usual hybrid knife. The other advantage of this knife is that triangular tip can really help with dissection and also for the myotomy portion of the palm procedure. So this is one of the most commonly used knives for palm, along with the hybrid knife. So knife in. OK, so again, we're going to get back in our tunnel. So. Again, we have the muscle there at the bottom and the mucosa on top as we're approaching it from the from a posterior angle, we're going to have the knife out. And you guys, I don't know if you guys can appreciate the difference in terms of the width of this knife as compared to the hybrid knife, right? So a smaller profiles, smaller shaft. But as opposed to the hybrid knife, this knife has triangular shaped tip, which really allows hooking of fibers as you start dissecting. So, again, you generally like to start want to start from the left and then you can come to the towards the right by gently rotating the shaft of your scope. And then you repeat that motion back and forth. OK, so again, that's that's the demonstration of this knife. This knife, again, can inject as well. So if I'm in the in the spot that I want to be, as you can see, I can press on my pedal. And inject through the the pedal that's already connected to the water jet. So, again, you always want to come back, make sure that your tunnel is straight. In this particular case, if you guys see from here, the tunnel may be slightly veering to the right. So by knowing this, I would be dissecting a little bit more on this left side. And again, importantly, keep your tunnel wide enough that it's not gelling off your scope as you move towards the G junction. So again, for purpose of time, we're going to just briefly demonstrate the closure. The closure of the tunnel is going to be pretty much identical, excuse me, to the closure of an interior approach. Again, in this particular case, it makes it a little bit easier for me, because with the tunnel being previously on the interior approach, I had to rotate my scope to position the mucosal incision at six o'clock. Now because it's on the posterior plane of the esophagus to start with, I can just go ahead and not have to rotate my scope at all to have it lined up with my clip. So again, you want to, the first clip, you want to make sure that it's centered well. Close, deploy. That first clip is going to start bringing those edges towards you, and again, by lining it up well, you facilitate the placement of your subsequent clips. I strongly advise, obviously, having a clip that has a rotatability. It's going to make the closure a lot simpler than a clip that does not rotate adequately. And we're going to open the clip, line it up to the gap, make sure the middle of the clip is lined up to the middle of the gap. So when we close both arms, it's going to grab equally right there, close. And before you fire, you want to be able to see that's lined up right in the middle. As you can see there, deploy, fire, perfect. The other nice thing about these clips is they have a very short profile, so after placing the clips, it does not impede your visualization of your lumen or your mucosal incision for placement of your subsequent clips. Open. Open. Great. So again, we're going to make sure we're right in the middle, center, and fire. Close. We confirm we're happy with the position and then we go ahead and fire. Perfect. And this will wrap up our session today, kind of, again, revisiting what we went over. We went over starting a mucosal incision on the anterior approach and posterior approach, with demonstrating how, what are the key components of trying to get that cap into the tunnel, which can be challenging during your initial stages of training. We showed a little bit of some mucosal tunneling, and now concluding with mucosal incision closure. Open. We're going to rotate the clip again. close the book. Alright so this pretty much concludes the learning objectives of today's session. You're welcome to, to join us later to for our additional sessions of this conference. Thank you for joining us.

Dennis Yang

Third Space Endoscopy

Center of Interventional Endoscopy

POEM procedure

Peroral Endoscopic Myotomy

patient position

endoscopy

mucosal incision

tunnel creation

mucosal incision closure