AATS General Thoracic Skills CourseAATS General Thoracic Skills Course

Esophageal DiseaseEsophageal DiseaseEndoscopic and Minimally Invasive TechniquesEndoscopic and Minimally Invasive Techniques

Thomas Varghese Jr, MD, MSThomas Varghese Jr, MD, MStkv@uw.edu

@tomvarghesejr@tomvarghesejr

April 25, 2015April 25, 2015

TopicsTopics

Endoscopic evaluation of Barrett’s Endoscopic evaluation of Barrett’s Endoscopic staging and Rx of Esophageal CancerEndoscopic staging and Rx of Esophageal Cancer

EMR, RFA, CryoEMR, RFA, Cryo

Minimally Invasive Treatment of Benign DiseaseMinimally Invasive Treatment of Benign Disease EndoscopicEndoscopic

POEM, Linx, Endoscopic Anti-RefluxPOEM, Linx, Endoscopic Anti-Reflux Laparoscopic PEH RepairLaparoscopic PEH Repair Stitch, Stents and ClipsStitch, Stents and Clips

Ross Bremner MD

Wayne Hofstetter MD

Daniel Miller MD

John Wee MD

Brian Louie MD

Hiran C. Fernando MD

Virginia Litle MD

Shanda Blackmon MD

Barrett’sBarrett’s

Risk Factor for Esophageal CancerRisk Factor for Esophageal Cancer Most will not develop cancerMost will not develop cancer No way to risk stratify at present with exception of No way to risk stratify at present with exception of

degrees of dysplasiadegrees of dysplasia

Biopsies unreliableBiopsies unreliable

Expense of surveillance very, very highExpense of surveillance very, very high

Esophageal CancerEsophageal Cancer

HGD to T1a Esophageal CancerHGD to T1a Esophageal Cancer What is the ideal treatment?What is the ideal treatment?

AchalasiaAchalasia

PerOral Endoscopic Myotomy (POEM)PerOral Endoscopic Myotomy (POEM) Laparoscopic Heller Myotomy + partial Laparoscopic Heller Myotomy + partial

fundoplicationfundoplication

J Laparoendosc Adv Surg Tech A. 2015;25(2):123-9Wei M1, Yang T, Yang X, Wang Z, Zhou Z.

No difference in complications, reflux, symptom recurrence No difference in complications, reflux, symptom recurrence

RefluxReflux

LINX™ SystemLINX™ System

Endoscopic Anti-Reflux ProceduresEndoscopic Anti-Reflux Procedures

Magnetic Sphincter Augmentation Magnetic Sphincter Augmentation (LINX™ System)(LINX™ System)

• Series of titanium covered magnets

• Roman Arch Design with magnets supported by “dumbell” shaped titanium wires

• Dynamic – opens and closes

• Fit to the outer circumference of the esophagus

Images courtesy of Torax Medical Inc.

Patient Selection

• Age 18+

• GERD

• Hiatal hernia < 3 cm

• No major dysmotility

• No visible Barrett’s esophagus

• BMI < 36 kg/m2

• No strictures

• No prior esophageal surgery

• No metal allergy

Paraesophageal HerniaParaesophageal Hernia

Laparoscopic ApproachLaparoscopic Approach Now the most commonNow the most common

Esophageal TearsEsophageal Tears

Stitch, Stent, ClipsStitch, Stent, Clips