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applications are due March 1st. Again, applications are due March 1st. All specialty teams will get access to BTK resources, including microphones, software, help with editing, social media love, and so much more. dominate the day. Welcome to the first episode of Behind the Knife from your surgical endoscopy team. We're coming at you from Endeavor Health, formerly North Shore in Evanston, Illinois. I'm excited to introduce this topic to our behind the knife listeners.
So first things first, we're going to get started with introductions. I'll introduce people from most senior to least senior. Kind of tell us a little bit about yourself, your current role experience with advanced endoscopy. Dr. Uchiki, we'll start with you. Well, thank you, Sully. This is great, and I'm excited to talk about virtual endoscopy. Um, I am a minimally evasively trained surgeon. I trained with Lee Swannstrom in Oregon back in eight.
did my residency in northwestern medical school there as well prior to that and i do mostly foregut and bariatric surgery and as my practice has gone over the years evolved into more and more and ask me probably about 30% of my cases now are endoscopic. So excited to talk about this. Awesome. Dr. Hedberg will go with you next. Also a partner of Dr. Ujiki at Endeavor.
yeah happy to be here originally from massachusetts i came out to chicago area for residency at university of chicago and we had a partnership a teaching partnership with north shore So I was probably spending 40% of my time up there. Met Dr. Yajiki my second year and, you know, latched on. I tried to learn everything I could from him. And I was lucky to stay on as a fellow. And now I'm here as an attendant. So I have a similar kind of practice, but I haven't narrowed down.
too much yet i'm doing some robotic abdominal wall in addition to foregut flexendo and bariatrics and i'm trying to get a gastric stimulator program going for the patients who aren't too happy after their g palms That's great, Dr. Heberg. Trevor Kraft will go with you next.
Yeah, thanks, Soli. I'm the most junior person. I recently graduated from training, so I did residency at OHSU in Portland, and then I did fellowship with Drs. Ujiki and Hedberg at North Shore Endeavor. And I am now a minimally invasive surgeon at the...
Rocky Mountain Regional VA Medical Center in Denver. So I'm an assistant professor of surgery at University of Colorado. And my clinical time is just getting started in the last couple of weeks, but I will be splitting time between bariatrics, foregut, and general surgery practice. with an endoscopy component of my practice as well. Fantastic. And lastly, I'm Sully Uso. I did my general surgery training at Carolina's Medical Center in Charlotte, North Carolina.
the current fellow in endeavor so following in trevor's footsteps work with doctors ujiki and hedberg on an everyday basis and plan to incorporate flexible endoscopy into future practice hopefully get to do some foregut and abdominal wall reconstruction So Trevor, I'll turn it over to you to kind of get things going.
Perfect. So to go around the room, we just want to start by asking for each of you, if you could discuss why you think proficiency in endoscopy is an important skill for surgeons and trainees in today's day and age. Now we can start with Dr. Ujiki. Yeah, sure. I'll start with that. When I first started my training, surgery was open by 90% of the cases we did were open. I think laparoscopic cholecystectomy had kind of shown itself to be.
feasible and safe and was really caught on but even laparoscopic appendectomies and other procedure really hadn't started yet during the middle of my residency when those things started to really catch on i mean we were really still doing bariatrics open open gastric bypasses for example and the laparoscopy really revolutionized the specialty we had
Patients that were spending sometimes days to weeks in the hospital going home after a night or two or sometimes same day, less complications. The outcomes just were so much better. Well, we're starting to see that again. We're starting to see the next evolutionary step in the minimally invasive surgery, and that is surgical endoscopy. So now we are doing cases without any incisions we're seeing.
patients have even better outcomes even less complications even less recovery some of these cases we're doing patients are just going to work the next day and I think surgical endoscopy is incredibly important because it is what patients are going to want in the future. They want it now, but they don't even know that it exists for the most part. But as they start to understand that, hey, you can save your colon.
by doing an endoscopic submucosal dissection or an endoscopic mucosal resection instead of having a colectomy for a benign precancerous polyp, who is not going to want to save their organs? who is not going to want to avoid incisions if you can have an equal or better outcome so it really believes all of us to continue to make ourselves better and that step now is going to be learning how to do endoscopy proficiently And Dr. Hedberg, can we get your thoughts? Yeah, absolutely.
I mean, part of it for me as well, and I agree with everything Dr. Ujiki said, I think also in terms of progression of how surgery training has changed, I can probably count the number of open inguinal hernias I've done on my fingers and toes. But almost everything was laparoscopic when I was training and I was lucky to get the early exposure to the endoscopic surgical endoscopy as well. Part of it for me, I think, is being able to very...
and have a good sense of what you're operating on, what it looks like from the outside and the inside. And then we get our CT scans and... can understand what the anatomy is we know you have an idea what it's going to look like once we're in there laparoscopically or open for that matter but understanding the anatomy with an endoscopy and seeing what is going on the inside of the organs before you get in there
surgically i think is important in terms of diagnosis and understanding the anatomy you're working with the other thing i wanted to say i'm glad dr ujiki didn't say it but one thing he always impressed upon me is In terms of being a complete physician, you're treating disease processes. You're not a proceduralist who can do a certain kind of...
you know, task. So if someone comes into your clinic with achalasia, you know, sometimes you're going to recommend a helleromyotomy. Sometimes it might be better to do a fall. Usually it's better to do the palm, but you have to be able to offer all these things, all the treatments available for the disease you want to treat. I mentioned in that vein, I was trained to do GPOM, but I would have some patients coming back with gastroparesis.
and they weren't satisfied after that. And that's why I picked up the stimulator, kind of moving in the other direction. But as a doctor, I think having all the tools at your disposal to treat the diseases that you're trying to treat is very important. Fantastic. Thank you. Dr. Uso, do you have any additional comments before we move on? Yeah, I think the surgical endoscopy as it feels very intriguing to me. Where I did residency, there was not...
abundance of that being offered to patients. But as I was getting to go to meetings and seeing videos online, listening to podcasts like this, I started to see that that you know is the way of the future in a lot of in a lot of ways and so even though i'm getting to the point in my training where i'm finished it's just the beginning and i think that to have a very sustained career that is
you know, again, offering all the options to patients and thinking 20, 30 years in advance that this is something that I feel like not only myself, but hopefully general surgery residents in the future get to pick up. So couldn't be more excited to be talking about this. So Dr. Ujiki, how do you teach this? How do you teach these skills? Yeah, well, I think, first of all, the American Board of Surgery has recognized the importance for surgeons to know and be trained in endoscopy.
I think about 10 to 15 years ago, they increased the requirements, and rightfully so. They also required that all residency training programs employ a flexible endothic curriculum that you may or may not even know is happening, but it is happening and that's purposeful. And so that is important. So it starts in your training. It starts during residency.
but it will continue throughout your career. And again, I just want to stress that the technology that I have seen that's coming is pretty remarkable. We are going to be doing... operation that we're currently doing laparoscopic and open all endoscopically anastomosis um you know bariatric procedures and I'm not just talking about endoscopic sleeves I'm talking about bypasses and switches and so forth so it behooves
all of you that are listening to do everything you can to get as many repetitions as you can in during your training, whether that be a residency or a fellowship, every chance you get to do an endoscopy in the operating room, you should do it. Absolutely pay attention in your GI rotations. And endoscopy, like other skills, can be trained through stimulation. We've published quite a bit on various endoscopic.
basic endoscopic procedures like dilation placement and how to do that in a simulated fashion so that you can then come to the warts and the OR and the GI lab and do those procedures well. the the key though is that you need repetitions and to do some of these complex procedures you need fundamental skills so What I see as the biggest barrier to someone, the biggest barrier for a trainee to learn how to do a complex procedure, say, for example, a poem procedure is basic.
endoscopic skills if they have basic endoscopic skills they will learn the procedure quickly all of all of us are surgeons for a reason we enjoy working with our hands we have hand-eye coordination we enjoy manipulating tissue in a safe way and endoscopy is really no different
but you need the fundamental skills just like you need fundamental surgical skills you need fundamental endoscopic skills and once you have those you can train and learn the the more complex surgical procedures i'll also say that almost 80%, maybe more of the surgical endoscopy procedures that I do, I did not learn during fellowship. I learned after fellowship. Poems were not around when I was a fellow. I learned that after fellowship.
you know z-pole g-pole all the pole endoscopic sleeves for example the endoscopic revisions the way we do them now all of these things came later but i think what i am grateful for is the basic training i got from my mentors like Lee Swanstrom, Christie Dunes, they taught me how to use an endoscope well. And I think if you just focus on those fundamentals, then you're going to be, you're going to have a solid foundation. You're going to be able to learn all the procedures that are coming.
That's great. I think that for our listeners, we have people that are listening from medical students down to undergraduates all the way up to attending. So it is worth reviewing briefly the requirements from the American Board of Surgery now. So as Dr. Ujiki alluded to, increased emphasis within the last 10 to 15 years on exactly, you know, what's being required for people to graduate a surgical residency. So 850 major cases, 35 upper endoscopies are required.
and then 50 colonoscopies. So I think it's the expectation from the board that once you complete a general surgery residency, that at the very least you can perform a diagnostic upper endoscopy or colonoscopy. One of the interesting things about this, though, is there's a recent publication in Surgical Endoscopy that reviewed the ACGME case logs for residents graduating over the last 14 years.
And what they found is the relative number of endoscopies has remained stable. So about 130. So even though that there's this recognition from the American Board of Surgery and from societies like Sages that, you know, this is very important, the volume of scope.
has not necessarily been increasing over time. In addition to this case component requirement from their American Board of Surgery, there's also the fundamental endoscopic surgery curriculum, which is now a requirement to graduate residency. This consists of both modules that are performed online. So 13 modules that prepare you for a didactic test that you need to pass. And then there's a skills component as well, which is a five-part test, mostly focusing on lower endoscopy.
which includes different endoscopic skill sets. These are things like essentially staying within the lumen of the intestine, reducing a loop. So these are skill sets that the FE helps to test. So how comfortable are residents with endoscopy once they graduated?
In the largest survey of senior residents conducted by a group from Yale and published in the Journal of Surgical Education in 2016, only two-thirds of residents felt comfortable performing upper endoscopy, and only about half of residents. felt comfortable performing a colonoscopy. So despite the fact that we're having this podcast today, the American board is recognizing this as important, there's still a long ways to go.
So Trevor, I think this is a perfect leeway to our transition to talk about your training as a fellow and kind of what the requirements are through the fellowship council. Yeah, absolutely. So I guess my personal experience, I think it's maybe everyone's interested. I always like to be transparent with these things because I feel like sometimes in surgery, there's a lot of ambiguity when we talk about like someone's experience, clinical experience and person to person.
So as I mentioned, I did my fellowship at North Shore, which is now Endeavor. And so it's a busier referral program for a lot of these things for other reasons that both of these other surgeons just discussed. But in fellowship, I did about 250 upper endoscopies. which 150 were therapeutic. About 40 of those were myotomies of some form, about 10 to 15 endoscopics, futuring cases, and a wide spattering of kind of all the miscellaneous indications that come with a surgical endoscopy. prior to
fellowship, I had the opportunity to see and help out with a handful of cases in residency. But certainly the bulk of my hands-on experience really came like almost entirely in fellowship. And so I think broad strokes, my first impression of things with quote unquote, picking up.
endoscopy as a fellow, where that one, even coming in comfortable with basic endoscopy, as Dr. Yuduki mentioned, it's pretty imperative to kind of have some of those basics down as you work toward the more complicated devices and techniques. But starting out... is definitely tough. We're used to picking up new surgical techniques and procedures, and usually these are an adaptation of a motion or a technique, something that we've done before many times in another realm or scenario.
But really, one of the bigger entry costs with surgical endoscopy are new devices that you probably never used before. And so I think that actually the initial part of the learning curve, this is the steepest part. In general, you can do a lot of these things in the lab and that's super helpful.
I think when you actually start doing it in clinical practice, the learning curve is by case volume, probably shorter than a lot of complex, minimally invasive surgical procedures that we'd otherwise be used to. And so an example.
If you think about a procedure like a poem, fundamentally, you're doing a mucosotomy. You're making a submucosal tunnel. You're cutting the muscle and you're closing the tunnel. So like three or four steps. And so it's not that it's technically easier because it's not. You can...
Yeah, so the trainee will fumble around just like anybody else picking up a new procedure. But there are fewer steps and subsequently fewer areas for pitfalls and things than the complexity of surgeries that we're used to otherwise. And then the third part of things is that I...
It's almost sheepish to say this, but patients really do so well in a lot of cases. Intuitively, it's kind of a lower physiologic burden than an actual, like a more formal, minimally invasive surgical procedure. And obviously more so than just a basic endos.
endoscopy typically surgical endoscopy procedures carry a low but obviously very real surgical risk that by and large by the end of your fellowship year you know you're doing a lot of sub one hour procedures the patients wake up with kind of minimal to no pain and
often go home the same day as Dr. Ujigi said, they're going back to work the following day. And when I started fellowship, I think I always put these procedures in kind of the same category as, you know, kind of like quote unquote, minimally invasive surgery, what we think of as conventional laparoscopy. robotics, but soon realized this was kind of a category all its own. From there, I would say, you know.
Despite, you talked about training programs in general or across the country, despite kind of the increased number of procedures that people are doing and this becoming an ever-growing, more popular field, the number of advanced training programs has kind of remained fairly stagged. And so one of the hard things as I perceive it in retrospect is that bees are often kind of...
disease processes and indications that are a little bit rare. And so a lot of practitioners around the country are doing a few of these a year at kind of consolidated referral centers. But then how many trainees are coming through these programs every year and what's their hands-on experience?
every instance. As I mentioned, they're also technically complex procedures and there's a high entry cost of learning a new technology. And so for a surgeon that's out in practice, that's going somewhere to learn these things or, you know, working with reps to adopt these. And so it's not quite the same. is just we might translate another laparoscopic or open procedure.
And Dr. Jickey, I don't know if you have any other thoughts from like a fellowship council perspective on the current state of surgical endoscopy or where that is and where that's going, but I'd love to know if you have anything. Yeah, I mean, it's going to grow. uh what you can't stop progress uh when it comes to patient care patients are going to demand it and when patients and they will speak with their feet
They're going to seek out those that do it. We saw this with laparoscopy. The first to start doing laparoscopic cholecystectomies became very busy very quickly. People were lining up in clinic to... have their gallbladder removed by those surgeons, while those that did not think laparoscopy was here to stay and persisted on performing colostectomies. Open, for example, saw their practice dwindle.
We're going to see the same thing. I'm confident with that. As that happens, then trainees are going to demand more programs that offer this. And you're seeing right here, you have Dr. Hedberg, yourself, you both. trained and learned endoscopy and you're, you're now going to train more and more people as well. And then they're going to train more people. So it will continue to spread. There's no doubt in my mind. Awesome. Thank you.
Yeah. At present, currently, I think in prep for this, Sully and I talked about it, but there are basically, I think, five fellowship programs now that have the quote-unquote... Fellowship Council designation of comprehensive flexible endoscopy. And so these are kind of the programs that most heavily focus on therapeutic endoscopy. The Fellowship Council designation requires that fellows have 100 cases and they cover 10 of the...
EPAs, which are one of the more new developments in the fellowship requirement. And then obviously you have to complete FES and FUSE as part of completing an MIS fellowship for your certificate. I think personally, this is a great start. But even still, this is a pretty heterogeneous designation because of how differently things are being done and what kind of different techniques are being employed at every center and what they're focused on.
Sage's Flexible Endoscopy Committee is looking at this, and surely there'll be an active evolution of this over the next couple of years. And hopefully we'll see more programs doing more of this, as Dr. Ujigi mentioned, and striving for this designation. I think one thing that's hard to quantify is how much flexible endoscopy is being done at MIS programs that don't apply for or meet this designation of quote-unquote comprehensive flexible endoscopy. And then moreover...
Even if there are programs that aren't doing as much, what about all these fellows or practitioners that have a personal or clinical interest in these things, but don't have a direct line through training and how do they then learn?
And so one thing that's come to light in the last couple of years is Sages or the fellows has a number of very helpful courses, which I can personally attest to, but there is a newer flexible endoscopy course each year, which is like a weekend where they fly the fellows out to a certain training site.
And they have usually pretty strong junior faculty with a surgical endoscopy experience. And they kind of get one-on-one training to learn basic and advanced techniques and even do some training in things like POEM and POP. And this is an attempt to make access. learning these platforms a little bit more widespread or to get the
yet more hands-on experience for people who may not be doing that as a primary, you know, uh, focus of their fellowship. I think this is great because if we imagine what we think of as like an ideal comp quote unquote, comprehensive for God or bariatric practice, learning about these things and physically.
having experience doing them is not only helpful in the sense of being able to offer it to a patient yourself, but more so even you just become that much more familiar with the tools that exist and the options that are open to patients for their particular.
clinical scenario. So for example, even if you haven't done a bunch of poems in your training, but you know that you have a patient that it would be advantageous for and is well suited for it, you have the wherewithal and the knowledge to connect that. patient to somebody who may be doing it in your area and give that person the option. And so I think that kind of just expands your ability to care for patients in any scenario by being that much more experienced with what, you know.
all options for your, the disease processes you treat. You, you, you and Dr. Hedberg are making me very proud of listening to you talk and, and I, I'm just going to stress. That's because you can't watch us operate anymore. But the point that Dr. Hedbert brought up earlier is so important. There's no question in my mind, getting away from surgical endopathy for a second, but just performing your own Bravo test.
Your own pH probe placement at the time, preoperatively for an anti-reflux procedure where you're actually looking at that patient's anatomy from within, it makes me a better surgeon. Or, for example, doing the endoscopy after. The procedure has been performed. It makes me a better surgeon. So it's not just about surgical endopathy, but just doing your own endopathy makes you a better surgeon. That's perfect. So I think.
As a little taste of what is to come with future episodes, we're going to try to go through a few quick case studies here to see what surgical endoscopy options might arise. So first patient is a 35-year-old woman with an history of CDH1 mutation, underwent a laparoscopic total gastrectomy with Ruin-Y reconstruction.
This is post-op day six. She's tachycardic and febrile. Got a CT scan with oral contrast showing a leak from the anastomosis. So what endoscopic options would you have in this case? I think Sully, you're going to start this one.
Yeah, I would like to say that each of these examples that we're going to go through briefly today have arisen in the last few months since I've started my fellowship. So these aren't things that are spaced out over the course of years. These are things that we're seeing every day.
Um, so for this patient, I mean, the biggest thing that you need to address is source control or else they're not going to get better. And so you got a couple of endoscopic options that come to mind. You know, the first thing is to place a covered stent. You don't necessarily need to rely on your GI.
colleagues, if you are familiar with this. So that is one option. Depending on the size of the hole and the degree of contamination, another thing that you consider is actually doing an endovac. And there's good data to suggest healing rates. over time with the endovac procedure. For those of you not familiar, an endovac in this case would be a actual black vacuum sponge that is sutured to the tip of a nasogastro tube and then passed down into the esophagus and placed into the.
cavity where it's the site of the leak. Typically it's our practice that we change these a couple of times a week, but you know, we see the granulation tissue form over the course of time.
And I've had a really good, uh, kind of success rates with these things happening. Uh, the one thing that should be mentioned is in cases where the endovac is utilized to not have opposing suction. So a lot of times, you know, these people could have chest tubes in place. When you do that, it makes the endovac. back less efficacious, but this is a, you know, a technique that has, has good utility. So I'm not sure if you had anything else to add to this particular scenario, Dr. Ujiki.
Well, you had mentioned source control, and so you have to be a little bit careful because, you know, like a covered stent doesn't... control the source so you would you know if you i think a stent is is not a bad idea if it's an early leak and there isn't really an accumulation of too much fluid outside of it but if you do have
fluid outside of it you're going to have to drain that somehow and whether that be percutaneously with a covered stent or as you mentioned an endovac is really a nice way to to get source control and also speed up healing
um and the other thing i would mention are our internal drainage so double pigtail stents if it's a small hole you know endovac sometimes it's not ideal in that scenario if it's a big hole like if you have 25 to 50 percent of the anastomosis that's disrupted i think the endovac is a great option But if you have a small bowl, you know, there are seven to 10 French stents that you can put internally that get you source control and allow you to eat around them too. So again, you can place these.
get source control, and patients can eat, go home, and have those stents, you know, removed over time. So these days we have better options than ever to treat anastomotic leaks endoscopically. Perfect. Yeah, I'm sure we're going to dive into that in more detail. Those internal drains are awesome. Second case right now, this is not uncommonly encountered in general surgery. So it's a 72-year-old male recently underwent a cardiac stent.
and came to the EDU with acute calculus cholecystitis. This was managed with a percutaneous cholecystostomy tube. He's not on your clinic a couple months later, and he wants to know if there's any options for him besides having surgery. I think, Dr. Ujiki, this one goes to you. Well, there's, I don't know how new it is, but I guess maybe the surgeons, it might be considered new, but biliary endoscopy. So biliary endoscopy now is commonplace.
Scopes have gotten better. The technology has gotten better. There are ways now that we can image from within the bile duct with digital imaging. These scopes have kind of a typical endoscopy paradigm with working channels and multiple degrees of freedom with different dials. And so... There's actually a procedure now called PEBL, P-E-B-L, or percutaneous endoscopic biliary lithectomy. And what that means is that...
we can actually go through the percutaneous train track once it's been in long enough. So this patient in particular, you'd have to leave that train in for six weeks. You could then bring them to... Whichever suite you have, whether it be in the OR, the GI suite or somewhere else with little to no anesthetic, meaning you could do it without much sedation at all. You could use a very light.
MAC or moderate sedation. You don't have to stop anticoagulants. So in this case, it would be applicable. We don't want to stop antiplatelet agents. But let's say that the gentleman doesn't want to have the drain in for a year.
you know or maybe he can never come off agents well maybe he'll never be a good candidate for surgery but we can leave them on those we can do it without anesthetic and we can go through that track with the cholangioscope and we can actually remove those stones now you know very very easily and it's a very safe procedure and it's been very exciting and it's really amazing when you start to perform the procedure and patients start to hear that
there is a way to get that drain out, people will start seeking you out for that as well. And it's amazing how many people are out there that have been told. you can't have surgery they might not even make it to a surgeon's office quite frankly because the internists don't want surgeons to even think about surgery so you don't even know how many are out there
There are quite a few out there that would like to have their drain removed, but really are not surgical candidates. Now we have, again, that endoscopic procedure too. to treat that. So it's a procedure that's just going to, again, become more and more commonplace. It can be performed by surgeons, interventional radiologists, even gastroenterologists can do it as well. So I think it's a procedure we're going to see more and more.
speaking of being sought out this third patient seems to find me somewhat frequently it's a 93 year old woman she had a helromyotomy for achalasia 45 years ago She was doing pretty well, maybe in the last 10 years, noticed things going down a little less easily. And then she gets admitted for esophageal impaction. She's got a huge dilated end stage looking esophagus.
All that gets cleared out is you get sent to your clinic to see what you're going to do. And here you go, Trevor. I'm pretty sure we had a couple of these last year. Yes, I think we certainly did. So for this patient, I think, you know, as we work up anybody kind of starting from the ground up, especially if they're so far out from myotomy and doing an upper GI or sophogram and getting a look at exactly.
what the esophagus looks like, and then having some sort of measurements of the lower esophageal sphincter and the esophageal pressures, whether that's with manometry or with endoflip. when these typically come about, and of course, the person's not going to be a surgical candidate in this case, for end stage achalasia, we see this kind of dilated, blown out.
aperistaltic esophagus and patients have these persistent life limiting or in this case like life-threatening symptoms and historically what we think of is it's unusual but it does happen that people get an esophagectomy so one of the big problems aside from this woman being 93 is that for patients with achalasia, they can often have a very, as you mentioned, dilated esophagus that kind of takes up their homeosteinum, and then they've been intervened on whether it's
Botox or myotomies or who knows what, and they can have scarring. And this can really be a fairly hazardous esophagectomy. And so, and also actually, if you look into studies of patient's quality of life after esophagectomy for achalasia, you know. historically we've done what we had to do but uh it's typically less than favorable so it's kind of an area that's ripe for a better option for these patients and so in looking at the i guess
technical or clinical aspects of her disease process, she had achalasia. So she had, you know, a peristalsis and an esophageal outflow obstruction, but she had a myotomy. So presumably if we can assume that when we do our testing, that her myotomy was complete or that she'd know.
longer has an esophageal outlet obstruction she still has this esophagus that doesn't really empty and you know classically this will be sigmoidal and maybe have like a pooling or gravity kind of sump process where things are collecting and preventing them from blowing into the stomach
And so we can assess by, like I said, menometry or like more easily endo flip by, you know, scoping the patient ourselves, doing an endo flip at the lower esophageal sphincter and, and looking at the patient's distensibility index. So if her.
If we see a value that is low, or I guess classically something less than, let's say, two, we would assume that maybe she had an incomplete myotomy, and maybe, maybe not, we would see some benefit in acting upon that. But presuming, as the case that we often see, that the di is actually within the normal or high range that the esophageal outflow obstruction is theoretically relieved it's just that this
anatomic structure she has no longer functions well and so one thing we've tried to do is in order to offer at least symptomatic relief is what we call pope or prooral placation of the esophagus and basically we endoscopically suture the kind of redundant or baggy portions of the esophagus and essentially re-tubularize it like geometrically and so we're
gradually accumulating a series of these patients, but they seem to do well. At least, you know, we've only been doing this for a couple of years now, so we'll see what. time shows, but it seems to be at least an option to temporize or hopefully get them out of having to have an esophagectomy and you can always do the esophagectomy later. There are certainly some hazards in...
maybe distributing this information that's worth noting. And that's that when you endoscopically, so you typically have a tissue capture device. And instead of working in intra-abdominal, you're in the mediastinum. So certainly that's a high real estate area and being full thickness with a tissue cap.
device would be, certainly is a hazardous thing in the mediastinum and worth considering. But for the moment, the OPE procedure, peroral placation of the esophagus seems to be an option. Yeah, perfect. The 90-year-old ladies like it. I remember when Trevor did his first hope and he said to me, man, I would do this 10 times before I would have an esophagectomy. Yeah. Absolutely correct.
All right, fourth and final case is a 50-year-old male comes to your office with suspected LPR ENT sent him over for laryngeal reflux. He has a cough. He had a Bravo study, and it does show that he has reflux disease, no heartburn, just the cough or paryngeal symptoms. I'm going to add to this case, he does not have a hiatal hernia. I think that is critical. You know, when I see patients with reflux disease...
That's kind of the first thing I'm looking at. Do they need a laparoscopic repair of their hiatal hernia or not? We still don't have a good way to do that endoscopically. I'd be surprised if we ever do. But that said, for patients without a hiatal hernia...
the way i think about reflux disease in general is you can either squeeze the valve you know squeeze it externally like a like a links device or there's this procedure anti-reflux mucosectomy that we do where you essentially it's doing emr of the gastrocardia And as it scars down, just lowers your hill grain a little bit. Just kind of squeezes the valve down slightly. The other way to do an anti-reflux procedure is a flap valve.
which doesn't necessarily squeeze the sphincter. So our partial fundiplications make a new flap valve. Our Nissen fundiplication is actually a combination of the two. You get a flap valve and you're squeezing the valve. And we've found over time that that's not necessary. One or the other is sufficient to control reflux disease. And you get more side effects if you do both. So endoscopically for this guy without, you know, he's got a cough.
does not have a idle hernia i would offer her arms i do get manometry before any procedure that will squeeze the valve because we need to demonstrate that their esophageal function is good enough to be able to swallow after their valve has been tightened down. But patients seem to do pretty well. In our series, we've got almost 80% of patients off their PPIs or eliminated symptoms doing that.
It doesn't burn any bridges. You know, if it doesn't work, then you can always go and do a fundiplication or something else. The other thing in this realm, you know, that I talked about the endoscopic tightening procedure, there is an endoscopic fundiplication, the TIF. Personally, I do not do that myself. I've never trained to do them. Dr. Yujiki's done some. The discussions I've had with him is long-term results do not seem to be as good as a laparoscopic multiplication so far.
And obviously you can't fix a hiatal hernia with that. So I don't offer TIF to patients, but there may be a time where we're doing that more frequently in the future, especially, you know, we've been talking about patients who have had a palm and have reflux. That might be a perfect opportunity for a TIF.
If I can add, I don't think TIF is a bad procedure, but I do think that you have to think about TIF and ARMS in the same way. And that is that you really need to have that Cura intact for the TIF to work well. And I think as you... you all know there's this movement towards a feature for this kind of combined you know laparoscopic hiatal hernia repair and the tiff and i believe that works and you're closing the crew laparoscopically
And so if the corona defect is non-existent, I think a TIF or ARMS, either one, my guess would be they would be fairly equivalent if you did those. But I think when we first started doing TIF many years ago, we probably were... performing them on people that had crews that were a little bit too open.
But we did see some good results in people that didn't really have much of a cruel defect. So I think everything you said is correct, but I think TIPS is also an option in somebody that doesn't have much of a high defect. Awesome. we can move on to the conclusion of our episode and we'll go through our quick hits. So number one, first and foremost, surgeons have played an integral role in the pioneering of modern endoscopy.
Number two, therapeutic endoscopy procedures are used for both de novo procedures to treat disease processes in themselves and also to manage surgical complications in less invasive manners than their prior options.
three in order to learn surgical endoscopy it's necessary to first master the basics and this can be accomplished with the help of simulation Four, there are fellowships that specifically train surgical endoscopists and are accredited by the fellowship council as well as Sages, and hopefully there'll be more every year. And number five, endoscopy represents an area ripe for further innovation and development for the field of general surgery.
Awesome, Trevor. Thank you guys so much for listening to our first episode and make sure to tune in for our next episode where we'll be discussing endoscopic applications and bariatric surgery. And this will be accompanied by instructional videos for some of the techniques that we discussed.
For now, this is the Behind the Knife Surgical Endoscopy team from Endeavor Health reminding you to dominate the day. For additional training and education on this topic, Boston Scientific's Educare platform... provides online access to a wealth of educational and training content all in one convenient place. Visit educare.bostonscientific.com That's educare.bostonscientific.com
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