Endoscopic sleeve gastroplasty: live uncut procedure

In this key lecture, Dr. Lopez-Nava presents the main principles of endoscopic sleeve gastroplasty (ESG). He briefly introduces the fibre optic endoscope system, single port surgery, and the evolution of bariatric surgery, as well as endoscopic sleeve gastroplasty using the Overstitch™ procedure. He also briefly describes the physiology of endoscopic sleeve gastroplasty and long-term weight Loss results in different case series, including complications, limitations, and follow-up results.

In this video, we show the case of an intraluminal migration of a gastric band, which was endoscopically removed by means of a mechanical lithotripsy system, after the patient refused to undergo laparoscopic surgery.

In this key lecture, Dr. Whiteford outlines the transanal approach for early stage rectal cancer with current indications and video demonstrations.

Confocal laser endomicroscopy (CLE) is a new diagnostic technique that allows microscopic examination of the digestive mucosa during ongoing endoscopy. Different types of tissue and diseases can be diagnosed immediately, and analysis of the in vivo microarchitecture is helpful to better target standard biopsies and reduce the number of biopsies required. In this lecture, this interesting technique is presented.

POEM (peroral endoscopic myotomy) is an emerging procedure, which has evolved from the era of NOTES. The most cardinal indication for POEM is achalasia of the cardia. Other indications include diffuse esophageal spasm, jackhammer esophagus, and surgically failed cases.
The steps of POEM include the following: mucosotomy, submucous tunnelling, myotomy, closure of mucosotomy.
The myotomy is started 2 to 3cm distal to the mucosotomy and is continued to the end of the tunnel at 2 to 3cm distally to the gastroesophageal junction (GEJ). A partial myotomy is most commonly performed by means of careful dissection of circular fibers, hence avoiding longitudinal fibers to prevent entry into the mediastinum. The mucosotomy is then closed to prevent any leakage with the use of endoscopic clips or of an endoscopic suturing device. About the EndoFLIP™ (Endolumenal Functional Lumen Imaging Probe) Imaging System: this is a functional endoluminal imaging probe, which helps in the assessment of gastroesophageal junction distensibility and compliance after the procedure.
Complications of POEM:
Inadvertent mucosotomy is the most common complication.
Complications due to insufflation (pneumomediastinum, pneumoperitoneum) can be controlled by using carbon dioxide for insufflation. Esophageal leak is the most dreaded complication with rates ranging from 0 to 5.6%.

This video shows the case of a 56-year-old man with a T2N2M1 sigmoid cancer managed under radiochemotherapy referred for bowel obstruction without gas and without faeces for four days, with a dilated abdomen. An abdominal CT-scan confirmed the colonic obstruction caused by an obstructing lesion at the rectosigmoid junction, 18cm away from the anal verge. An endoscopic colonic stenting is demonstrated.

Argon Plasma Coagulation (APC) is an innovative non-invasive endoscopic treatment used to reduce the anastomotic diameter.
Technology: Argon gas is used to deliver evenly distributed thermal energy to a field of tissue close to the probe. The heat which is generated devitalizes, coagulates, desiccates, and shrinks the tissue.
Argon Plasma Coagulation is performed by applications of 0.5 to 2 seconds in duration. The depth of penetration is around 2 to 3mm.
Side effects: gaseous distension, pain, stricture, bleeding, pneumoperitoneum, and rarely perforation.

This is the case of a 75-year-old lady who presented with recurrent symptoms of dysphagia and regurgitation associated with a significant weight loss due to recurrent achalasia. She developed progressive recurrence after a first surgical treatment by an open Heller myotomy and Dor fundoplication back in 1974. This first operation was complicated by an esophageal perforation which required a thoracotomy to be controlled. Several dilatations were attempted with no significant symptoms improvement. One of the most important aspects of POEM is to ensure that the submucosal tunnel adequately extends into the gastric cardia in order to perform a complete and adequate myotomy. To this aim, proper orientation is key but may be difficult even to the experienced eye of the interventional endoscopist familiar with ESD techniques and dissection planes. Six endoscopic cues that assist with this determination have been identified so far. The most useful cue was deemed to be the characteristic appearance of the submucosal space of the cardia of a slightly different color with a somewhat yellowish hue, more capacious than the esophageal submucosal space with more and larger vessels. Identification of the thick, cord-like circular muscle fibers of the lower esophageal sphincter was deemed as the second most useful cue, and noting a bluish coloration of the cardial mucosa from the colored submucosal injection via a retroflexed luminal view was the third most useful cue. Endoscope insertion length within the submucosal tunnel and the palisading mucosal vessels marking the gastroesophageal junction and visible also from inside the submucosal tunnel were deemed helpful but to a lesser degree. Nevertheless, identification of these endoscopic landmarks is not easy nor always reproducible. Creation of the submucosal tunnel is very sensitive to case difficulty and accounts for the large fluctuations in procedure time. Another area of technique variability involves the orientation of the myotomy. In order to improve the recognition of the essential landmarks, we developed a myotomy technique guided by the EndoFLIP® catheter. EndoFLIP® is a unique physiology test that uses both volumetric assessment and pressure readings to calculate compliance and high pressure zones as well as distensibility changes at the gastroesophageal junction. It allows intraoperative assessment of myotomy completion. The use of this device provides a direct immediate feedback with regards to the efficacy of the myotomy. The EndoFLIP® catheter used in this case (EF-325L) has been specifically modified for the POEM procedure. It differs from the standard EndoFLIP® catheter in that it contains an integrated illuminating LED adjacent to the centre measurement electrode. When the catheter is positioned intraluminally at the gastroesophageal junction and secured to this position taping the distal end to the endothracheal tube, it allows to direct dissection towards the cardia.