Okay, hi everyone and welcome to ASGE Endoscopy Weekend from the IT&T Center brought to you by Medtronic. I'm Prateek Sharma and I will be the moderator for today's event. And it's my great pleasure to introduce a whole bunch of experts here today. We are live at the IT&T Center in Chicago and joining me also is Dustin Carlston. So Dustin, welcome. Dustin is here locally at Northwestern University and one of the leading experts in gastrointestinal motility specifically on esophageal disorders. So it's our pleasure to have you here. Then we have a whole bunch of folks who are joining us virtually. First and foremost is Dr. Greg Haber in New York. Greg, good to see you. How you doing? Yeah. Welcome, welcome. Yeah. So thank you. And when we start with you, we'll have you introduce your wonderful team. But thank you, Greg, and the team in New York for being live with us on a Saturday morning. We understand the challenges with that. So we're very appreciative of that. Greg, as all of you know, I wouldn't say deserves no introduction, but does not need an introduction. Greg's one of our leading therapeutic endoscopists, not just in the U.S., but globally. And today he will be demonstrating a live poem case for us. Then we move to actually two people on the West Coast. And Caitlin Houghton is in Los Angeles. Caitlin is one of the leaders in minimally invasive foregut surgery and also a therapeutic endoscopist. And it's our pleasure in this multidisciplinary conference today to have Caitlin with us. So Caitlin, welcome. Great to have you on ASG Weekend Endoscopy Live. And finally, last but not least, is John Clark. John's in Stanford, again on the West Coast. John's been a good friend of ASG by joining us at odd hours to share his expertise on, again, gastrointestinal motility. And he'll be sharing with us a number of videos on high-resolution manometry as well as FLIP. So with those introductions, again, my welcome to the audience for our version of ASG Weekend Endoscopy Live from the IT&T Center. So with that, Greg, we're going to turn it over to you to take us through the case and then look at the videos. Greg? Well, it's a real pleasure to join the ASG for this introductory sort of Saturday morning experts review. So of course, being a Saturday, a special thanks have to go out for the whole team that's here with me. We have our nurses and techs. We have Dana, John, Danny. I mean, they've been absolutely critical in setting all of this up, as you can see. Gopal, our anesthetist, and my trusty advanced fellow, Kiyoon Kim. And then behind the scenes that you don't see, we have our IT folks. So I really want to thank them all. It's above and beyond. So we'll turn over to the case. Let's get started with the case. Kiyoon, could you introduce this case to the audience? OK, good morning, everybody. Thank you, Dr. Haber. We have a case for POM today, peroral esophageal myotomy, for a 20-year-old woman with type 2 achalasia. And she represented with years of symptoms that's demonstrated under the Eckert score. Namely, we look at four types of symptoms with weight loss, dysphagia, retrosternal pain, and regurgitation. We also classify the score based on the frequency, as you see in the table below. Daily, occasional, or with every single meal. And for this particular patient, she reported at least three years of daily dysphagia, retrosternal pain, and regurgitation and or vomiting. And also, within the past year, had an unintentional weight loss of 5 kilograms. And as you see in the table, each score amounts to 2 per symptom, resulting in a total of Eckert score of 8. And as you see below, she also underwent high-resolution manometry in August of this year. And what she had was she had 10 swallows in total, and 100% had failed swallows with what we call esophageal pressurization, those vertical green margins that you see in the high-resolution manometry seen below. And what she had also had IRP pressure, medium pressure of 33.7. Normal is considered below 15. Consistent with type 2. That's good. Yeah, that's fine. So we're ready to go. Thanks, Kyun. So classic type 2 achalasia. What's interesting, she is one of eight children, believe it or not, and has a twin. I was speaking to her mom. And like most of our achalasias, the first year of diagnosis is almost always regurgitation, treated for reflex before somebody clues into the fact that this weight loss is not normal. So we're going to start. Let's have a look. We'll show you what we've got here. Interesting. I'm going through the upper esophageal sphincter. Anecdotally, what I've noted, and this has also been shown in motility studies, that patients with achalasia have a hypertensive upper esophageal sphincter greater than average. It's probably some sort of physiologic protection mechanism against aspiration. But we've noticed this in some of our patients. So then we go down. In her case, I've already done the mucosotomy because of the limited time we have. But we'll go down to the GE junction here. We measure it because we want to know the distance when we go to do our myotomy. You can see it's fairly snug, fairly tight. And we're going to push slowly through. We don't have a cap on this skull, but we pop in the stomach. Now, you'll see here that we're just going to do that right now. A lot of people also have disturbed gastric motility and delayed emptying as well because of the vagal effects. So what I've done here is I've already done a mucosotomy, which I'll show you here. And we'll go back to create our tunnel. You can see we're not very far from the LES. Two recent randomized controlled trials have shown that the short myotomies in types one and two is equally effective. And there's some evidence that it is associated with less reflux than the long standard myotomy that we started out with 10 years ago. I had the opportunity to learn the poem, Way Back When, from Haru Aino, who started it, and Professor Zhou in Shanghai. So that's how I learned. I've been doing it now for about eight or nine years, have over 400 poems under my belt, so to speak. So this is where we are now. And I think what we'll do is, because we have some wonderful motility experts here to share their experience with us, we will put down the endoflip. And we'll have a look at that. So we'll take that. Greg, while you're advancing the flip catheter there, just my question here to Dustin is, should we be routinely doing flips prior to a poem? Let's say you have a good HRM, you've made the diagnosis. What's your approach? Greg, sorry, go ahead. You can start with the flip, and we'll come to you right away. Yeah, no, no. I'm just showing one little thing we do with, I think, a lot of people, the flip do. We stick the end of it in the scope, guide it down with the scope, because it's... Oops, can you turn off the light on the scope, please? Yeah, so you can see that. We turn it into the scope that way to guide it down, because if it's a tight LES, or more importantly, if it's a dilated, tortuous, or sigmoid, it's sometimes difficult to get the flip down just with the peroral passage. So we can ask our experts. We can turn on the light. We'll put this down now. A good technique, Greg. That's really good. So Dustin, any comments on that? Yeah, I think for your first question, I think a lot of it has to do with the certainty of a diagnosis. And yeah, if you have a classic story, classic endoscopy, and a classic manometry, you probably don't need an endoflip on all of those patients. You're already sure of what you're doing. I think, as we'll see here, you're using it to help tailor and confirm the adequacy of a myotomy. And so having it during the poem has, I think, become a really, really useful adjunct to using endoflip. I think when it comes to placement, often when we're placing it just at the time of a diagnostic endoscopy, there's not an open mucosotomy within the esophagus. So that does add a little level of reassurance. Yeah, but I usually do try to just place it. Well, you put the cap on the scope, and I'll turn the light off. Take the suction off. You can feel it. Usually a nice pop when it does go through the LES. OK, where are we now? Coil, there is a little pushback with advancement. It's not difficult to get past the scope at that point. Often just a few little nudges guide it through. Greg, we can start seeing some of the tracings as they're coming up. So Greg, is this pretty standard for you? Do you do this prior to all your poems? Or in some cases, what's your practice? Yeah, I mean, I would agree. We don't do it in all of our cases. If it's classic, if it's not, we know what we're doing. We get a lot of borderline cases. And we sometimes will do this just before the start to confirm that the DI, the distensibility index, is low. So I think at this point, I cannot say that this is practically something that needs to be done. Let's start to fill the balloon, please. Inflate, yeah. But I think it's certainly something in evolution. Abe Kahn and Rita Knotts are motility people here. And they've been a tremendous help. And they do a lot of work on endoflip. Abe has done over 200 endoflips, or pardon me, flips, and has helped us understand, to a large extent, what goes on. There are things we don't understand. When we fill the catheter, we get a higher DI than on the defill. So there are lots of things yet to be understood. But let's just show you the main metric that we use, which is the DI. Where are we at now? Hold on. Stop. We're just filling up, usually, to 30 to position. So just let me deflate. We're at 39. Usually, we like to have about 2 centimeters below the LES, conventionally, with the 16-centimeter flip. So there are two flips. There's the 8 centimeter, the 16. The 16, of course, because of the longer length of the balloon, will give you information on the contractions and the esophageal motility. The 8 is more or less used for sphincter measurements. Our surgeons are using it now when they're doing any kind of fundoplication surgery. So I'm going to pull back. We can see here, the waist here is a little bit high. Her GE junction was at about 42. So if I pull back to 42 on my catheter, I should be... There we are. Let's see here. We've got to pull back here. We'll get to the appropriate spot. Now, let's just pull back a little more here. We want to have about 2 centimeters below. You can see, as I pull on the balloon, I'm pulling back at the mouth. I'm not sure we can insert. You can see we're now getting a little bit of a pinch lower down. And we're just at about 30 ml, and that's just for positioning. And now we're going to inflate our first measurement. Generally, with the 16-centimeter balloon, you can inflate up to 70 ml total. But the measurements are usually 50, 60, and 70. A lot of people use the 60 ml fill as the standard that they like. So let's just... No, we're still on. We've got to pull back here a bit. Sorry. I'm going to pull back more. We're down too far. There we go. Let's just... Yeah, there we go. Nice. Now we're going to get it coming back a little bit now. Just get it back. Okay. Yeah, I think about... Yeah, I think this is probably a good spot. So if we look at our high-pressure zone in red, you can see that. Right now, the DI on that with a very low volume of 40 ml is around three. We're going to increase the volume now. We look at three different measurements. We're looking at the fill, of course, the volume. We're looking at the pressure, which on the top of the screen is at 17. Generally, to get accurate measurements, we like a pressure over 20. And then we look at, of course, the diameter there. So we're going to now go up to 50 ml. So we'll inflate here. And you're supposed to wait about 30 seconds at the whatever fill you go to before you take the reading. We're not quite that sticky about it, but we're at about 50 ml now. And we can see here the pressure now is over 20 at 22.7, 23. The DI, I have to say, is a little bit high. It's 3.4. It's in an equivocal zone. We like to see a DI of less than two. So this is a little bit surprising. But one thing I have noticed is that if you've already gone through the sphincter two or three times with the scope, or if you fill the balloon initially, you'll get a higher or lower DI. It'll be tighter. But on the defill, after you've popped in and out two or three times, the sphincter loosens up a little bit. So I think we have to be a little bit careful with that. So now we pause, usually take a measurement here. But you can see there's no contractility above that. We've slipped up a little high. We're going to pull back a little bit on our catheter. And we're going to go up to 60 ml. I'm not sure if our motility folks have a particular protocol in their institutions that they use. Yeah. Another thing, if I can, about the DI here is your pressure is still quite low. I mean, now you're with some more filling and movement. You're getting it up a little bit higher. But the DI is almost an overly simplistic measure in that the pressure is used as the denominator. So even though we'd like to see it more than 15 or more than 20, the measure really is more accurate when it's up in the 30 mm mercury or more range. But I think that's where you hit it right on the head by looking at all of the measures involved by using, kind of recognizing where you are fill volume-wise, but also using the diameter measure as a nice complement. And even here with the DI being in a borderline range, I mean, the diameter at the EGJ is still quite low. I mean, it's still kind of in that less than 12 range. So this is still definitely consistent with achalasia. But I think also it's not ever meant to be used at a single volume or a single point of the study. But instead to take the whole study at a global impression. So there's still some room to go here. So I'd like to see what this flip looks like at the 60 and 70 ml fill. And again, for our audience, you know, if you're joining us now, you can put in your questions in the Q&A box. And we'll make sure that those are answered by our experts. So while Greg's doing that, Caitlin, a quick question to you is that, you know, Greg mentioned the short versus the long myotomy, you know, compare and contrast the Heller's versus poem for us in which, you know, we can regulate the myotomy. We've gone from a long one to a short one. What's your practice right now for Heller's, for example? How do you approach that versus a poem? Yeah, so I actually think this is such an interesting area. And we can, we have to study really for Heller's because traditionally Heller's we were taught it's a five centimeter esophageal, five to six centimeters esophageal length with two to three centimeters on the gastric cardiac, which, so that's like a total of us, an eight to 10 centimeter myotomy. And what we're learning from home is that we might be able to tailor that with endoflip. So in every single one of my Heller myotomies now I do use endoflip. And we haven't started tailoring and doing the shorter myotomy yet, but I think that's the next step. I think we've been using endoflip right now just to confirm the myotomy, the adequacy of the myotomy intraoperatively. But I think the next step is really to take that information from poem that we can probably do a shorter myotomy and tailor it to the endoflip and do a shorter myotomy. And I think that will really change kind of our practices for the myotomy. Okay, great. Okay. So basically, I don't want to take too much more time with this. We've went up to 60 ml. We have a DI of about 2.5. I'm going to come out now. I think that it's all compatible with what we find on her HRM. And so we'll just come out, we'll deflate, and we'll go back down with the scope. Could we go to a room image, please? So with our scope, we're using an Olympus HQ. One of the things we will show you is, sorry, I'll just hold that. Thanks, man. That we like a tapered cap as a rule. We use this for all of our basically ESD, all our third space work. The one we use here is 29, the DH 29. There are different sizes, obviously, depending on the scope. The HQ takes a 29. The Q takes a 28, that sort of thing. So now we'll put on our suction, and we'll go back down and start tunneling. We've taken this out. We can stop that. We're okay to go with that. We take that out. Okay. So we have the cap on now. And you can see where we've done the mucosotomy. You could either go posterior, which is not really true posterior. We usually go by our landmarks by looking at the spine. Patient is supine. The reason they're supine is that we're constantly feeling the abdomen. We always feel the abdomen before we start because, believe it or not, we have some people who are morbidly obese with achalasia, but we want to know how distended that abdomen is because if we get capnoparent neum, we want to be able to compare it to what happens before we start. So we've always got a hand on the belly beforehand, and we'll go down. So as I said, you can either go posterior. If you're not sure where posterior is, then you just put water in. You put water in, and you see where the water lies on her back. Obviously, the water is going to sit posteriorly. So we've already done all of this, and her GEJ was measured out between 42 and 43. With achalasia, when you're pushing in because of the tight LES, you get a longer measurement down 43, 44. On the pullback, because of the grip, it's shorter, 42. So we take the average of about 43 centimeters. And we're taking it now. We're doing shorts, as I said, on the types one and twos. So we're back about at around 37. The idea is or 36. And then what we'll do is two centimeters below the mucosotomy is where we start the myotomy. So we've already performed the mucosotomy here. You can see this is a little more anterior, which is we've tended to go more anterior. I'll talk a little bit about the anti-reflex poem, which is, of course, avoiding the sling fibers, which are important in maintaining the acuity of the angle of hiss. So we're trying to, as much as we can, preserve the sling fibers in order to reduce the amount of reflex. I can talk about that, the studies on that. So here we are. We've done the mucosotomy. The tapered tip cap helps us get in quite easily. We flip it around sometimes. We'll just mechanically spread this apart. And then we'll, we've injected it before. So we'll just, we should be able to get in in a moment. There we go. It takes a little bit of back and forth motion. And then we're in, here we are in the tunnel. Now, what we're using for our tunneling is we use the i-knife, which is the hybrid knife, which we can inject, of course, and cut. One of the things I always do, I'm not sure if the room camera can show this, Sean, is, but when I put my catheters down, whatever they are, I put them down to the end of the scope. And then what I do is we just always tape all of our devices. So we put a tape on. So we know as we go back and forth in and out, sometimes you want, you want to be careful you don't jam the device into the tissue. So that's why we do that. Now we'll put the knife out, please. Advance the knife open. Yep. Knife out. Needle out. Yep. I know, there it is. Okay. So now we can just to inject it in the submucosal plane. So now we're, and we're, our settings on our vial, um, we have what we call precise sect. We kind of flip-flop between force coag and precise sect. I'm not 100% certain which is better. The theoretic advantage of precise sect is that it will coagulate vessels as it cuts through. We've seen this work some of the times, not all the time. I use an endocut program for cutting through the tunnel. Some people use dry cut. I like endocut because of the pulse nature of it. I feel I have better control on dry cut depending on the tap of your foot. So we're using endocut 223, and then it's on precise sect. Now we may flip to force coag. Okay, so let's just open this up a bit. This is a very, you know, a young woman, as you've heard. I've already cut some muscle here to show you something here. So you can see here the muscle, the circular muscle. So we want to go, of course, uh, perpendicular to the circular muscle so we can follow the the direction of the tunnel. So we'll just keep cutting here. This mechanically is opening up. You can see kind of the the air bubbles. Now let's just try to get this turned around here. Now we're just trying to get the right angles for cutting. Now, so there's a little vessel there we see. We'll coming up out of the right where blood is always your enemy. And so we're very careful to try to identify these vessels before. We'll give this precise sect a chance to work. We'll see what happens. We'll go very slowly. It's fairly aggressive precise sect, I have to say. What we always have in our back pocket, of course, is a is a Kauai Grasper, which is for larger vessels. You know, in any arterial with one millimeter or more, we tend to like to use that. So we'll keep going down the tunnel. Here's a vessel a little bit bigger. Let's take the Kauai Grasper. I must say I've become a little bit more, I would say, cautious, if you like, because I hate bleeding. It just interferes with your vision of the tunnel. So even though this vessel is not that large, and maybe the precise sect would coagulate it, I tend to err on the side of no bleeding whatsoever to deal with. And once again, this is a new device. I'll take my tape, grab an inset of what I'm doing as we do this. Let's have a PIP, please. Okay. So while you're doing that, is there a knife you can use so you don't have to switch between the knife and the Kauai Grasper? What's that? Oh, well, I mean, you could use, there are different techniques. Open. You know, you don't have to go back and forth. Open. Close. But a lot of people use what I call the Saito technique, which is using forced coagulation at very low wattage, 8 to 10 watts, to coagulate the vessel with whatever your cutting knife is. So it's sort of a coagulate the entire vessel with low wattage and then cutting through. And that way, you don't really have to change knives open. But, and that, again, works for vessels up to about a centimeter. Gotcha. Greg, what we are going to do is, you know, have your end-of-view on as we go now and look at some of the HRM cases. And at any point, if there is, you know, if you reached a landmark or something you want to show, just interrupt us, we can go back to you. But we can see you, PIP, as well as the end-of-view. John, you've been quiet, but also quietly answering some of these questions online. So I can see that very nicely done, John. So, John, we'll have you share your screen. And while you're doing that, you know, Dustin, one of the questions that John was trying to answer is about, you know, these different volumes being used during flip, you know. So how do you do that? I mean, it appears like everybody has a different technique of doing it. Either you fill it up to 30, you stabilize it, and then you start at a higher volume and then drop down, or should you just do it at one volume? I mean, what it seems like, is it not yet standardized? I mean, what's your approach? Yeah, I think that standardization is important, and we've certainly done a similar, but we, you know, it's an internally standardized protocol that we would hope people would adopt. Because it is important, depending on the protocol that you use and the outcome and the measures that you'll get. Part of it has to do with the parameters and just the performance characteristics of the flip. Obviously, incomplete filling is going to have a different degree of stimulus on the esophagus that can have impacts on pressure, as well as even susceptibility to some artifact in measurements. You know, we talk about kind of filling and then emptying the flip balloon. That has a different stimulus on the esophagus. There's that active distention that is going to elicit some of the tone and contractile response that you see with active distention of the esophagus. But if you fill and then remove that stimulus, that's a completely different stimuli now, and there may be a little bit more relaxation that is actually elicited. Yeah, we have some data that shows that those parameters, even within patients, can actually be pretty different among patients. The clinical relevance of that is one of those things that remains in evolution. But yeah, but I do think that, you know, if you're applying normative values, if you're applying values from disease states, that looking at the standardized protocol from which those were derived is still very important, and that involves the filling protocol as well as the volume of the flip. OK, thank you. John, we can see your screen, and thanks for sharing that. So what we are going to do now is have John walk us through a high-resolution manometry tracing. For those of you joining in who are interested in POEM or wanting to learn more about it or motility disorders, I mean, this is the key. You need to understand the basics. So John, over to you. Sounds good, sounds good. I'm going to do three very quickly. And this first one, if we take these files and open them, this is what we get with the first few. We start off looking at the landmark. And so as I click on this, I've got the upper sphincter right here with the mouse. I've got the lower sphincter at the bottom. The very first thing that I'm doing is I'm going to look and find the point where you get a change from the abdominal towards our thoracic pressure, which is right around here, and that's the diaphragm. So I'm going to mark that, and then I'm going to mark this point at the top of the sphincter, this point at the bottom, set the range looking at sphincter opening, and then I'm going to set the gastric baseline. Then once I've got those in place, then I'm going to lock that, and then I'm going to look through each swallow. And for each one, what I'm looking at essentially is first what's happening with the sphincter at the bottom. And is that going to a pressure which is appropriate? And here it looks like this does open. And then I'm looking also at the esophageal body, looking at the contractions. Is there peristalsis that looks regular? Does pressure look pretty appropriate? And do we see any sort of interbolus pressure? I then can click on also the impedance, which looks at flow, and that's something which can be as bright or dark as you want. I'm adjusting this so it's not quite as distracting. And if you look at this, it's clear that we've got a very nice contraction that's going down. We're not seeing any retrograde escape. It looks like the sphincter is opening, and this looks appropriate. And then I'll very quickly just look through every other swallow, and you can see that this looks approximately the same. Now, you don't have to have 100% peristalsis to have a study that's normal, but in this particular case, we do. Now, once those 10 swallows are done, we then look at a few extra maneuvers. And so in this particular one, we ask this patient to swallow five times very quickly. And what you should see is that you should have this extended relaxation of the lower sphincter, and then you should have a post-agglutinative contraction that's augmented. And so this looks totally appropriate, as this one does not, but typically we do three of these, and we use the best case example. And where this factors in is that if we were thinking of doing a reflux operation with this patient, if they do have a post-agglutinative contraction, which looks augmented, they are less likely to get issues afterwards in terms of a post-operative dysphagia. We then switch towards upright swallows and do exactly the same thing with five. And these are not marked appropriately, but the bottom line is it looks like everything looks normal. Now, contrast this with this next study, which I'm going to show. And so let me go back towards the landmark. And what you're seeing here with the landmark is that the LES is up in this area, and I'm going ahead and doing a marker there, but you can see that you've got a large pressure band that looks like it is well sort of beneath the LES. And so based on this situation, you have a hernia. I'm going to lock this in place. The background that I'm not telling you in this particular patient as we go through is you can see that there's higher pressure in this area. It's not relaxing. You do have peristalsis that's appropriate. And as we go through, you're seeing peristalsis that looks pretty good, but it looks like you've got very high pressures at this area. And what you're seeing here is that this patient has had a LYNX device, which has slipped down. And what we're now seeing is outflow obstruction with the hernia with LYNX. And if we turn on the impedance and kind of adjust that, what you actually can see on this one a little bit is that you've got bolus flow coming down. It's getting pushed down with peristalsis. It's then sitting above the LYNX and going back up. So, you know, this is a patient where unfortunately there's not a lot to do except for going out and taking the LYNX out. Now to briefly just show one more, I'm going to stop sharing here and then load up the next one. Since the theme of our day is echolasia for this, I wanted to show one case as well of that. And if you think back to those first two, which I showed that had peristalsis that looked pretty normal, contrast that with this. Now in this particular study, you can see that we really don't have a great gastric baseline. And so when I'm setting this right now with the landmarks, I'm putting the gastric baseline at the very bottom of the screen, but just keep that in mind because our sphincter relaxation parameters are referenced towards gastric baseline. If you don't have a great gastric sensor, it can throw that off a bit. Now, going through as we look here, you can see you're not seeing any peristalsis whatsoever. And you can see, despite the fact that we don't have a great gastric baseline, we still have an IRP that's listed at 29. And as we go through and this person's swallowing more and more, you're starting to see pressurization within the esophagus. So this is, we go through more, you're getting a little bit of pan, a little bit of pan esophageal pressurization. With rapid swallows, this is more prominent because the volume ingested is more. And then once we go towards upright, at that point, it's more obvious and there's pressurization. If we were to look at this as well with impedance and turn that on, you can see that as we go through, there are no swallows in which this is clearing. Everything is really dystasis. And so based on this, you're very comfortable saying that this patient has achalasia. Technically, the type one, type two distinction is based on pressurization with an isobaric contour above 20 within the supine swallows only. This patient may not quite meet the type two with that, but we're seeing a lot of pressurization with the rapid swallows, with the upright. So I would treat this patient the same way as with the type two. And I think home in this situation is very appropriate. This particular patient would probably do well, quite frankly, with any of the interventions which are out there. So I'll stop sharing here and turn things back over. Okay, thanks, John. Wonderful examples. Again, for our virtual audience, please have those questions coming. And we can still see the nice tunneling which is still going on in New York. And Greg's doing a masterful job if you are paying attention to making sure he's, you know, making sure those vessels don't bleed. And he's got a very nice tunneling happening there. So Dustin, perhaps as you start sharing your screen and we look at some, maybe some cases with you. John, my question to you is that, you know, we've been talking about POM. Of course, that's the theme of, you know, this weekend endoscopy live program today. But how about PD? I mean, we haven't touched upon pneumatic dilation as a treatment for, you know, the tracing that you just show of a possible type two. So what's your approach? I mean, would that be a reasonable option to offer these patients? Yeah, yeah, it definitely would. You know, I think that for type two patients, they're likely to benefit from any of the interventions and it often factors into what the patient wants and also the individual characteristics. And so, you know, people who are older, if people tell me that after they've been stretched, you know, prior to 20 or after just endoflip, they felt better for a week or so afterwards, I'm a little more inclined to push towards, you know, at that point doing dilation. My general, you know, approach with them in clinic is after we get the diagnosis, I sit down and we talk about the options. We say, we've got POM, we've got Heller, we've got dilation. You know, based on the information that I have from your barium, your past clinical history, your manometry, your endoscopy, I think you're likely to get benefit from, you know, from one, two or three of those. And then we sit down and talk about what's important to them in terms of outcomes. There are some people who say, you know, I feel miserable. I want the one thing that's most likely to just resolve this. And those people I'm more inclined to send towards Heller, towards POM. There's some people that say, you know, I really don't want to be in the hospital now. I wanna just, you know, get this done quickly. And we can typically set up dilation faster than we can set up the other two. So in that situation, we are doing it. At my peak, I was probably doing about 15 to 20 pneumatics a year. And I'd say right now it's probably about five to 10. Most people that I see are opting to get POM now. And I'll say a lot of the cases that I'm doing pneumatic on now are people who either got it before and got benefit and then come back about five years afterwards, or people who have had a prior Heller or POM and aren't doing as well. And that group, you know, we are starting to see, I think, a little more often. Okay, thanks, John. Caitlin, we'll come to you in a second, but let's go back to live to New York. So, Greg? I just thought I would mention that, you know, we're coming to the end of the tunneling, just to let you know what we go by. So obviously, it's sort of like going over the top of a mountain and into a valley when you go beyond the LES into the gastric side. But other things we look for are the spindle vessels that we see this on the side, I want to point that out. These are kind of vessels with little knobs on the end, little ectatic areas to them. And then, of course, we go by the distance. You know, we're down here to basically about 45 centimeters. We know that that sphincter is at around 43. We want to do a myotomy on the gastric side of approximately two centimeters. So we're more or less where we want to be from the point of view of being at the end of the tunnel. I'll take a little bit more, then we'll start the myotomy, which we generally start approximately. So I just wanted to point that out, and I'm going to do one more line of cutting, then I'm going to go to a TT knife to begin the myotomy. Okay, excellent, Greg, great progress. We'll continue following along as we move to our next comment here. Caitlin, so you're in a very sort of unique position of doing both the Heller's and the poems. So when a patient comes to you, which way do you lean? I hope this is the endoscopy program, so you'll say poem, but let's just see how do you approach this and what's your take on this with your patients? Yeah, you know, it is an interesting position because we know that both Heller and poem do a really good job at treating atlasia. And so that conversation for me is a lot about that, and then also about acid reflux. So, you know, if patients have true acid reflux, and I think it's hard sometimes because patients confuse some of their symptoms with acid reflux, so you have to be a little astute as far as when you're talking to them, whether they actually have evidence of acid reflux or not pre-op. So we talk a little bit about that as a concern. But I think, and I think that if they've had a lot of previous, so that's one thing. So if they are really concerned about acid reflux, I'll probably recommend the surgical approach with fungification. Although I've been really impressed with my poems, actually, with even doing objective studies post-operatively at one year, and they're not having the reflux that I expected them to have. So we talk a little bit about that. And then I also, if they've had a lot, if they've had years and years of atlasia and they've kind of been putting this off and they've had a lot of other treatments, like pneumatic dilations, they've had Botox multiple times. Those patients are challenging, especially right at the G-junction of the spleen fibers, they're really sticky. And so I hesitate to do a poem in those patients because I know how difficult that those fibers are to get out, to kind of release. And so I'd rather have the control surgically to be able to really visualize those fibers and tailor it then to the end of flip. But they tend to be more challenging. So if they've had a lot of previous interventions, I'll probably go towards a Heller. Honestly, at this point, it's a 50-50 for me. I do about the same amount of poems as I do Heller, honestly, at this point. Okay, great. Dustin, talking about, you know, Caitlin mentioned reflux, post-poem, post, and specifically, I mean, you see some studies analysis, it's as high as 40%, 50%. Then there's also this disconnect between, you know, that the pH study is positive or you're seeing low grades of erosive esophagitis, patients asymptomatic and the other way around. So tell us, what's the true number? What do you tell your patients? What percentage of patients will have true reflux after a poem? Yeah, I mean, that's a great question. And I think it especially comes down to trying to interpret some of these esophageal pH studies in a achalasia patient that has absent peristalsis. There always is that degree of retention and poor bolus clearance. And sometimes it's not truly acid that's coming up out of the stomach. It's not gastroesophageal reflux. It's more just acidification of the esophagus. Yeah, I still use the, you know, kind of postpone 40% to 50% risk of having reflux. You know, with Heller, I make it clear to patients that the risk isn't zero there. Even there, it's probably more like 20 to 30% over the long term. But I think also an important point that I do make to patients is that for the most part, in either of these scenarios, it's usually very easily controlled on PPI. And despite what they may see in the popular media, PPIs are very, very safe in both the short and long term. And so that being on a PPI long term is not really a bad outcome in my mind. But at the same time, it is at least just informing patients and educating them and allowing them to have a chance to weigh in and sometimes tailor to their, always tailoring to their preference to find at least the best treatment that they're comfortable with. John, anything to add to that? Do you tell your patients anything differently? And talk about this acidification that Dustin just mentioned. Is it fermentation from the bacteria? I mean, why do we see these abnormal pHs post-POM? And should we even bother measuring pH after, you know, in these patients with achalasia? Yeah, it's a great question. I can say in our practice, we, you know, typically 12 weeks after POM, we'll do upper endoscopy, wireless probe, barium study, and a flap. And it's partially to see where things are. It's also partially to get a baseline. So if in two or three years, they're not doing as well, we've got something to look back at and say, at this point, you had this. And right now, what we've done is we've, we've placed them upon a PPI after POM. We stop it about a week prior to testing, and then we test off. And if we look with the endoscopy and they don't have inflammation and their testing looks good with the wireless, then we keep them off. I saw one patient in, in fact, yesterday that I kind of scratched my head with, because she had no symptoms of GERD post-POM. She had no signs of inflammation with biopsies or with esophagitis, but her acid exposure was 28% with the wireless probe. And, you know, I think on one hand, you know, you don't want to just treat the numbers. And I don't want to keep her on meds indefinitely based on just acid, if she has no inflammation and no symptoms. But on the other hand, you know, 28% is not nothing. So, you know, I think these are the things that we wrestle with. The other thing, just to kind of, you know, to add a little complexity to it is that, you know, patients who get GERD after these interventions, you know, there is also a subset that gets barren. And if they get any, you know, just plastic change, you can't necessarily ablate them with, with, with, with, with AFS myotomy. So I think this is something that we need to keep in the back of our mind, because I have a cohort of patients who have Barrett's, you know, with achalasia and prior therapy. And I think as, as POM really takes off and we do have more, more, more GERD, that this is something that we'll probably see more, more in the decades to come. Okay, thanks, John. Greg, we're going to move back to you. I mean, it sounds like you're just ready there. So tell us, you've started with the myotomy and finished quite a bit of it. Yeah, so if you have the image here, I'll show you what we've done. I mean, basically the sphincter segment itself is about 3.6 on average, three to four centimeters. So we do a full thickness, longitudinal and circular over the sphincter segment. I tend more proximately to preserve the longitudinal just as a little safety measure for me. When I see a little band like this, I'll probably just take that out because it looks like it might have some influence, but I use just Swift-Coag. I can burn through those little bands without going too deep. One of the other things we do is, our anesthetist has the patient on a PEEP of eight because there is percolation of CO2 into the medial sphinum, and we want to preserve lung expansion. So we do a PEEP of eight. Now you can see full thickness here. And when you go down here, you can actually appreciate sort of when you go over the Rubicon, if you like. You can see the valley of the stomach side back there dips down, and this is sort of the last remnants of the sphincter. So we'll just cut through here, and we just use Swift-Coag, and then we'll cut underneath. We always are very cognizant of big vessels in this area, so we're very careful. A little bit of Coag, Coag, and then we'll go through. On the reflux, I have to say that since we've sort of been paying more attention to the sling fibers, Stavros has perhaps got the most experience in the U.S. of anybody with Coag. Did a beautiful study presented at DDW last year going into press soon, where he looked at the differences in the reflux since we were paying attention to the sling fibers and the penetrating vessels and going more anterior. And his, on over 300 patients, comparison of prior to 2018 and after, the number of patients who had a reflux episode more than once a week was only 7% in the patients who had the anti-reflux poem, where it was about 20% in those who didn't. So I think we are making some head roads into sort of controlling the reflux. So we're just gonna keep going here a little further. So Greg, show us, you know, again, for the people just getting started with poem what are the landmarks that you use to say that, okay, you're close to the LES, now you're getting to the gastric side, you see this thing opening into the tunnel area when you do that. So show us some of those landmarks, Greg. Well, I mean, there are basically three things that we use. We use, and we confirm later, we'll show you the double scope technique in about five minutes. But basically we look at the distance, so measured from the luminal side, and then we go back into the tunnel and see. So if we come out to the luminal side, we go down here, we can see, for instance, the bulging underneath from the injection. There's a little cautery effect there. So that's a little burn. We watch for an mucosal injury. So we look at that, we look at the bulge that we've created. We're down to about, on the gastric side here, we're down to about 44. I'll suck out the stomach while I'm here to reduce that. Now when we come back and go into the tunnel, which is here, we'll just work our way, something a little tricky, there we go, we're in. Now we'll go down here, we've done, we start our myotomy two centimeters below the mucosotomy. And in the short myotomies that we're doing, almost immediately we're cutting into sphincter. So here we see complete eradication of the circular and longitudinal. And then we go down to what we thought was the sphincter, which is around 44. We're at 44 now on the tunnel side. But I can see I have a little bit of a band to go through here. So we want to take it about two centimeters down onto the gastric side. Now here we're going to see epiphrenic fat pad. We're going to see, we see a big vessel down there. We've got to avoid the gastro duodenals in this area. So we've got to stay very superficial. And we burn very carefully. And you can see here, we're going through to the subsurrosal area, if you like. At this point, we're watching out for our CO2. And I'm going to just take this out here now. And what we always have handy, which I'll show you, which our surgeons, of course, are very familiar with, we have disposable varasneal. We'll go close up on this. So this is if we get our sort of perineal cavity full of CO2, we fill. Early on in my experience, the first 100, I think I did this about 20% of the time, relieving the pressure. But now it's down to about maybe 5% of the time. I know you're not showing the needle here, Sean. Needle's here. You're looking at the wrong person. So our cameraman's just a little bit tough. It's a remote camera. Anyway, I think people, a varasneedle is a disposable varas. It's the way you can puncture the perineal cavity. It's got a retractable obturator in the middle. Prevents damage to the gut there. So let me finish this so we can show you how we, you see that big vessel there? You gotta avoid that, obviously. We're very cognizant of vessels, as I've told you. And now then we'll go back with a double channel. We'll show you how we confirm that we've cut enough of the muscle. So Greg, nicely done. We have exactly four minutes till the end of the program. So we'll let you wrap that up and come back or we'll continue watching and just let us know when you're doing your double scope technique there so we can get back at you, okay? We'll do it right now. Okay, perfect. So I'll be waiting on that. Dustin, do you have a brief clip on what the flip looks like post poem? Sure, I can pull up a post. So because we just looked at what it looks like pre-poem, so let's try to figure out how that looks like. Okay, go ahead, Dustin. Sure, yeah, so here's a patient who has had a poem and is doing very, very well, a resolution. You need to have this here if you want to do it. Stasia, good emptying on a barium esophagram. Did have some Los Angeles diabetes, actually, at one point of an earlier evaluation. Yeah, esopharospheres, global. Yeah, here at the 50 ml fill volume. Based on time, I'll skip ahead. We do focus more on the 60 ml fill volume, just reaching a point here where the flip is at a good point of still being within a compliant range of filling, but yet exerting enough pressure at the EGJ to open this up. And we see here now, very good opening at the EGJ, diameter here coming out at 18 millimeters, DI here at seven, even with the pressures right around 30 here. So looking at all the factors together, and as I mentioned, it's not just focused on DI, it is looking at the diameter and pressure as well. But this is obviously showing that this patient had an adequate myotomy. It did have some mild reflux esophagitis, and GERD is not really as well detected with FLIP or even manometry. But certainly the outcome here is still based on the endoscopic finding. But this is a good adequate myotomy. They're not showing to the audience. There we go. Once they come back on, yeah. Excellent. Well, great. Great, we are back at you. And you can see, you know, literally the light at the end of the tunnel. Can you see? Yeah, so basically what we do is we take an XP scope, which is in the stomach retroflex, and our dissecting scope is in the tunnel. So that's at the back in the tunnel. And you can see on that side, it's anterior. So we've got an anterior myotomy, which is what we want for antireflux. And we're well beyond the GE junction. So we're happy with the extent. Now we'll come out and put clips on, but that more or less is the end of what we're gonna be doing. Okay, nicely done, Greg, and congratulations. I mean, it's been less than an hour since you put the scope in and didn't even start the dissection, and you're done with the poem. So very nicely demonstrated. So we are right towards the end of the program. So first of all, Greg, congratulations, and thank you to you as well as your team in New York, number one, for a masterful job at poem, but number two, also on a Saturday morning for being with us. So that was great, Greg. Thanks a lot. I truly appreciate that. So thank you very much. And my team here has been unbelievable. I think I mentioned Ashford, anyway, everybody. Yeah, absolutely, Greg. So good. We'll see you soon in person shortly, and then, of course, to the rest of our panelists, starting with you, Caitlin, thanks again for bringing in that very important perspective of a surgeon who's involved in advanced endoscopy as well and being able to do that and how you manage your patients, and then to our motility experts, both John as well as Dustin for being here and for walking us through this very complex yet common area that we see now of achalasia and different motility disorders, which now we have a very good endoscopic treatment for as well. So guys, all around, thank you very much, and to our virtual audience for joining us and for some great questions, which we'll continue answering, and then this will be available on GI Leap in the near future. So thank you all very much. Signing off from the IT&T Center in Chicago, this is ASGE Weekend Endoscopy Live. ♪♪

poem procedure

Dr. Greg Haber

achalasia

myotomy

high-resolution manometry

gastroesophageal reflux disease

live demonstration

IT&T Center

Chicago