Video Endoscopy Conference 10/30/20 Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Endoscopy Conference 10/30/20 Overview Three cases presented here: • 00:00 – Mechanical Gastritis • 12:56 – Hemospray in Active Lower GI Bleeds • 30:15 – Transoral Incisionless Fundoplication So today I'm going to present a case that is from the V A, which is quite unusual, but hopefully this will work out well. It's a case of a 56 year old man who has a history of quadriplegia due to a spinal cord injury, which is very common in our V. A population gives us a lot of experience doing screening colonoscopies in these tough spinal cord Collins. He has a history of prior ischemic colitis, and he presents the V A to do his colorectal cancer screening. He was well appearing. Abdomen was mildly distended due to lack of muscle tone, but he was non tender and a very benign abdomen. He did have an iron deficiency anemia with the hemoglobin in the nines alot fairer than a low transfer in saturation. And given that we decided to add an E g. D to his impatient colonoscopy, where she was admitted for with a three day prep, which is sort of the spinal cord unit they're specialists in. So this is what we found on his e g. D. So I apologize that it's from a cell phone, but in the V A, we can't take the videos from the machine. And this is this sort of trying to wash off this very friable mucosa with overlying like almost like a zebra pattern. There's, like stripey white superficial and then almost this kind of brown discoloration and in the linear on linear folds up near the Cardia. Um, hopefully, I'm trying to see if I can get better. Maybe I'll just go back to the very beginning just to freeze on a the best shot. Mhm. Maybe that's one of the better ones. So in embracing some of the guidelines, that's a teacher now provided us with. I would love to hear some thoughts from the audience about what anyone thinks this could be because I had no idea when I saw it. Um, so I'd love to hear how other people think about the finding like this on endoscopy. Oh, this is the part where people are supposed to participate. Sorry, it was this change in format. I've never done an intra intra presentation participation. I have the power to call on people. Just, you know, Uh huh, I would say, Let's take a bunch of biopsies. I think it's very hard to There's oftentimes we see these very bizarre gastritis patterns that I think are going to be something insane. And then there's something like chronic, non specific gastritis. So I probably would have just taken samples from multiple areas in the stomach to try to get a sense of sort of the global picture of the, um, mucosa and then more specific targeted leisure, uh, biopsies in this particular area. So these are these thickened gastric folds. Is that what you're showing us? Yeah, so they are. They're thick and sort of inflamed with little white stripes. Ulcerated folds what they look like or like, shallow alterations in the folds. So the differential diagnosis for thick and gastric folds includes monetary, A airs, disease, secondary, syphilis, lymphoma occasionally, maybe not specific gastritis. But those are the things that come to my mind. Thanks, Dr Sweets. I was worried about lymphoma because it was sort of infiltrating a lot of the folds and I haven't seen I've only seen one or two cases of gastric lymphoma, but similar to Zoe. I was like, Maybe this is just a strange gastritis, but I'm worried that it's a bizarre malignancy. This is all that you found to explain his anemia. Yeah, his colon was fine. Doesn't look very ulcerated. No leaving, right? It was Yeah. It was like just washing it. Blood? Yeah. Try not to describe things as inflamed, by the way, because you really don't know that's really a pathologic diagnosis. If it bleeds, if it bleeds on contact with washing. I've seen that in lymphocytic gastritis or collagen is gastritis. Usually those have, like like, it's not these linear lesions there. Pinpoint punk, Take lesions. Not it doesn't look like this, Right? Right. Yeah. Phone was the phone is an interesting thought, though. I mean, it's sort of like it doesn't have a typical appearance. It can kind of just Look, it's sort of like non specifically abnormal. Obviously need a biopsy. Yeah, So we did biopsy. But first, I'm gonna ask one of the applicants a question. Let me see. Only Johnson. Yeah, only joking. Unless you would like to offer your thoughts. Move on to the pathology. Um, So the pathology showed us predicted by many of the audience that there was It was it was superficial. Ulceration, mild, chronic and specific gastritis and no h. Pylori. So I think it was a good learning case for me and that things can look absolutely wild on endoscopy. And then the pathology will really often give you the the answer. So I think it's so important to take biopsies from everywhere. The other thing that we noticed was, if you look at where the gastritis was, it was up near the cardia, and what I think it was was mechanical gastritis from the patient retching during his bowel prep. And this is a phenomenon. It's like a Mallory Weiss tear. Except what happens is in patients with sliding hiatus hernias when they reach their stomach and slide through the hernia and you get friction right where the diaphragmatic rain is and that causes. What we saw was that the gastritis is parallel and on the two sides opposite each other, like almost circumferential e. That makes us. And it was very close to the G junction, making me think that maybe it was due to his hernia and due to the gastric mucosa sliding against the diaphragmatic ring as a prolapse, I coined a term for it. The Mallory Weiss tear of the stomach, which hopefully will help you remember this mechanical gastritis of the Cardia. There was one case series that I found looking at it. So they had five patients with huge upper GI bleeds who had emergent inpatient endoscopes. All had been vomiting prior to hemodialysis and just like a Mallory Weiss. Tear the vomit, as was non bloody initially. But as they continue to vomited, turned into a coffee ground or bright red, none of them need blood trend needed blood transfusion. So I guess it gives you a sense of there's been a sort of lower volume G, I believe. And then, just out of interest, I pulled up all the patients who were not like our patient. They were young. Most of them had either over eaten or drunk some alcohol. So it's sort of that similar to the Mallory wise population. Um, and then I was curious in China in the 19 nineties. How quick would you get an endoscopy? Actually, pretty quickly, I think they probably if we looked at a case series of five of our patients. These Chinese patients might have gotten there more quickly to their e g d. So quick as it was four hours. And then there was an outlier. At 58 hours, they all had hiatus. Hernias And you can see they marked where the gastric mucosa became congested looking not going to use the word inflamed, congested and, um, like erosions, Um, and like active, using of blood. So this was sort of laid out here. They all had hiatus. Hernias. And the good news is they all had a cure, which was it was great to see. They also looked at 748 patients who came in for serial endoscopy is they looked at the e g d findings of other patients over a period of time. And they found that if you were nauseated, if you had serious nausea and at a hiatus hernia, you are more likely to have congestion and erosion in these areas that we mentioned. So that sort of lended more weight to their the hypothesis that this was a mechanical gastritis of the cardiac. So to conclude it can occur as a sequel of retching and vomiting. It's found in patients with a slide and hateful hurting, often alcohol use. It's a rare cause of G. I bleed. I certainly haven't seen it except in this patient who was bleeding slowly, and the history might be similar to that of a Mallory Weiss tear. So if you're getting the history of initially Brown and then bloody vomit is, maybe keep this possibility in mind. So with that, I'll open up to any questions. And this is a Halloween theme. Slowly slide from the good old days. So happy Halloween. Yeah, I have a question. The for the scope was anemia, right? So presumably something else was probably driving the actual underlying anemia is are you guys going to do a capsule or something like that? We are actually going to do a capsule. I think there is something else driving the anemia because I don't think that gastritis has been intermittently bleeding for months and months. Got it? And how well substantiated was his history of ischemic colitis. Oh, we pretty well substantiated. He was scoped by us in, I think, by a cash in 2000 and 18 for bleeding, and they saw a really second area in the sigmoid that they thought was malignancy, actually, and they were consulting oncology and surgery, and then the pathology came back as ischemic colitis and then on repeat, they went back and had healed up. Why do you ask? Well, you know, you haven't really explained his iron deficiency anemia and, you know, occasionally s chemical itis can be also mechanical. It could be like a value list that twisted and then a twisted or an internal hernia. And somebody who's quadriplegic and doesn't have the same degree of sensation may not have the same degree of pain that some someone with an intact nervous system would would feel the pain of ischemia. So when you did the colonoscopy, was it a very redundant floppy colon? Or, I mean, it's definitely, you know, could he be sort of intermittently, you know, could be a populist or something else. Intermittent that's causing some a little bleeding drops his hemoglobin occult Lee. It's just a thought. Yeah, definitely. Antos Cameron Ulcers. Uh, that's That's a good point, I think. The distinction. I don't know. Maybe the history of the Von Machine and the fact that it's it's more of a like it's not. It's mucosa. That's not usually in the hernia, but prolapse is all the way up from much more distant in the stomach. I think that might be the difference, but, yes, they're very similar. I think Cameron's also is a little bit more chronic, like a longstanding feature. Um, as opposed to something cute. That step describing what this acute vomiting we used to. Um, First of all, I love your Halloween party, and I'd like to be there. Um, uh, if you look up, you might find this under another name. We used to call this something a meta genic injury. So, you know, like a missus. Um, So there might be some more literature on a meta genic injury if you look it up. Cool. Thank you. Of course. Great. Any other questions? Comments on this case? No. All right. Before we go over to you young, we should have done this before. And that was my mistake. Steve, would you like to, uh, introduce the applicants that are joining us this morning? Yes. Yes. Thank you. Feel so we'd like to welcome our applicants. Today. We have six people visiting us remotely. And I apologize if I don't pronounce your names correctly. So please forgive me. So we have Danny Wong from Brigham and Women's Hospital. Feel free to wave if you like. Amanda to Benetto. Suzanne from Mass. General Suzanne El Shafee from Mass. General Frederick Rosenstein from Icahn School of Medicine at Israel Campus. Brian Horwich from University of Southern California. Brian, Thank you for waking up early and Amanda Sue from Johns Hopkins. So thank you all for joining us, and we look forward to speaking with you later. Okay? Nicole. Thanks. Thanks. Steven again. Welcome to all the applicants. Um, you and you want to present? Yes. Oh, let me just share my screen. Okay. Mm hmm. Oh, um, welcome, everyone I'm meeting and one of the first year fellows. I'm excited to share a cool case that Dave and I did a couple of weeks ago. So our case begins with our case begins with a 64 year old female. She has a history of CKD three alcohol cirrhosis. Have path. Your usual Sinai patient who initially presented with volume overload. She had a really long hospitalization. By the time we saw her, it was she had been in the hospital already for 20 days. Um, and we were consulted for human acacia, and she had a CT, abdomen, pelvis. That was done a couple of days ago that was just notable for colitis. She had some significant stool burden in the rock dome that was noted. And, um, she was starting on some tracks on fragile empirically. But despite having like almost a complete course of the antibiotics, she had persistent local. Santos is to the twenties. Her last colonoscopy in 2016, done by a doctor, Escalates actually had just a particular Asus and the transfers Colon. Um, and when David I went to see her, she was very delirious. And when we did our rectal exam, it was something Um, like some I've seen before, she had this very large stool ball that we could see protruding from her rectum with over light lion cloth. So we recommended disinfection eating. Um, I think you're in a presenter mode, so we only see We can see. Uh, sorry. Let me see. Sorry to interrupt. No worries me. See if I can share my other screen and this while she's doing that. This large stool ball looked very much like, you know, sort of obstetrical views of baby's crowning. I mean, this is like the biggest thing I can ever remember. Fecal crowning. It was definitely fecal crowning if you had. I mean, if we if we were able to take a picture, which would have been all wrong there, I mean, that's exactly what it would look like. What was the what was the Apgar score line or the patients? I mean, it was bad. Yeah. I had to grab Dave because I wasn't sure what I was looking at. Getting to come look at it with me. Okay. So hopefully this is better. Yeah, that's better. Thank you. No worries. So after the team dis impacted the patient, um, she had large volume Humenik Asia came through multiple paths, um, with hypertension requiring oppressors. Um, and we thought the bleeding was secondary to structural ulcers. Um, which result from pressure necrosis from the music mucosa as a direct effect of the adjacent hard fecal masses. Actually, term Sibyl, Um um, overtime depression of the Sibyl, um, can result in local skin necrosis ulceration and in rare cases, actually to perforation. Um, all the constipation sequel imp action are commonly observed as complications of leading to circle ulceration. It's actually quite uncommon. The risk factors in our patient included sort of like renal failure. Most commonly happens in the rectal sigmoid region, Um, and show a little bit later on the scope where her alteration was. But, um, commonly in the left side because it's more dehydrated. A hard feces in that area, a more narrow diameter with high pressure and a relatively poor plus supply. And I was just thinking how rare it was at a fecal disinfection left to this massive Humana Keyshia. But there's been some case reports, um, that have shown that fecal disinfection can actually precipitate rectal hemorrhage when you remove the fecal mass because you're kind of disturbing the adherent clot that had formed over the alteration. So, unfortunately, I don't have a video, but I hope you guys can appreciate that These are for the applicants very abnormal endoscopic images. So as it was ended being a flexible sigmoidoscopy because this patient was in the ICU. Um, and the first image just shows, um, what I encountered as soon as I went in, which was a massive amount of clot of blood in the rectum that was ultimately dislodged bravely by Dave because I was too scared to push through, push through this, um and then after we pushed away the clot we saw sort of so many areas of, like, really deep ulceration along the rectal wall. We ended up using, uh, first by public Kateri, um, many applications because she actually started hemorrhaging actively while we were in the scope. And then ultimately, we were not able to achieve homeostasis, which just bipolar Kateri. So we performed rescue application of him. A spray, um, that resulted in temple ization of bleeding. Her hemoglobin remained in the eighth after multiple transfusions. She ultimately received, like, eight units of blood, three minutes of F f P and platelets as well. The rectum was packed by surgery overnight, but she continued to have bleeding. Um, so ultimately, this is not What would I think? Your first step, obviously. But I are symbolized for bilateral inferior rectal arteries. Um, which allowed us to a definitive control. Um, and this is just a review of the rectal arterial supply. Um, which gestures at the imperial rectal arteries are coming off of the internal l e x mhm. Um, So I thought I would talk a little bit about something. You know, this is the first time I've seen he must pray being used. Um, and what is the evidence for it? An act of lower GI bleeding so lower GI bleeding remains, I think, a management challenge and that it's still relatively controversial in terms of evidence of the role of early colonoscopy, meaning within like 24 hours. It's Some earlier data showed that I can identify the source of leading up to 80% of patients, although there was just a review published in the theater that showed that colonoscopy within 24 hours doesn't reduce further bleeding or mortality in patients hospitalized with acute lower GI bleeding. I think a lot of this is heterogeneous data because obviously the approaches differ depending on the nature of bleeding and timing the presentation, especially in our patients case, who was, you know, after we're leaving out. In general, Lower GI Bleeding, um, can be self limited in up to 90% of patients, but 10% have, like severe or ongoing human anesthesia. Um, are traditional endoscopic treatment approaches for the applicants for bleeding includes sort of like injection therapy, mechanical therapy, like using clips, Orban location and thermal therapy with mono polar bipolar Um, calculation, a PC, Um, and endoscopic treatments usually can be used, you know, alone or in combination. Um, one thing we don't talk as much about is, um, topical human static powders. Some of the implicit some of the pros for them, including the fact that they can be applied to sites that are difficult to reach with an endoscope because it can be applied conventionally over wide field, especially in cases were like, um, you know, direct contact with the site is actually very challenging. It can also treat large areas with diffuse hemorrhage or areas where you can't exactly see where the bleeding is. And it does not require contact with the bleeding site, so it doesn't cause additional mucosal damage. It can also be used as a mono therapy, which, you know we don't such aspect. Combination therapy with other human static methods. A rescue therapy in our case for like a failed, different human static method. Um, and sometimes it's used just as a temporize er, before transferring the patient to a more stable setting so that we can try some other things. So how does this work? Um, so each canister of human static powder contains 20 g of this proprietary inorganic material. The delivery device has a compressed carbon dioxide for Poland, this threat thing that you have to load up before you use it, and the delivery catheter that is threaded through the working Channel two endoscope. When the powder is sprayed on an actively bleeding site under Direct and Scotland visualization, it becomes a cohesive as a cohesive sort of adhesive powder informs mechanical barrier to additional bleeding. Um, the powder is non toxic, and it does not absorb or is not metabolized by the body. Um, for the successful application, the Hema spray catheter must be kept dry. I think one thing that we encounter that was challenging was that the Katherine can become clogged during the Hema spray application. It's such a common problem that each of the human spirit actually come with two catheters because the powder actually reacts with moisture to form this adhesive gel. Um, the theoretical risks of the chemo spray included perforation, delivery of powder under pressure, especially sometimes in the right side of the colon and Zika or in the presence of diverticular. Um, and I think many people had heard that he most spray had a class two device recall in from 2019 to early 2020. Secondary to miss assembly of the device. So it wasn't working when people were trying to use it in bleeding cases. So I found this, um, great article in G i E. That was the first sort of randomized control study for the successful. He must ask human Stasis of active lower GI bleeding. Um, the study was called the approach Study Prospective observational cohort Study of human spray for lower GI bleeding. Um so the use of chemo spray has been reported in several case series in patients with upper and lower GI bleeding. Um, and this represents sort of the most comprehensive perspective study with an established clinical protocol and a 30 day follow up. So 50 patients with active lower GI bleeding from multiple different causes were enrolled in this perspective multi center study F for tertiary centres in Canada. The powder was used in monotherapy, combination therapy or rescue therapy, and the primary endpoint was actually adverse events within 30 days of the index procedure and then the secondary endpoints were initial homeostasis, as well as recurrent bleeding and mortality. Within 30 days of the intense procedure. So most patients in the study had bleeding at a single bleeding site, and most bleeding was secondary to pull it back to me, Um, pull it back to me. Um, so not on this table was the size of lesions. So most of the the lesions in the studies were less than 17 m of, um, quite small. The powder was applied as monotherapy in 13, leaving sites as combination therapy in the majority of cases, um, in 42%. And as rescue therapy in 32%. And very notably, I think it was really The takeaway from the study is that human status was achieved in 98% of patients and no patient experience the powder related adverse events. Um, 10% of patients developed recurrent bleeding within 30 days. Um, and then one patient died within 30 days, but it was not related to the human static powder use. So the recurrent bleeding rate of the 10% I think is, um, sort of within range of what's reported for non topical human static treatments and lower GI bleeding. Um, so my takeaway points are that like a high rate of human status was achieved with a low rate of recurrent bleeding. There were no adverse events. Um, and the mortality rate is sort of in line with what's reported for other metastatic treatments. So it's an effective and safe tool to have in your back pocket for lower G I bleeding, for that matter. For upper GI bleeding as well, it can be used in combination with our traditional approaches with a comfort comparative, sort of like the bleeding rate versus or the other traditional process that we have should always have a backup plan. Um, in these cases as, uh as we did immediately after the procedure, they had to call, you know, iron surgery. In case that, you know, even your he must pray fails to achieve durable he most basis. Yeah. Um, hey, it's my, um so we can actually give you, uh, follow up on this case around service now, and we were called about this patient yesterday, um, with Lauren. So, um, to kind of talk about what you had said at the beginning, which is when they dis impact, it might kind of squeeze briskly. So I guess the team of being super aggressive after she had developed after for also the first time. It was this impacting her daily, and I'm not sure how long their fingernails were, because they seem to have caused visible vessels just kind of like open up about one centimeter across multiple state lines. So when we went into school for yesterday should become hypertensive and technocratic, it was quite unstable, and the old ulcers were clean base. They were not actively bleeding. And there was a very kind of risk visible vessel that, like I said, was just about one centimeter proximal to the dentist line. Um and so Lauren, very expertly injected MP and tamponade, is the vessel and then just burned into oblivion. And the bleeding stops and the patient so far been stable. Um, so I think it's going to say that they should just In fact, the medication is Mexico. Aggressively, um, we have been worried about sending her back to IR, and I always worried as well, because it wasn't clear to bleed yesterday. It was in the same territories of leads when you guys had a doctor two weeks ago. So there was a very big risk of concern for anemia. Um, So that's why shouldn't go to IR immediately. Um, but we were able to treat a fingers crossed, will stay stable for analyses. Um, but the other thing that we were thinking about because it was so close to the state line and of the surgeons on the top comment that maybe over selling that visible festival could be an option as well. Mhm. The event is definitely a possibility. That's Brian Cats. That's brain. That's definitely a possibility that redid the practice. Copy. Yeah, striking How much bleeding has occurred from this? Um, you know, I don't want it's called seemingly trivial, but I mean, this sort of like routine problem has caused this woman just an unbelievable amount of let her into a zillion procedures, difficult procedures. So it's sort of a working that common problem can really lead down a bad path. The other comment about him Oh, spray is that obviously is temporizing, right? You're not really treating the underlying problem, so you do have to address what's actually going on underneath it. All of this is really buying time and either allowing, you know, life to solve the problem itself or give you time to make another plan? Yeah, with him. A spy. Kind of look at it as a salvage technique when traditional endoscopic ones have failed. And, you know, we've only had this in the States in 2018. There was that brief recall which was related to the C 02 canister getting dislodged and in some cases, almost projectile, uh, to have the potential cause injury. But just a couple of other points to note with him a spray. Um, sometimes I've actually completely switched to a dry new scope because, as you alluded to, um, it really, any any time there's moisture, any witnesses when that nano powder is going to get activated, so using a new scope sometimes will be beneficial. Um, you don't want to. I won't even hook up water to the, um, to the scope because you you have the temptation of stepping on the pedal to clear your visualization, and then you're gonna introduce again water and moisture. Um, and then, you know, once you once you use the spray, you really won't be able to see anything. I mean, it's a profuse white out, um, so you you spray and then you kind of let it be. And you do have to be mindful about the re bleed rate as you alluded to 10% in some cases, up to 20%. So you have to make sure we keep an eye on those patients. And, um, you know, continue to follow them. And one of the other areas that I like, which we traditionally have not had. Great endoscopic therapy is all Is malignancy bleeding? You can utilize this, um, endoscopic technique as well. So, um, just an interest of time. Well, well. Kick over to Nick are advanced endoscopy fellow for, um, for one last case before, uh, we have our great grand round speaker, Ali re PCI nic. Thanks, Nichelle. I will share my screen. Okay. Hello, everyone. I'm Dick on the events of that fellow, and I'm going to present a case of trans oral incision. Was funded creation. No diagnostic mystery. This one's more endoscopic focus. So first the patient, he was a 39 year old male presented with curd he initially presented with chest pain. He was found to have pretty severe esophagitis. His esophagitis actually healed with the FBI, and he felt better. And then he made some lifestyle modifications, but he still had persistent Kurds. So any time he came off PP I basically his symptoms came back, and this is a good patient. That highlights kind of where Tiff might fit in for good treatment. But he's a young man. Basically. His options are to continue p p i to help him feel better. But that might be a lifelong many years of medication, which he didn't want to do. Surgery, which carries the risks of the surgery but also with fund application. Many patients have postoperative symptoms, including dysplasia, bloating and flash land that can be very uncomfortable, sometimes more uncomfortable than the GERD, um, or tiff. And so ultimately, we chose to do tiff and I'll show the procedure and then explain a little more about it. So pre operatively this was an endoscopy, A little bit of an irregular Z line, no esophagitis, no giant Heidel hernia. Um, he has a whole grade one flat valve, which is relevant because we're trying to shape this anatomy, right, so this is sort of, uh, it's reasonably tight, but, um, sort of flat, and we will reshape that to be more of a reflux barrier. This is an image of the device in action. So outside the body it's two operators. It's sort of like a gun like device, and it's the scope actually goes through the channel. It's a 60 French device. So, um, the scope is really used almost like in a laparoscopy case. Just as a camera, you don't do the procedure with the scope. The device itself does all of the work. Uh, and we will see that here. So this is again before doing the procedure just to look, to evaluate the valve. You want to carefully evaluate the anatomy and make sure that it's going to be safe and appropriate for this procedure. Yeah, and this is the device. So again, the goal with this is that we're trying to lengthen this flap, and then we can also actually simulate essentially a fund application with a rap. So by grabbing the tissue and twisting the device, you can simulate a rap endoscopic lee and actually create a 270 degree wrap around the G junction, and you can also pull the tissue in, and then there are full thickness fasteners that hold it in place to lengthen that flat felt. So the main steps of this procedure are that, as you can see, there's a tissue helix in the tissue and then using traction on the tissue helix and using, uh, suction, the tissue is pulled up into the device and then the devices fired, and it places these full thickness fasteners, as we will see. So this is all getting set up to pull the tissue in. And then we will start using suction to deflate the stomach, and then tissue will come up and the fasteners will be fired. Skip through a little bit of adjusting here. So this is the section in part kind of lose visualization, while during this part, actually, a lot of action is happening outside the body. This is when the device is rotated and the flap is created. The rap, um And then as we re insulate the stomach, you're going to see a big difference in the valve so you can see that the tissue has been wrapped around, and also it's significantly longer more tissue into the stomach Here. Once we think we have a satisfactory rap satisfactory tissue in the device than the devices fired, and we'll actually see the fasteners kind of. So those are the Let's go way back. Sorry, Nick. Are you looking upside down at it? Right. So that is in red reflection. The devices, the scope is through the device, and it's completely retro flexed, and we're just using it as a camera. So we're looking back up essentially at the at the G junction. Is that right? Yes. I should have explained that to start. I'm sorry. So these are these little blue things? Uh, here are they. They're like h shaped fasteners, and they're like, full thickness fasteners that go through the mucosa. So as this proceeds, we place two of those fasteners there, each firing of the device, places to fasteners. And ultimately, you place 20 or potentially more fasteners to create this rap. So we had already on the left. We repeated that process a couple times on the left side of the G junction for six fasteners. Now we move to the right and we're going to do the same thing. Instead of wrapping around to the left, we wrap around to the right to try to create this full wrap and place six more fasteners there on the right, and then it does get a little bit bloody. And then we go back to I'm just skipping ahead in the interest of time. But it would go back to the middle and place additional fasteners, kind of to bolster this flap and really increase the link. How long does this take? Uh, it depends. You know, there's definitely a learning curve with this device because it's very clunky. Ultimately experienced, uh, centers. It's less than an hour. Once you get going, there's sort of a rhythm to it. And and you know, what Nick's not saying is that there's two endoscopy pistes. So I'm controlling one portion of the scope. I'm controlling the device. Nick's controlling the scope, so we have to. It's sort of like a dance, and you have to work in conjunction with each other. But once you sort of get the rhythm, it takes about a half hour, 40 minutes. Uh, so what's Chris dance? Yeah, um, so in the end, this is the end result. On the left, you see the pre op kind of a flat valve. It is tight, but it's not much of a reflex. barrier on the right. You can see a bulked up lengthened valve with a rap that's really tight to the scope and that, ultimately, is what creates the reflex barrier. So I think, is a good option in two main patient populations, either patients that aren't responding to B P I or with proven guard or patients that RPP responsive but don't want to take medications. The only formal contraindications are a large hide, a hernia, which does make it difficult to perform the procedure, UH, large BME or surgical anatomy that would prevent you from performing the procedure. I will say the hiatus hernia doesn't stop us necessarily because we can engage our surgeons to repair the hiatus hernia at the same time as we do. The tiff, which is called a hybrid tiff for a combination, uh, I don't have any repair it. If so, that's not an absolute either. And then some kind of relative contraindications are a large, open, flat valve or severe esophagitis. And here's some outcomes. Um, on the left. This is a quality of life. Score higher is worse, so you can see these patients were improved with P p I, but still had a pretty high score and then after tiff persistently for up to five years, they had much improved quality of life. On the right, you can see the percentage of patients that came off P p I at five years, uh, 34% of patients were back on PBS, but that means over 60% were off pp I completely after tiff and this is pretty consistent with surgery without those side effects that I mentioned potentially from that. Is that Yeah, I have two questions. First, um, it looked like there may be a short barrett esophagus. They're very short on one edge of the sea junction. What happens to a bear it when you do this? Good question. I'm glad you asked. We are actively researching this question. We because the pathogenesis of barrettes probably involves acid exposure, and we think the tiff can reduce acid exposure. Were actually investigating potential use of tiff in refractory barons patients and we will let you know. So stay tuned. But this patient did not have barrettes. Biopsies Inouye who brought us Oh, um, has a new method for doing this. You make an injection just like an EMR around the C E junction. Put a snare around it and you snare off big pieces of gastric mucosa near the sea junction and with secularization, the, uh the or if it's actually closes. Sometimes it's a close, a little bit too tight, and you have to dilate it. But in a way, has this new method of doing it. Um, I've seen it done, and, um, in India, and there was so much bleeding, I didn't know what to do with it. The third thing, the third thing I'd like to say is Congratulations. David Greenwald, who was this week and sold as president of the American College of Gastroenterology. Congratulations, David. Thanks, Terry. I think Bruce has a few words you'd like to say as well. Yes, it's a perfect segue. I, too, want to, uh, just pause for a minute and recognize this very momentous occasion where Dave Greenwald, our wonderful friend and colleague, teacher educator um, clinician extraordinaire, um, rises to the presidency of the A. C G. It's an incredibly big job in an incredibly difficult year, which will make it a very different year for him as a president. But we know that Dave um is so accomplished. So smart, So hard working, so energetic, So nice. Just really. As I said, such a wonderful friend colleague, teacher that we know this is going to be a successful year for the G. So I want to offer him congratulations. And the keel has a short video that he's going to show. Can you guys see the see my screen? Yes. Yes. It is a great honor and privilege to bestow this presidential medal. Represents the leadership a little. Thank you. Your year as president of the American College of Gastroenterology has been amazing. And I am very proud to step in as president of this great organization. Now, for the next year. Thank you. So congratulations, David. Thank you. Yeah, Mark. It is a tradition of the American College of Gastroenterology toward a past presidents medal to those who served as president. And so now it's my turn. Give you that test President's medal, Your name engraved on the back. Thank you so much. Thank you, David, that this has been game right here. Thanks. Uh huh. Central Park, of course. Our wives and then some bystanders who thought that, like I think they thought we were getting married. But congratulations, Dave. It's such a huge job, and you're going to do an amazing job. Thanks very much. It was really fun that that ceremony usually occurs at a business meeting in person. So, you know, we were able to take it into Central Park, do it on our own and, uh, kind of create our own our own appropriately, socially distanced, masked and, uh, little ceremony. But it's really nice. And yeah, it is a big job, but it'll be a lot of fun. And I thank everybody for the support around the institution over the past number of years that I've been here and in the coming year because that's the way that you accomplished anything. It's with great support from the people around you, so thanks, everybody. Published December 7, 2020 Created by Featured Faculty Stephanie Rutledge GI Fellow, PGY5 Icahn School of Medicine at Mount Sinai Yuying Luo PGY4 Icahn School of Medicine at Mount Sinai Nicholas Hoerter, MD Advanced Endoscopy Fellow Icahn School of Medicine at Mount Sinai
