let's begin... we need to ensure that we make a tunnel of at least 12 cm. gentamicin, please. thank you. first step is to... inject gentamicin. perfect. gentamicin. okay, perfect. did we test to know this works properly?
out, please. no, posterior. i am only deciding where is our 6 o'clock. let's inject. here's our 6 o'clock. that's the technique. let's look for our 3 o'clock. around here. this is our 6. let's enter... inject...
and begin. we begin cutting we can see here... the epithelium is a little stiff. this can be seen with achalasia every so often is stiffer than normal inject more. we advance slightly open just slightly.
we can now see... the opening has been established... to facilitate entry... of the endoscope... we will be using... pure cut for a moment. pure cut, just a little bit here. to increase the size of the window. let's begin slowly.
very important to... be face to face... with this opening. clearly the epithelium is stiff. stiffer than normal. for this reason we have to... find the best way... to open the submucosa. here... slowly begin...
slowly... we open. open the window slightly more. do the same on the other side... to enlarge the window. here to facilitate... entry... we are nearly inside.
now, it is critical to inject... inject. we are nearly there. and cut. here... there... a little patience... here. almost... it's slightly more stable now.
inject. stabilize. this esophagus is a little torturous. we have here... it may be easier... to work... with a lateral position. as we can see... here the muscularis is... to the right. the epithelium...
is to the left. this allows us... to stabilize. the entry... begin... very important... to understand out planes. here we can see... the intensity...
of the fibers... that we have to cut. i'm working... proximal... to the muscularis. let's check what happened to the tunnel. it looks good. it's good. now we have slightly more stability.
we can decide to... make... a more posterior approach... we just placed the muscularis... posteriorly. in this plane. we advance. and cut. the advantage of using the spray coag is...
that coagulation... is transmitted. it's different when only... pure cut is used. for example, this here is using pure cut. pure cut is good for... wound healing. like that. but when one wants to...
have... a more dispersed effect.... spray coag presents... the most interesting option. we can see here the junction... between the muscularis... here... and the epithelium. inject some more... to reinforce... the separation.
super important... to do this. there is a vessel here... coagulation. it's the benefit of having... this... erbe knife. as it is called in english: multi-purpose or, in spanish, multi "function."
because it allows us to inject... allows us to coagulate. and allows us to cut. a very fitting name.... for the function... of this knife. now we can see.. the separation...
a very good one, between the muscularis... slightly more torturous here... but we keep sight of the muscularis. to release the fibers here. we are very proximal to the junction. it will be a little more... harder to... advance through. take some time...
to open the fibers properly. inject some more... and more. advance. advance further. inject. inject. inject. we are just about to cross... the fibers here are... different...
time to check... where we are. there are additional vessels, too. we are very, very proximal... this here is the muscularis... vessels. super important to understand the planes. precisely when one is nearing... the time to cross toward the stomach.
to understand the planes. clearly the fibers here are different. it is now the moment to do the famous 'test' and we'll see if we arrived... or not at the stomach. this here is the muscularis here, tunnel. good opening, not too large. we will see now...
if we can feel any resistance. see. we are now in the stomach. this is the most important step here: verifying that we have crossed. we can now begin the myotomy. perfect. we begin slowly, here. we enter the tunnel... we place ourselves...
in the midline... of the... muscularis. we keep in mind the position of the opening.... and we begin here... to have 12 cm in front of ourselves, if possible. alright, this place is fine. this is the most critical step: to ensure that we are...
in the midline of the muscularis. we must stabilize our position.... to allow... still a lot of muscularis, but we can observe here the planes... between the two... stabilize. the longitudinalis over there... and here the muscularis.
slightly deep. we will try to... adjust. i like to do... slightly deeper than we hoped... the patient's longitudinalis is very thin. in younger individuals it can be observed... especially how... how thin is the... longitudinalis in comparison to the...
circular muscle. this here is the circularis. i just cut it through. yes it is very...it's is almost nonexistent. there is almost no... alright. we must check the patient's abdomen.. to ensure there's no need for decompression. okay, here. there.
everything alright? just a little emphysema... it's fine, it's normal. how is the abdomen? we don't have adequate insufflation. can we check what happened here? no air, only co2. no air. air...
is not allowed. ready? much better. to have this access... here... we are finally here. we are nearly done. finally. the end of the end.
last few fibers... last few fibers. we are now in the stomach. peritoneum... mediastinum... there is no... longitudinalis here. that's is the problem. now we will feel if...
the endoscope passes through nicely. super nice. there is no resistance whatsoever. so we are done. let's inject... gentamicin inside the tunnel. close it, please. a bit of emphysema... but that will disappear...
within a few hours. gentamicin. ah, thank you. could you give me some clips, please? super. more please. super. okay. rotate, please. rotate. there, super
let me see. close, close, close. yes! yes, now. release. perfect. another one. that was done perfectly. well centered... outside the tunnel to provide... a gravity effect. this will allow to....
make an approach between... the two labialis of the opening... it will... it will facilitate it's closure. she has more emphysema than normal... but... the most important step... is to check the abdomen for tension. how are the parameters?
the blood pressure... heart rate? everything fine? perfect. and is there any co2 retention... in the... in the lungs? the lung volume is fine? that is important because if the volume is decreasing.... it means there are...
there are (out, please)... signs of co2 retention. okay, close. close, close. yes. yes! yes, there. let go. yes, yes.
did we perform a barium test for yesterday's patient? yes? super! how is the contrast flowing through? good. super. open. close. close. yes. yes! okay, another one. there's no more co2, huh.
i'm not getting enough co2. there's no more co2. it seems like... i have little insufflation. a little better... okay. out, open... rotate more. okay, open. okay, there. yes, now.
now. now! now and relax. okay, super. let's see now... we'll check... this side... maybe one more between these two... yes, one more right here. open.
yes. yes! yes. super! ...closed.... ...on this side... and now... ...this other side... this technique is from the japanese. closed.... as well. we are done.
thank you very much. excelent this illustrates the importance... (thanks, johny, lupita) of making a tunnel... dedicated... through the esophagogastric junction. the moment the tunnel is completed.... that you have extended the myotomy, because
your tunnel is good, clear and open... even with the presence of little longitudinal muscle... we accomplished a complete myotomy. this is fine, because the tunnel is... well centered, it is.... it acts as a gps the tunnel acts as the gps of myotomy. so everything works very well. excelent. now, tomorrow we will...
perform a contrast... to check for any leaks within the tunnel. to ensure that the contrast is passed down... without trouble. and, if all goes well... she begins with 3 days of liquids... 3 days of soft foods, and slowly... return to a normal diet. yes. significant reflux...
that needs, for example, fundoplication... only 5% in our recorded cases. so...everything regarding gastric reflux... are slightly exaggerated... because poem preserves... the diaphragm fibers... that surround... it is a natural protection... and this is the difference with the heller
the heller does not protect these fibers... because the approach takes place... anteriorly, through the fibers... of the diaphragm. so... there's the need for fundoplication... at the same time... as the surgical myotomy. with poem, since it is performed from inside...
all of the external fibers... of the diaphragm remain intact. it is an advantage of poem. no. there is no.... relationship. it's something entirely... independent. some patients will present significant gastric reflux... some patients don't. some patients have silent reflux, but...
20 to 30% of the population has... silent reflux... and addresses it with otc medications. so... there is reflux, and then there is reflux. what we are interested in... as scientists, is reflux... that needs fundoplication. and that accounts for only 5%. voila!
thank you for tuning in today with us... in juã¡rez. it was a... symposium of interventional endoscopy... super... super good, super interesting... with many novel features... and we hope to return soon for more... thank you for joining us. goodbye.
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