So, we're proceeding with the last portion, which are going to be the cases, tips, techniques, and tricks for POEM, TIFF, and STIR. And Dr. Riker, the director of Endoscopy at Harbor UCLA, and Neil Sharma, who's the president of the Parkview Cancer Institute in Fort Wayne, Indiana, will be coming up to present these. I want to thank course directors for including me in this amazing course. I have no relevant disclosures. I chose this case because I thought it would nicely echo the discussion that we had earlier today in the first session. This is a 33-year-old gentleman with chronic heartburn, nighttime regurgitation. His GERD scores are high of PPIs. He has no chest pain, no dysphagia. After starting PPI and losing some weight, his symptoms get much better. But when he came to us, we already knew that he has a long segment of Barrett's. He has 10-centimeter circumferential Barrett's, and we opted actually to ablate it because of how long it was and how young he was. And he achieved the complete response. He has a small hiatal hernia, and although he doesn't have dysphagia, on the high-resolution manometry, half of his swallows have failed, like illustrated on the image. Overall, he's not happy. He is worried about his prognosis. He worries he had to go through several sessions of ablation. He worries he's going to come back if we don't do anything for his reflux. And he's young. He doesn't want to take PPIs indefinitely, and he is honest with us. He forgets to take it sometimes, or frequently enough. And he opted to undergo translural incisional fundoplication, and this is a procedure that achieves the same goals of surgical fundoplication with rotational wrap and lengthening of the esophagus. And before I show the video, I just wanted to illustrate the steps of the procedure, so it makes a little bit more sense. We use a helical retractor to elongate esophagus and reduce small hiatal hernias. The purative is set for hiatal hernias of less than 2 centimeters, and then the wrap is achieved. There's additional step where a suction is applied and esophagus sort of gets plastered to the device that allows advancement of this as one unit and achieving the wrap below the diaphragm. So this is how it looks. As you can see, he has a small hiatal hernia, and fortunately we don't see the barrets anymore. And you would see the device advance as essentially an overtube with the scope going through the device. And then the helical retractor is advanced and manipulated and retracted the tissue. And here is how just a simple insertion now is being released from the device. And so you will see that the wrap is being performed as we rotate. So place where the fasteners are placed are posterior aspect at 11 o'clock. So we're essentially rotate device clockwise, and later you'll see it's being rotated counterclockwise. So the wrap is being achieved now. And then the fasteners, cirrusal fuse fasteners are going to be placed. The device underwent various modifications now makes it much easier to perform this procedure. Two fasteners are placed now at the same time, which shortens procedure time quite a bit and allows to achieve the main goal, which is 270 degree omega shape valve, two to four centimeter in length. And then I think one of the advantages of this device is we try to go in a stepwise fashion going 11 o'clock now, you're looking at fasteners being placed at one o'clock, and later placed at five and seven o'clock without a wrap. But you can always re-evaluate right there the procedure you'll see at the end of this video. We felt that at one o'clock we didn't put sufficient number of fasteners and we just added at the end. And that's what you saw that now it's finished, helical retractor reduced and devices withdrawn. This is sort of the view after the devices was drawn. You see the fasteners on the esophageal side and you will see in a minute retroflex view, which with a nice omega shape valve. It's a safe procedure, I believe to now more than 15, 16 cases that are performed, but the rate of complication are less than half of a percent, but they could happen. And in this particular case on withdrawal of the device, we noted that there was a esophageal structure, esophageal tear that you saw earlier was fixed with clips. And finally, since our session titled tips and tricks, I thought I mentioned this, spending couple of minutes really cleaning your endoscope because we use a lot of lubrication to get it through the device and for the placement of the device is going to save you a couple of minutes of aggravation later where you can get a nice valve, but your image and video is not going to be very clear. So it's always helpful to do that. Thank you.

POEM

TIFF

STIR

transluminal incisional fundoplication

endoscope cleaning