So I think I'll share my video and go from here and then probably we can take some questions together if there are any. So there was a question actually in between about fund application, so we'll just discuss a little bit about that. That reflux has been reported after a poem and the incidence varies from 23 to 57 percent and endoscopic fund application has been described as an anti-reflux procedure following poem Harry Inouye described that two years ago and the learning objective of this video is to learn the technique and just try and understand what this procedure is all about. So it's basically what we do is we do an anterior poem and once the myotomy is completed we perform a full thickness myotomy and after the myotomy is completed we open the serosa on the anterior gastric wall and we enter the peritoneal cavity. Once we enter the peritoneal cavity we attach, we go leftward and upward and we visualize the fundus of the stomach and we attach an ender loop using a few clips to the fundus and then we pull back and we attach the other end of the ender loop within the tunnel to the edge of the myotomy within the tunnel and then we tighten the ender loop and what that does is it pulls the fundus forward and it covers the myotomy to a certain extent and provides a partial wrap. This is very similar to the dorsal fundoplication wrap that is described after laparoscopic helical myotomy and so let's see what this patient has. This patient that we are going to discuss today was a 24-year-old male with dysphagia for solids, seven months history with regurgitation, chest pain and 13 kilos of weight loss. The Zekar score was 10 and manometry showed IRP of 26, he had type 2 akalasia, there was no prior intervention that was performed. So this is a video, so we start with an anterior standard anterior podium, so we are starting about 8 centimeters proximal to the gastroesophageal junction. One important point is we need to be dead at 12 o'clock to perform the entry so that we can access the peritoneum exactly at 12 o'clock. So this is submucosal tunneling and following that, so this is when we are at the gastroesophageal junction and we can see the muscle on top with the palisading vessels and the spindle shaped vessels. The lumen is narrow and we are dissecting across the gastroesophageal junction. Now we perform a full thickness myotomy and we have always been performing a full thickness myotomy, so this is nothing new for us, so we are using the triangular tip knife and we perform a full thickness anterior myotomy and once the myotomy is completed and let me just come back over here for a moment, as we are going down, yeah, so this part I don't know whether you can see my cursor over here at 12 o'clock, so this part is the diaphragm and beyond that is the gastric side, so we need to cross this and then make sure that we open the peritoneum on the opposite side. Now what we do is we pass a transnasal slim endoscope alongside the gastroscope which is inside the tunnel now, so here you can see in the PIP view you can see that the regular scope is within the tunnel and we can see the end of the myotomy and this is the view of the slim scope which is going into the stomach and we position the scope in the fundus and we transilluminate to make sure that the gastroscope is beyond the gastroesophageal junction on the gastric side, so this is how you see the transillumination and this is the diaphragm and the landmark for the peritoneal entry site and beyond that we make the entry over here. So now what we do is we open the peritoneum and one has to be very careful not to injure or damage any of these vessels because these vessels can remember, you need to remember they can bleed into the peritoneal cavity and that can be a nightmare, so we need to use a quiet grasper as the surgeons do and we snip off the peritoneal reflection and first the areolar tissue with some of the fat and if the patient is a heavy patient this can be quite difficult but here we can see that we have opened the peritoneum. Once the peritoneum is opened we usually switch to an insulated tip knife because we don't want to damage the left lobe of the liver although we did create a little bit of a burn on the liver. Okay, so I'm just going to go back and forth over here because this point is the most crucial point of entry into the peritoneal cavity, so we extend the peritoneal incision so that the scope can be introduced inside and once we go inside the peritoneal cavity we insufflate using carbon dioxide and then turn the scope leftwards and upwards and retroflex so that we go onto the fundus. So this is the serosal aspect of the fundus that we can see over here and in the PIP view you can see the view from the transnasal endoscope. Now what we're going to do is we're going to grab the fundus using a big bite, using a firm body forceps, we're going to pull the fundus forward and come back into the tunnel, pull the scope back into the tunnel and this is just a simulation of the wrap. So this is how the wrap is going to look finally, we've just switched the images so this is how the wrap is going to look finally. So now we're happy with this wrap so what we do is we again go inside, we release and what we do is we use a triangular tip knife to create a little bit of a coagulation mark at this site so that when we come back with the endo loop it becomes easier for us to identify the spot. Now we have the luxury as Mohin mentioned of using this detachable endo loop which comes from Leomed company, it's a Chinese company and at the same time one can use the Olympus endo loop as well, it's just that one needs to carry the endo loop along with the applicator down through the, alongside the scope so that is the only issue but what we've done over here is we've taken a clip, we're holding the endo loop, the tip of the endo loop within the clip and now we're going to introduce the endoscope again into the esophagus and into the tunnel. So here you can see we're going inside the tunnel, carrying the endo loop back inside, we go into the peritoneal cavity. We go and find the mark which we had placed over there, we open the clip, make sure not to lose the endo loop from the clip and we take a nice big bite and at this point in time it's important for your colleague who's holding the slim endoscope to desufflate, deflate the stomach a little bit so that you can get a really nice, grab a nice bite over here. Typically Inouye described four clips, we put either three or four clips, it's important not to take any of the peritoneal fat as you're applying the clips, push it aside using insufflation. Now that's the peritoneal side completed, now we pull the scope back and this is the distal end of the myotomy that we can see over here, so we're going to apply three more clips on this side. Now for this we use the short clips because we don't want too much of the clip to remain inside the tunnel because these clips can erode through the mucosa if they are too long, so we use short clips over here, so this is the third clip coming in and now all that remains is to close the endo loop as we observe the wrapping form, so this is the hook on the detachable endo loop which we are now attaching and now we gradually close the endo loop as we are observing in the PIP view, so it's important not to pinch any of the mucosa of the tunnel as you close the endo loop, all that thing can happen, it's important to stay away from the clips and make sure that the closure happens properly and gradually you close the endo loop, you don't want to close it very tightly and very rapidly because then it can cut through, but here you can see how the wrap is being formed, you'll see it a little bit better when that view is made bigger, now the endo loop is trimmed using a loop cutter and we remove the remnant part of the tail of the loop and then the formal closure can be performed but before that an important step, this part of the endo loop, the plastic sheet is quite stiff and this too can erode through the mucosa, so we need to turn it back into the peritoneal cavity where it's going to form a granuloma and there will be adhesions over there, so we need to turn it out, so we just push it out through the opening that we've created into the peritoneal cavity and then we pull back the endoscope, we close the mucosal incision as we would normally do for a poem, this is how the wrap looks, there is of course quite a bit of edema over here because of the dissection but even later on the wrap will be pretty much like this even at follow up, so that is basically the procedure of endoscopic fundoplegation concomitant with poem and we did present our video during DDW last year although it was online, so these were a few of the technical tips that we described that a double scope trans elimination was important to ensure that one remains beyond the diaphragm, decompression of the gastric fundus is very important and using a long reconstrainable clip sometimes to grasp the fundus is important, marking the location of the fundus and not including the perigastric fat is very crucial and using a detachable endo loop really makes things very easy and an important point which we could not show a video on is that we need to perform abdominal paracentesis to reduce the capnoperitoneum at the end of the procedure, so with that thank you so much and I can stop sharing if there are any questions we can definitely take that as we go along or if Moeen is ready to show the rest of the procedure then maybe we can go there as we can continue the discussion. Great talk Amol, I think we are ready to go back to Moeen and answer any questions while we're talking with him as well.

endoscopic fundoplication

peroral endoscopic myotomy

anterior podium

endoloop

technical tips