Live procedure by Prof. Ralf Kiesslich, Germany

Introduction:

The following 31-year-old female patient has suffered from very serious gastroesophageal reflux disease since puberty. It is only thanks to a long-term highly dosed therapy with a proton pump inhibitor that she has been able to avoid any further complaint. The question whether there was an alternative to medicinal treatment came up in our consultation January of this year. After a complete explanation of the possibilities of the treatment, I decided to subject the patient to a new endoscopic anti-reflux procedure (MUSE™) which Dr Käslich will now demonstrate.

I would like to show you an external model of the system in order to understand before using  it. What we would like to achieve is that this endostapler, which can be bent, links the stomach and the esophagus and then using a stapling system, joins these two parts, the stomach and the esophagus, together and this happens on three stapling sites in order to create a flap-valve.

The (MUSE) system includes the smallest camera in existence today, the stapling system, and the hardest part about the examination is precisely joining the right tissue, that is esophagus and stomach, together, making sure that the (tissue) thickness is precisely correct for the stapling system and we use the two screws before we apply the staples (for assistance). First we have an ‘alignment pin’, that is, just a pin that secures us in the mucous membrane and this means that the screws that will be applied find the nuts located on the other side of this single-use endoscope or single-use endostapler. The staples are then applied and you can see that there is now a link between the fundus and the esophagus.
What we did next was to precisely measure the Z-line, that is, the distance, 45 cm from the incisors, and then the (MUSE) system tells me at the top that the stapling must occur at 63 cm. On the left, you can see the individual steps that I will follow and that often happens without the endoscopic image, but we still need the endoscopic image at the beginning, as we first need to see what the cardia looks like. We have already tried this once, which is why it is bleeding slightly; this is the white receptor system, as it were, where the staples are. The staples, will then be applied.

You can see here the end of the endoscope. I will now use the end of the endoscope somewhat differently, nearly straight in fact, now at an inwards bending angle of 169, which is very good. I have now switched on this mechanism and I will now pull the endoscope back until 63 (which can be controlled). Now I move it more to the left. Now I bend– here you can see that once I reach a bending over 270°, the system moves on and we now see the bending force, that is, the force applied to the tissue, and now with small movements, I’m trying to obtain an ultrasound signal.

You see here above a 100% ultrasound signal. We have the gap, the distance between the tissues of the stomach and the oesophagus, reaching 2.5 mm, which is well in the green zone, and on the animation on the right, you can see that this middle screw, this pin, the alignment pin, is joining the endoscope to itself and this gives the possibility of screwing in the two screws located on the left and the right, called ‘anvil screws’ and I do this with a small wheel at the end of the endoscope. It is hard to show, but I move it forward and you can see that the tissue gap is increasing, so we need to go back and forth – this is called tango phenomenon – because the tissue is, how should I say, going into the thread, which is why I am slowly moving forwards and backwards until the small screws are in the exact right position. We have now compressed the tissue to around 1.57 mm, which is ideal and indicated by the system. And underneath, we can see that these screws situated on the left and right in the tissue and, on the other side, the endoscope, are stopped at 96%, which is why I now have at the top ‘press and hold the fire button’, which I now do. It is up here, a switch that you can’t see very well, but it is at the top of the handpiece of the endoscope. I now press it, and then, once it has been applied, which we can’t yet see, I will take the screws back out again and then take the system apart again and have a look at the first stapling (sight).

I repeat the whole process another two times and then we’ll have the final result. And then I go back, you can see I am already taking the screws out, I’m at 88%, 87%, 86%. Now we need to have a quick look at the screen. Sometimes you can see what you’ve done, that the staples have been applied and, for this patient, you can see from the anatomy that there is no need to apply any more staples here, but here we need another and I think we will then have a nice ring completely surrounding the endoscope. We can still see some hernia, but I think this first stapler has already helped her a lot.