Can you hear me well? And we can hear you. Okay, good. You know, with these masks these days, you never know. So you know, we have a lot of people here, my excellent team, and anesthesia, and we appreciate everybody's help. So this is an achalasia type 1 sigmoid esophagus, a very achalasia young patient, and we actually spent an hour cleaning up her esophagus afterwards, on liquids for a week. I made three incisions to be able to get in, extreme submucosal fibrosis, then my incision now is only two centimeters above the GE junction. So with extreme achalasia, you don't have a submucosal space or there's extreme fibrosis open. This is more difficult than usual, and here I'm doing a posterior colon. Typically, I myself, I'm more used to anterior, but in this patient, we're just taking what we get. I'm not going to get out of the esophagus now, because it might be very hard to get back in, but I'll show you eventually her esophagus. We couldn't get a submucosal injection, so you see here, there's a lot of neovascularization in these patients, so you encounter more bleeding than usual. We're in the, just above the GE junction, I'm using a triangular tip knife, and we're using an Olympus gas stove with a cap, so here on the muscle side, and it's one of these perforators. Let's see if I can spray it like that, if I can't, then we'll get a COAG gas stove. What setting are you using? So this is just spray COAG 40 effective, and because we're on the muscle side, I can do that. And if this doesn't work, then we'll get a COAG gas stove, but as you guys know, we just encounter a lot of bleeding in these guys because of the neovascularization. So this is not a case, if you're starting colon, this is not a case to start with, this is, I'll say, a little extreme, even, you know, at the beginning, I almost avoided, you know, we were lucky at the end to, let's clean the knife, and we get a submucosal layer. Actually, I'll be able to show you the other panel that I created, and you can see how the muscle is attached to the mucosa, so it couldn't funnel. Right. Muscle is at six o'clock, and mucosa here at 12 o'clock, you can see I'm funneling at the surface of the muscle. We need to put a mucosa, so that's the main principle with home and submucosal endoscopy. Here I'm using a spray COAG, it works very well, the instance is, you know, it's efficient, open, and I'm using the triangular technology, which was made for these indications. So here we're again seeing a lot of vessels. So once you see a vessel, you want to continue, you don't want to stop. And if you see a large vessel, of course, we are inclined to perform prolactic coagulation. Here I turn my scope a little bit, and you see the muscle is splitting already there. Andrea, you were saying something? Yeah, two questions. One is that, you know, all of the knives that we've been shown so far are jet knives, in which you inject and cut at the same time. My impression is that the one that you're using now is not. So how are you injecting fluid? What's your method? So, you know, we published on this a while ago, with POEM, such close space, you can see I'm just injecting through the scope, and it's a mixture of saline and methylene blue, and it works very well. So I don't need a jet knife. On this knife, as you know, there is a jet, a PTJ, but I don't feel I need it. We go through the scope, as you see here, and it works very, very well. I've done, you know, poems for the last nine years using this knife. Are there any specific settings on your irrigation that allow you to get enough injection with just flushing? Just a regular pump with a regular flow. I mean, it's a good pump. You want a standard setting, nothing really special, but, you know, we published on this maybe in 2013, and we've continued with this technique since then. You see, here, this is the muscle here, and this is the submucosa layer. It's not that clear, but the layer... It's very facile over here. So Moin, just one point about the TTJ knife. One advantage of that knife is, I think, the triangle or the star is much smaller, and so it gives you a much more precise cut. So, you know, that is something which could come handy in a case like this, where there's a lot of fibrosis, because, you know, that can sometimes help. So that's one suggestion. We moved on to a TTJ knife because we still prefer to inject through the knife. So that's our thought behind it. But, of course, this technique that you've shown of flushing through the scope is really fantastic, meaning you can do it with a foot pump, and that really saves a lot of time and also effort from your tech. So that's really nice. Yeah, you know, it's hard to believe that it works. I'm thinking it's probably close. So I've done about 1,700 poems using this technique. So I think that's enough experience that it works. But this is here, the coag raster, open, using a soft coagulation. So here, I like to just at the surface of the muscle with the tip of it, but it looks I'm still alive. Open, please. So you see here, once we get close, once we get to the G-junction, open, close, close. You're going to see a lot of vessels in this person now. So now once we get to the stomach side, get a little bit and do a lot of coagulation. Let's change it now. Mohin, a couple of questions which I have, and there are a few others which have come in very relevant questions. One is, what is the length of the myotomy or the tunnel that you're anticipating? So do you do a short myotomy in these patients, particularly since it's a sigmoid type 1 Echellesia, or would you still do the standard 8 centimeters? Yeah, I would say a standard myotomy is almost impossible in these advanced sigmoids. It's almost an S2 here, and you see a lot of fibrosis. So a short tunnel is okay. We know in type 1, if you do a 3-centimeter, open, please. So if you do a tunnel that's only even a 3-centimeter on the esophageal side, that's enough. I think what's more important is the gastric side. We're still doing 3-centimeter tunnel on the gastric side, but a short tunnel on the esophageal side is enough. We know that in every patient, that's true, right, for type 1, and especially in sigmoids, because it's really difficult and not feasible to tunnel, because the extensive submucosal fibrosis, not just the effacement of the submucosal layer, there's just no submucosal layer. You can't see that list. Sorry, Amita, I just wanted to add one point about the food which you had to clean from the esophagus before you started the poem. So there's actually a very interesting study published by, I think presented by a center from Surat Pankaj Desai. They tried a combination of cola with warm water, and they found that the esophageal clearance really is very good. So that's something that, you know, we also started doing, and we found very good results with that. So patients don't need to be fasting or on clear liquids for a very long time, and that really helps a lot. That's a great point. To be honest, she's been on liquids for a week, and you know, just for the audience, in patients with advanced achalasia and terrible mucosa, you know, all stasis, ulcers, and stuff like that, we do what we call esophageal rest. You know, we either put an NG or a PEG open, and start with it for a few weeks, close. Dr. Keshav, we're having some audio issues on your side, so we will go to Dr. Sawani Nang at Johns Hopkins, and we'll come back to you after. Okay, sounds good. Thank you. So this is the esophagus. You see how dilated and how sigmoid here? We need the endo view, please. Okay, perfect. So this is the esophagus. You dilate it, and here's how sigmoid it is, and now we're at the bottom. So my first incision was this one, and I went in, and I even cut some muscle to pass. Here we see some muscle, but there is no submucosal layer. There's nothing. See, it's attached, and then I just went a couple of centimeters below, and we were able to tunnel here, and usually we start the myotomy just after the incision, but here we have no room, so we started right at the incision, and you can see that the myotomy here is complete, and when we retroflex here, the G-junction looks great to me. Here we go. So it opened up nicely. So even with these short myotomies and these advanced ecclesia, we can accomplish it, but the key here is go to start distal in these guys, and if it doesn't work, then start more distal. So here, just above the LES, but you see the LES really opened nicely. So now all we have to do is close. So you guys can just start the closure with me and then move to other rooms. Moin. Yes. Yeah, Moin, I'm all here. So there's a technique described as an open poem by you know, this is something very similar to what you've done, although you've not really done an open poem. You've left about a couple of centimeters, barely a couple of centimeters there. So do you have any experience, and what's your thoughts about this? No, open poem means no tunneling. You just cut the mucosa, submucosal muscle right away. No tunneling. We tunnel here. It's just very ultra short tunnel. So we have a short tunnel, three centimeters. This is even but it works, you know, and here I want just a word for the audience about the closure. What I like to do is align the incision, longitudinal incision, with my channel, the seven o'clock, that comes at seven o'clock. And open please. So these are the Boston Scientific Resolution 360. So I'll align it with the incision, and please open the clip. Good. And then what you want to do is using your wheels, you want to push down to avert the edges. And close now. Open please. It's not good. Open. So the averting of the edges is important so that you have edge-to-edge opposition. So here, of course, this is not a very healthy tissue. Close. Open. Open. Yeah, open. So I'm going to probably get closer to that one. So Moeen there, this is a great demonstration of clip closure. And I know you also perform closure with two types of suturing methods. What are some things you think about when you're choosing your closure method? So standard is, to me, it's the clips, the easiest closure. If the mucosa is not healthy, you will have done suturing. But even in this case, we can do clipping. So here you see that when I was trying to get close to the first clip, I was not happy with the mucosal-to-mucosal opposition. So I went proximal, and that kind of averts the edges and makes the clipping easier. So here, I'm just going to continue here. And then I have one extra clip to put a little bit more distally. So you see how the clip is not really catching well because of the quality of the mucosa. Go ahead. I'm just going to now reopen. We're going to reinforce and put some clips in between. And just so you know also, for this initial incision that I did, I'm going to also have to close it because I cut a little bit of muscle. If I didn't cut any muscle, then I don't have to close this. But I did, so I prefer closing it. But sometimes when your first tunnel fails, you don't touch the muscle. You really don't have to close that incision. Do you guys agree with that? Yeah, mine usually may not require closure. Even I prefer to close them because there's also a little bit of chance of something bleeding from that tunnel or that attempt of the mucosal incision that you've created. So always a good idea to close it if it's possible. But it's always a good idea to close it if possible. If one cannot and if you've not really dabbled with the muscle, then you can leave it open and it's going to heal anyways. I just feel more comfortable closing it. Yeah, I think especially in these sigmoid dilated esophagus where early on you still might get some pooling of contents and you want good healing, you want to decrease the risk of lack of closure of that mucosa, it might be compromised healing. There's been a really nice description of a mucosotomy using a horizontal mucosotomy with then vertical clip closure that's been described in a video I saw by Caroline Saad from Brazil. That is another method in these type of situations where very thick mucosa, maybe not so healthy, dilated, and it allows a little bit more early entry into the tunnel. So that's a nice different approach. Yeah, and here this is a demonstration. Clipping bone is not difficult, especially posterior because it aligns very well. This is because it's not healthy, but you see it looks pretty good to me. So we're gonna, as I said, continue to close this second one and then we are done. So Mohin, there is a question from Mustafa Mohsin. So he's asking you whether you would want to do a fundaplication with this poem. So obviously this is a posterior poem, you cannot do fundaplication with a posterior poem, but what's your take on that? Well, I think they meant to ask you about that, Amol, but this is a sigmoid esophagus and I think orientation is going to be messed up. My guess is that the fundaplication is going to be very difficult here. I think we'll look forward to hearing a little more of that from Amol's video, but I think Aswani might be ready for us in the other room.

surgeon

peroral endoscopic myotomy

achalasia

sigmoid esophagus

submucosal fibrosis