All right, thanks everyone for having me here. James, Peter, Asma, thanks for having me at the stage in ASGE. Hope everyone's had a really good day and heard all these brilliant lectures. I've enjoyed listening to them as well. I'm Neil Sherma. I'm going to take you through two different cases. Here are my disclosures. The first case, I was asked to give poem tips and tricks. Maybe I'll pause a little bit and pick on Dennis and Peter as we go through this case. So I'm going to focus a little bit on the tunnel in this portion, but I think all the various steps broken down are important. So this is a 43-year-old male who underwent a hyaluronidotomy and a NISN for type 2 akalasia. About two months later, it comes back with ongoing dysphagia symptoms. Eckhart's score is actually about a six or seven. We're impressed by that. So we repeated an endo flip and he had a very poor distensibility, less than one. So we thought we'd do a posterior poem to help this young gentleman. So first thing I do when I go look at a poem is if I'm going to go posterior, I want to know what's posterior. So I do a drip test. Usually the patients are on their back. You can see the spine. I'll go a little bit lateral to the spine. So here you're just seeing me do a little drip test. Then I pick a nice flat spot. I typically am still doing somewhere around an 8 to 12 millimeter or 12 millimeter length or centimeter length of actual poem. So I like to pick a nice flat spot. You have some leeway to go back and forth. So you don't have to go at exactly 12 from the G junction. I certainly will pick a spot that's flat. And I know I can enter this area very easily. So I guess I'll ask maybe Dennis and Peter, what do you think is the most difficult part of the poem procedure? Is it the very first part, creating the tunnel, going through the tunnel, doing the myotomy or closure? Yeah, I can, your mic's not on though. So I think most trainees will agree that entering the tunnel can be one of the most difficult aspects of the procedure. As you demonstrated there, once you follow doing the mucosal incision, even though it's starting to open up, that mucosal incision is still being attached by plenty of submucosal fibers. So unless you clear that up, trying to sneak the cap in there can be quite challenging. Agree. Anything to add, Peter? Well, I mean, I guess the most difficult one is the one that gives you trouble. But in each stage has different challenges, obviously. Entry early in the learning curve tends to be a big challenge. Once you get past that, to me, preemptive hemostasis becomes the most essential part of the procedure because that slows you down tremendously. If you don't do it right. And that can make it or break it if hemostasis is not handled right. So if I am to pick up one, hemostasis will be the most difficult part. Okay, good. I have different answers. I think all those challenges, it depends on the patient for sure. You know, one thing I've switched for entering the tunnel is to use a dry cut now. I really like the dry cut. It allows me to get a nice clean cut and get into that area. I always dissect the fibers a little bit, the SM fibers to widen that tunnel in the very beginning. Part of the key you'll see is really making the tunnel wide. And since it's a posterior approach, I'll go upside down to get into the tunnel. I think in the beginning you might find that to be a little bit easier. Once the tunnel is created and you've extended the submucosal fibers to get a nice width, it's easy to come in and out. You need to be able to come in and out because there are going to be times we're going to go back, check the mucosa, and then go back again. This particularly getting into a wide aspect of the tunnel will give you a lot more movements, which will be important for the myotomy. It also gets you a lot more leeway if you were to get into some trouble like bleeding, for example. So you really want a nice wide tunnel. So take the time in the beginning to make sure the tunnel has a lot of width to it. You'll really be able to feel a difference in your scope. And most importantly, when you go down to the high pressure zone where it gets very tight, if you have a nice wide tunnel, you have a lot more room. The other big thing is to be aware of your surroundings. Here you can see sometimes you get these wispy fibers that have a lot of bubbles in them. So it makes it a little difficult to see beyond you. You've got to be cognizant that there can be a vessel sitting behind you. And how you approach those is really important. We talked about hemostasis. I'm typically now using, in no conflict of interest, an Erbio VIO3 generator. And I like Precisect because you can actually control the amount of cautery that you're delivering simply by slowing down your cut through a vessel. It's gotten me away from using coag raspers. I used a lot of coag raspers before. Now it's pretty rare if I have to use coag raspers in a case. I'll actually put the side of the blade out, pretty far out, and I'll actually cut with the side and I'll slow the blade down quite a bit. And I think you might see that here. And so I'll skeletonize a vessel, I'll open out a big branch vessel, I'll put the side of the blade instead of cutting with the front of the blade, and I come slowly through a vessel like this. And I rarely have to use a coag rasper, which I find is convenient both for time, but obviously it saves us some money as well for the patient. So that's become a big changer for me when utilizing this setting. The algorithm on this setting, it's very thoughtful in terms of how it delivers the current. So here again, you're seeing that coming very slowly through here. So that time of contact is slow and precise, it's thoughtful, and allows us to avoid perhaps other times where we would have used coag raspers in the past. Now we're getting into the high pressure zone. You kind of see this dip and it really wants to grab onto the scope. So I always am cognizant of the high pressure zone when I first do my index exam prior to actually going into the poem. The high pressure zone can be extremely tight for some patients. Often when you encounter sigmoid-shaped advanced stage akalasia patients, it can be even difficult because of the angulature. Look out for aberrant muscle fibers. Make sure that you're not actually dissecting and splitting open along the diaphragm. I've seen some live cases where people have actually split the muscularis propria there thinking it's aberrant fibers. So it's important to know that. If someone's had Botox before, sometimes you get fibrosis that actually looks like muscle and it's not necessarily going to be muscle. I also like to do a distal injection. I'll inject a lot of blue. You know, there's different ways to make sure that you have an adequate myotomy. We use endoflip before and after every case, but you can definitely inject blue and just retroflex to take a look. It's important to make sure that that myotomy is adequate. We're going at least a couple centimeters past the GE junction. Another way is a two-scope, twin-scope technique, but you need to bring a carton to the room. You can actually put a neonatal scope down into the track, then retroflex and look. Here you can see there's a big blue bleb. We feel like we've made the tunnel adequate. Now we know we can come back, recheck, make sure that the mucosa is intact, make sure there's no nicks, sometimes little cautery marks or white marks that you'll see on the mucosal side. Once that's all good to go, we go forward with the myotomy. We're really thoughtful about making sure that we have a good definition as we go slowly through the myotomy. We have started to vary our technique. In the beginning, we were not doing full thickness at all. Now I do a partial full thickness, so I'll go full thickness about one to two centimeters above the high-pressure zone, and I'll go full thickness one to two centimeters beyond that into the cardia. The other portions, as you can see there, I do a thoughtful, selective myotomy, and then closure is clip closure. I know we're pretty tight on time, so we'll go to the next case, but I can pause if there's any comments from the panel. Great. We'll take some questions at the end, but carry on. Thank you. Okay. Thank you. Not sure how to move to the next case. Be able to advance for me? Perfect. We talked about the alphabet soup for Dennis, so I was asked to talk about STR. This is another set of algorithm or letters. Basically, if you've learned ESD and you've learned poem, the two can fall in love and have a baby, and you have STR, which is submucosal tunneling endoscopic resection. I'll show you a case here of a STR case. Here you can see a gist. Endoscopically, it's been biopsy proven to be a gist by EUS, FNB. It gets reviewed on a multidisciplinary tumor board. The patient's in her 60s. She has a CT scan for abdominal pain, instantly shows this 4.8 centimeter gist. EGD showed a subepithelial lesion that you could see there with normal overlying mucosa. EUS proved that this is a gist with a DOG1 stain that's positive. She's had some cardiac myopathy issues and an MI before. The gist is 4.8 centimeters. It's very proximal. At our multidisciplinary tumor board, the patient was offered upfront resection, but due to her high obesity and cardiac events, they felt like there were some risks and it might need to convert to an open procedure. She opted for Gleevec upfront, got Gleevec, still had another cardiac event, but then recovered from that. She was very hesitant about surgery. We reviewed her again at tumor board. They said, well, now it's decreased in size to about 2.2 centimeters. Can we approach this with an endoscopic approach, with a minimally invasive approach? That's why we're doing a STIR on this particular patient, again, who had neoadjuvant Gleevec. First thing I do is a horizontal incision. This is the same type of incision I would use for a G-POM. I know some people use a vertical incision, but I like a horizontal incision here. Then I want to create a really wide tunnel, so again, very similar to a POM. I'm creating a tunnel and working that third space that Dennis talked about. I'm creating a working space for myself. It's nice because the stomach is so robust that you can really get a nice, big, wide space here in the submucosa, again, skeletonizing vessels. Here there are some very big vessels that approach this area, so I will use CoagRasper. Sometimes you get branches coming off the gastric artery. You seem to be very cognizant when you're into the space, because we're going to actually go full thickness, because as you all recall, GISTs often grow from the muscular layers to layer two or layer four. More often, they're in layer four, like in this case, so it's growing off the muscular as appropriate. To get a negative margin and remove that capsule, I've got to remove the entire lesion. It seems easy. Here's the tunnel. Where's the lesion, though? It's very hard to tell. You look for these little serpiguanous vessels that you're seeing on top of the lesion there. Those very subtle vessels are a marker for where I want to go. I have to be very thoughtful, because I don't want to cut into the capsule of the GIST. That by definition would make it a stage four lesion. I'd split the GIST, and those contents can split out. I want to make sure I dissect around the GIST, not into the GIST itself. Here you're seeing more lifting, and I'm again removing more and more of those submucosal areas that are on to this lesion. You see some heavy fibrosis. That's probably from our EUSFNB. We've actually come through the wall, so that heavy fibrosis is causing a bit of an issue. Now we're exposing the GIST. Now you're seeing this GIST sit up. Originally, when we got in there, we made the tunnel. You couldn't see the GIST at all. Now you're seeing this encapsulated tumor here. We're cutting down into the muscular dyspropria. Down below us is the muscular dyspropria. I'm using a little bit of powered injection to make sure I'm getting away from the organs below it. Remember, cutting through the muscular dyspropria, you barely see any serosa. You can see that powered injection makes it lift up, and here you can see the liver. Know your landmarks. The liver is there on the left, and I'm dissecting the last of the muscular dyspropria fibers off of this lesion. Here's a nice little pause. Liver, GIST, knife, and just dissection along that plane. The last few fibers are being taken apart here. I nicked the liver just a little bit. I like to show when we have some issues, but we had no bleeding from that. It was just a touch. Then here, we're going to take those final fibers off, and then you've got to somehow remove this from the tunnel. Again, adequate hemostasis in the submucosal area is so important. If you're not having adequate hemostasis, you're going to get in trouble. Then you're going to interpare to neobleeding, and you'll really get into some issues. Here, you can see an R0 resection for this en bloc resection for the GIST. Again, the GIST is encapsulated, so we bring it out of the tunnel. Now we go back down. Everything looks okay. You can see that there's a little incision. I go back and look at the tunnel and make sure the tunnel's clean. I go back and look at the liver again, make sure that looks nice. Everything looks fine. Here, you can see the liver edge. Everything looks okay. Now we're going to close this. For my GPUMS as well, I like to suture. I think the stomach's robust. The last thing you want, if you hear from the surgeons, is a gastric leak, so I want to make sure that there's no leakage. So I'm suturing closed this tunnel. This is one of the earlier ones, so I still continue to suture now, but I will sometimes send these patients home the same day. This patient got a 23-hour observation and then went home the same, that next morning, resumed a regular diet, is now over a year out with no recurrence. Hopefully these will not reoccur because, you know, it's an encapsulated R0 resection. Stop there.

endoscopic procedures

posterior poem procedure

tunnel assessment

dry cut technique

hemostasis