# Achalasia — GCMD Library living collection

Everything in the library about achalasia — built automatically from dossiers that name it.

Updated: n/a · 8 episodes · 171 cited statements

## Episodes
### Surgical Management
- [Laparoscopic Heller Myotomy](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252) — video · 3:32 · [machine version](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252.md)
- [Endoscopy and Surgery](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720) — video · 11:29 · [machine version](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720.md)
- [POEM by Surgeons – Dr. Jeffrey Ponsky](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722) — video · 20:52 · [machine version](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722.md)
- [SAGES/ALACE Symposium: Integrating New Technologies, Old Tricks, and Operative Approaches](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727) — video · 12:32 · [machine version](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727.md)

### In-Depth Reviews
- [Update Course 2023 - Updates in Pediatric Achalasia Management](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270) — video · 26:54 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270.md)
- [Update Course Rewind: 2023 Top Ten Key Takeaways](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758) — video · 16:22 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758.md)
- [Meet the Master: Jeffrey L. Ponsky, MD, FACS](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683) — video · 1:05:06 · [machine version](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683.md)
- [Ponsky and Gauderer invent the PEG tube](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724) — video · 7:03 · [machine version](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724.md)

## Chapters
- [0:06](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=6) Introduction to Heller myotomy and case presentation (Ep 1)
- [1:30](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=90) Myotomy technique without energy sources (Ep 1)
- [2:30](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=150) Completion of myotomy and postoperative outcome (Ep 1)
- [0:03](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=3) Introduction and Achalasia Classification (Ep 2)
- [5:10](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=310) Treatment Options and Fundoplication Debate (Ep 2)
- [11:14](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=674) Recurrent Achalasia Case and Diagnostic Approach (Ep 2)
- [15:41](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=941) POEM Technique and Outcomes (Ep 2)
- [21:13](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1273) Adoption Challenges and Training Discussion (Ep 2)
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=0) Introduction and POEM Procedure for Achalasia (Ep 3)
- [1:52](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=112) Blunt Cerebrovascular Injury Screening (Ep 3)
- [3:12](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=192) Early Discharge After Pyloromyotomy (Ep 3)
- [4:36](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=276) ICG for Sentinel Node Identification (Ep 3)
- [6:21](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=381) Anal Dilations Following PSARP (Ep 3)
- [7:58](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=478) Fertility Preservation in Pediatric Oncology (Ep 3)
- [9:40](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=580) Massive Transfusion Protocol (Ep 3)
- [11:24](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=684) Ovarian Torsion Management (Ep 3)
- [12:54](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=774) Total Pancreatectomy with Islet Auto-Transplantation (Ep 3)
- [14:22](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=862) Blunt Hepatosplenic Trauma Management (Ep 3)
- [0:08](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=8) Introduction and Early Background (Ep 4)
- [3:38](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=218) Entry into Endoscopy and Institutional Resistance (Ep 4)
- [10:40](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=640) Development of PEG Procedure (Ep 4)
- [16:56](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1016) PEG Innovation and Concept Extension (Ep 4)
- [22:07](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1327) Academic Career at Mount Sinai (Ep 4)
- [27:54](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1674) Leadership in ASGE and SAGES (Ep 4)
- [34:49](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=2089) NOTES and Noscar Consortium (Ep 4)
- [40:00](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=2400) American Board of Surgery Leadership (Ep 4)
- [44:25](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=2665) Cleveland Clinic and Return to Case Western (Ep 4)
- [53:24](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=3204) Intramural Surgery and Current Practice (Ep 4)
- [60:40](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=3640) Career Advice and Life Philosophy (Ep 4)
- [0:06](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=6) History of Surgeons in Endoscopy: From Fiber Optics to Therapeutic Innovation (Ep 5)
- [3:39](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=219) Modern Integration of Endoscopy into Surgical Practice (Ep 5)
- [6:05](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=365) Advanced Therapeutic Endoscopic Techniques and Collaboration (Ep 5)
- [8:48](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=528) Future Vision: Transmural Surgery and Robotic Integration (Ep 5)
- [0:13](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=13) Introduction to POEM and the case for surgeons learning endoscopic myotomy (Ep 6)
- [3:09](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=189) POEM technique demonstration and procedural details (Ep 6)
- [6:11](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=371) POEM clinical outcomes and comparison to Heller myotomy (Ep 6)
- [9:50](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=590) POP (peroral pyloromyotomy) for gastroparesis (Ep 6)
- [13:23](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=803) STEER for esophageal leiomyomas (Ep 6)
- [14:39](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=879) Endoscopic cricopharyngeal myotomy for Zenker's diverticulum (Ep 6)
- [19:28](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=1168) Conclusion: intramural surgery as a surgical domain (Ep 6)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- POEM (peroral endoscopic myotomy) provides 360 degrees of options to perform myotomy, whereas with Heller myotomy you have maybe 180 degrees and must worry about the vagus nerve. (clinical) [Ep 3 · 1:06](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=66)
- POEM can be performed after a failed Heller or previous POEM by choosing a different side for dissection, avoiding burned bridges. (clinical) [Ep 3 · 1:22](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=82)
- POEM does not require dissection of the hiatus, reducing concern for reflux. (clinical) [Ep 3 · 1:32](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=92)
- A patient with delayed diagnosis stroke from a missed BCVI prompted the institution to create a routine BCVI screening protocol requiring CTA head and neck for at-risk patients. (clinical) [Ep 3 · 2:24](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=144)
- If you are giving blood in the trauma bay, you need to activate MTP—giving blood equals MTP activation. (guideline) [Ep 3 · 10:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=615)
- For bad trauma with unstable or abnormal patients, whole blood would be the best option. (opinion) [Ep 3 · 10:39](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=639)
- The blood bank has not been able to provide whole blood for pediatric patients because it needs to be irradiated. (clinical) [Ep 3 · 10:48](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=648)
- The goal is 1:1:1 ratio of blood products (packed red blood cells:FFP:platelets), with FFP given after blood. (guideline) [Ep 3 · 10:53](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=653)
- Most hospital trauma coolers do not initially contain platelets, requiring separate call for platelets through MTP or direct request. (clinical) [Ep 3 · 10:58](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=658)
- In the acute postoperative period after TPIAT, glucose must be managed externally; all patients are on insulin in the ICU to avoid stressing the islet cells, allowing them to implant and find new vessels from the liver without doing work. (clinical) [Ep 3 · 13:27](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=807)
- In one institution's practice, 80% of pediatric trauma patients are transfers who have already had CBC at the referring hospital; hemodynamically normal children go to the floor without repeat hemoglobin. (clinical) [Ep 3 · 15:27](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=927)
- Achalasia types 1, 2, and 3 all have high LES pressure and require the same treatment (myotomy), but type 2 responds best to surgery while type 3 responds worst (clinical) [Ep 2 · 1:41](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=101)
- Type 3 achalasia is the most rare (11% in their series) and patients may have symptoms down the road that may or may not be related to myotomy (epidemiological) [Ep 2 · 1:41](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=101)
- The ECAR score consists of four components: weight loss, dysphagia, chest pain, and regurgitation, used for both diagnosis and clinical follow-up (guideline) [Ep 2 · 4:02](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=242)
- At their institution, they have observed cases where Dor fundoplication twisted the esophagus as children grew, requiring takedown of the wrap to resolve symptoms (clinical) [Ep 2 · 6:39](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=399)
- Approximately 50% of their pediatric achalasia patients had some intervention (dilation or Botox) before definitive surgery — Tim (epidemiological) [Ep 2 · 8:00](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=480)
- Botox injection causes significant scar tissue formation, while prior dilations cause minimal fibrosis — Tim (clinical) [Ep 2 · 8:00](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=480)
- Their standard myotomy length is approximately 6-7 centimeters total: 4-5 centimeters proximal and 2 centimeters onto the stomach — Tim (clinical) [Ep 2 · 13:19](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=799)
- Symptoms within one year after myotomy suggest incomplete myotomy, while later recurrence may represent true recurrent achalasia related to growth — Tim (clinical) [Ep 2 · 12:06](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=726)
- Manometry in post-operative achalasia patients often continues to show achalasia findings and is not routinely used for follow-up at their institution (clinical) [Ep 2 · 14:30](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=870)
- Endoflip measures esophageal distensibility index and diameter, with accepted adult standards that are extrapolated to pediatric patients (clinical) [Ep 2 · 15:41](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=941)
- Their institution began performing POEM in 2015 after taking a course with Lee Swanstrom in Portland in 2013 (clinical) [Ep 2 · 17:06](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1026)
- The first 2-3 POEM cases were difficult and had the option to convert to Heller myotomy if needed; no conversions have been necessary since 2018 (clinical) [Ep 2 · 17:50](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1070)
- Their current POEM volume is approximately 15 cases per year (epidemiological) [Ep 2 · 18:40](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1120)
- POEM offers 360 degrees of myotomy options compared to approximately 180 degrees with laparoscopic Heller myotomy (clinical) [Ep 2 · 19:40](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1180)
- POEM does not require hiatal dissection, reducing reflux concerns, and allows choosing different planes for redo procedures (clinical) [Ep 2 · 20:20](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1220)
- In their series of 73 POEM procedures, the re-intervention rate is approximately 15%, similar to their prior Heller myotomy experience — Tim (epidemiological) [Ep 2 · 21:13](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1273)
- Re-intervention is defined as needing balloon dilation within one year post-operatively — Tim (clinical) [Ep 2 · 21:50](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1310)
- Of 5 redo POEM procedures performed, 3 were in patients with type 3 achalasia, and these patients presented with recurrent symptoms within one year — Tim (epidemiological) [Ep 2 · 22:10](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1330)
- In their series, 11% of patients had type 3 achalasia (higher than most literature), and 62% had type 2 — Tim (epidemiological) [Ep 2 · 22:45](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1365)
- Type 2 achalasia patients have no peristalsis, so opening the LES allows them to swallow effectively — Tim (clinical) [Ep 2 · 23:20](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1400)
- Type 1 achalasia patients have spastic esophagus after LES opening and may have more persistent symptoms — Tim (clinical) [Ep 2 · 23:50](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1430)
- Biopsies of all pediatric POEM patients at one year show a reflux rate of approximately 5%, compared to 50% in adults (epidemiological) [Ep 2 · 10:20](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=620)
- Only two centers in the United States perform POEM in pediatric patients, with one center (Children's National) being the primary active program — Tim (epidemiological) [Ep 2 · 21:47](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1307)
- Many patients are referred specifically requesting POEM after doing their own research, not wanting to hear about Heller myotomy (opinion) [Ep 2 · 24:40](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1480)
- The same endoscopic pyloromyotomy technique used in POEM has been successfully applied to treat gastroparesis in 3 patients (clinical) [Ep 2 · 25:51](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1551)
- Modern endoscopy began with Basil Hersowitz in the late 1950s when he integrated flexible fiber-optic technology using fiber-optic cables to produce endoscopic instruments which could go through the mouth or rectum to produce images. — Jeff Ponsky (clinical) [Ep 5 · 0:59](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=59)
- Surgeons and gastroenterologists were involved in endoscopy from the very beginning, with Hersowitz using the technology to examine the upper GI tract first, then the lower. — Jeff Ponsky (clinical) [Ep 5 · 1:29](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=89)
- Gastroenterologists such as Gene Oberholt and Jerry Way were involved in the beginning using the scope to develop diagnostic applications of endoscopy. — Jeff Ponsky (clinical) [Ep 5 · 1:50](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=110)
- Surgeons saw the therapeutic applications of endoscopy and developed procedures including polypectomy using electrocautery (Hiromi Shia and Bill Wolf in New York). — Jeff Ponsky (clinical) [Ep 5 · 2:08](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=128)
- Greg Stigman from Colorado applied the principle of banding hemorrhoids in the rectum to variceal banding in the esophagus. — Jeff Ponsky (clinical) [Ep 5 · 2:37](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=157)
- Michael Godard and Jeff Ponsky applied surgical principles of percutaneous techniques to place feeding tubes using the endoscope to guide the procedure. — Jeff Ponsky (clinical) [Ep 5 · 2:50](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=170)
- In Germany, Nipsa Hendra, a surgeon, developed the first stenting of the bile duct. — Jeff Ponsky (clinical) [Ep 5 · 3:20](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=200)
- Surgeons have been involved in the advances in endoscopy, particularly the therapeutic advances. — Jeff Ponsky (opinion) [Ep 5 · 3:31](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=211)
- Modern bariatric and gastrointestinal surgeons use endoscopy to look at their anastomosis and test their anastomosis after they've done it. — Jeff Ponsky (clinical) [Ep 5 · 4:30](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=270)
- Surgeons use endoscopy to stent leaks or perform therapeutic stenting of strictures. — Jeff Ponsky (clinical) [Ep 5 · 4:42](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=282)
- Endoscopy for surgeons today is a technique they use to augment their surgical procedures. — Jeff Ponsky (opinion) [Ep 5 · 4:51](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=291)
- Not all surgeons perform ERCP. — Jeff Ponsky (clinical) [Ep 5 · 5:07](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=307)
- Surgeons in bariatric surgery use endoscopy daily to assess the results of their surgery, look for leaks, stent leaks, put in drainage tubes, and improve the treatment of their complications. — Jeff Ponsky (clinical) [Ep 5 · 5:12](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=312)
- Endoscopic submucosal dissection can be performed even in the colon to remove T2 tumors and extensive spreading tumors without the need for surgery. — Jeff Ponsky (clinical) [Ep 5 · 6:22](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=382)
- Emory Gorgon at the Cleveland Clinic has a huge experience in endoscopic submucosal dissection. — Jeff Ponsky (clinical) [Ep 5 · 6:38](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=398)
- Pre-malignant and early malignant lesions in the esophagus are being removed endoscopically by both GI and surgery specialists. — Jeff Ponsky (clinical) [Ep 5 · 6:50](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=410)
- Division of the esophageal muscles to treat achalasia can now be performed endoscopically where surgery used to be required. — Jeff Ponsky (clinical) [Ep 5 · 6:54](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=414)
- The purpose of endoscopic techniques is not to remove surgery but to augment it and choose the right procedure for the right patient. — Jeff Ponsky (opinion) [Ep 5 · 7:09](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=429)
- The only place surgeons and gastroenterologists fail is when they fail to work together. — Jeff Ponsky (opinion) [Ep 5 · 7:35](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=455)
- The gastroenterology community is excellent at endoscopic ultrasound, which has led to tremendous therapeutic advances. — Jeff Ponsky (opinion) [Ep 5 · 7:45](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=465)
- The ultimate potential of endoscopic ultrasound won't be reached unless surgeons and gastroenterologists work together. — Jeff Ponsky (opinion) [Ep 5 · 7:50](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=470)
- At the Cleveland Clinic, surgeons and gastroenterologists work together, combining surgical techniques with endoscopic techniques. — Jeff Ponsky (clinical) [Ep 5 · 8:03](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=483)
- In 10 years, the field will have advanced so much that current practices won't be recognizable. — Jeff Ponsky (opinion) [Ep 5 · 8:37](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=517)
- Future endoscopy will include transmural surgery, performing resections of pieces of bowel, removing tumors, and sewing up the lumen endoscopically. — Jeff Ponsky (opinion) [Ep 5 · 8:56](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=536)
- Future procedures will include gastrointestinal anastomosis performed endoscopically or using combined endoscopic and percutaneous techniques. — Jeff Ponsky (opinion) [Ep 5 · 9:18](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=558)
- Complications will be managed endoscopically in the future using ultrasound and endoscopy. — Jeff Ponsky (opinion) [Ep 5 · 9:32](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=572)
- New modalities will be integrated into endoscopy to deal with biliary disease, colonic disease, pancreatic disease, gastric disease, and inflammatory bowel disease. — Jeff Ponsky (opinion) [Ep 5 · 9:39](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=579)
- The integration of surgery and gastroenterology will improve the whole specialty. — Jeff Ponsky (opinion) [Ep 5 · 9:56](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=596)
- The robot refines surgical maneuvers and helps perform procedures better and more exactly. — Jeff Ponsky (opinion) [Ep 5 · 10:25](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=625)
- Jeff Ponsky was initially a critic of the robot in laparoscopic surgery when it first began because it was expensive and he thought it unnecessary. — Jeff Ponsky (opinion) [Ep 5 · 10:35](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=635)
- Robotics must be integrated into everything surgeons do and will be used with flexible endoscopy just as it has been used with colorectal and intestinal surgery. — Jeff Ponsky (opinion) [Ep 5 · 10:47](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=647)
- Myotomy can be performed in a precise manner without the use of any energy source (clinical) [Ep 1 · 1:20](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=80)
- 5 millimeter trochars were used for the laparoscopic approach (clinical) [Ep 1 · 1:50](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=110)
- An 8 centimeter silk suture is used to measure the distance from the diaphragm to the cardia (clinical) [Ep 1 · 2:00](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=120)
- The posterior attachments of the esophagus to the hiatus are kept intact during mobilization (clinical) [Ep 1 · 2:10](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=130)
- An arthroscopic knife is used to initiate the esophageal myotomy, then scissors deepen it (clinical) [Ep 1 · 2:20](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=140)
- A right angle grasper spreads the muscle fibers, and once the longitudinal muscle is mobilized, traction in opposite directions achieves satisfactory separation without injury to the submucosa (clinical) [Ep 1 · 2:30](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=150)
- The myotomy proceeds from distal to proximal, with the outer longitudinal and inner circular layers well identified (clinical) [Ep 1 · 2:45](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=165)
- Individual circular fibers can be precisely divided by the tip of the instrument with the heel protecting the submucosa (clinical) [Ep 1 · 2:55](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=175)
- The dissection is bloodless when performed with this technique (clinical) [Ep 1 · 3:05](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=185)
- After reaching the proximal extent at the diaphragm, the direction of dissection is reversed to extend the myotomy onto the gastric cardia (clinical) [Ep 1 · 3:10](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=190)
- The cardiomyotomy continues for a distance of approximately 2 centimeters (clinical) [Ep 1 · 3:20](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=200)
- The myotomy is tested by pulling the nasogastric tube back to the hiatus and performing air insufflation (clinical) [Ep 1 · 3:25](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=205)
- The patient had near complete resolution of symptoms postoperatively (clinical) [Ep 1 · 3:30](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=210)
- A postoperative contrast study confirmed resolution of the esophageal obstruction (clinical) [Ep 1 · 3:30](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=210)
- Laparoscopic Heller myotomy is the gold standard for the treatment of achalasia. — Jeffrey Ponsky (clinical) [Ep 6 · 0:51](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=51)
- In Heller myotomy, the operation fails if the myotomy does not extend 4-5 centimeters down onto the stomach. — Jeffrey Ponsky (clinical) [Ep 6 · 1:28](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=88)
- A fundoplication (Dor) is added to Heller myotomy based on a Vanderbilt paper, but surgeons know in their hearts it doesn't provide significant benefit. — Jeffrey Ponsky (opinion) [Ep 6 · 1:40](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=100)
- Dr. Inoue, a thoracic surgeon in Yokohama, performed the first POEM procedure in the world in 2010. — Jeffrey Ponsky (clinical) [Ep 6 · 2:55](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=175)
- The POEM procedure takes about one hour. — Jeffrey Ponsky (clinical) [Ep 6 · 3:29](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=209)
- In POEM, the mucosal entry is made 14 centimeters proximal to the EG junction. — Jeffrey Ponsky (clinical) [Ep 6 · 3:14](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=194)
- During POEM, the longitudinal muscle splits automatically when the circular muscle is divided. — Jeffrey Ponsky (clinical) [Ep 6 · 3:27](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=207)
- Occasionally during POEM, the mucosa cannot be separated from the submucosa; in these cases (three in seven years for the speaker), the procedure should be stopped, the entry clipped closed, and a Heller myotomy performed instead. — Jeffrey Ponsky (clinical) [Ep 6 · 7:03](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=423)
- POEM patients have almost a 40% incidence of abnormal reflux. — Jeffrey Ponsky (epidemiological) [Ep 6 · 7:51](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=471)
- All POEM patients should be placed on a PPI once daily indefinitely because they can develop strictures without it. — Jeffrey Ponsky (clinical) [Ep 6 · 7:51](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=471)
- POEM is effective in over 90% of cases. — Jeffrey Ponsky (epidemiological) [Ep 6 · 8:13](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=493)
- POEM patients have 35-40% abnormal reflux rates. — Jeffrey Ponsky (epidemiological) [Ep 6 · 8:13](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=493)
- Long-term data suggest POEM may be equal to Heller myotomy in every way after three years. — Jeffrey Ponsky (clinical) [Ep 6 · 9:08](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=548)
- Gastroparesis is caused by diabetes, idiopathic factors, and post-surgical complications including esophagectomy. — Jeffrey Ponsky (clinical) [Ep 6 · 10:00](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=600)
- POP (peroral pyloromyotomy) involves creating a 4 cm tunnel to the pyloric ring and dividing it, and takes 15 minutes. — Jeffrey Ponsky (clinical) [Ep 6 · 10:17](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=617)
- The speaker's institution has performed about 400 POP procedures. — Jeffrey Ponsky (epidemiological) [Ep 6 · 12:42](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=762)
- In the first 100 POP cases presented at a meeting, three-quarters of patients had normalized gastric emptying studies at three months, all of which were abnormal before the procedure. — Jeffrey Ponsky (clinical) [Ep 6 · 12:51](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=771)
- POP is an easy procedure that takes 15-20 minutes and is easy to learn, unlike ERCP. — Jeffrey Ponsky (opinion) [Ep 6 · 13:09](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=789)
- STEER (submucosal tunneling and endoscopic resection) is used to remove esophageal leiomyomas by creating a submucosal tunnel and shelling out the tumor. — Jeffrey Ponsky (clinical) [Ep 6 · 13:27](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=807)
- All esophageal leiomyomas undergo endoscopic ultrasound before STEER. — Jeffrey Ponsky (clinical) [Ep 6 · 13:45](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=825)
- The speaker treated a 17-year-old girl with a 7 cm esophageal leiomyoma causing dysphagia using STEER, dividing the tumor in half to remove it through the tunnel. — Jeffrey Ponsky (clinical) [Ep 6 · 13:38](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=818)
- ENT surgeons are now referring Zenker's diverticulum patients to the speaker because elderly patients with kyphoscoliosis and tight jaws are difficult to manage with general anesthesia and open neck surgery. — Jeffrey Ponsky (clinical) [Ep 6 · 14:13](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=853)
- Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum. — Jeffrey Ponsky (clinical) [Ep 6 · 14:28](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=868)
- Endoscopic Zenker's treatment takes 15-20 minutes. — Jeffrey Ponsky (clinical) [Ep 6 · 16:39](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=999)
- For endoscopic Zenker's treatment, patients are kept on clear liquids for a couple of days before the procedure to clear debris from the diverticulum. — Jeffrey Ponsky (clinical) [Ep 6 · 17:12](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=1032)
- During endoscopic Zenker's myotomy, if a hole is made in the mucosa, it does not matter because the mucosal flap will cover it. — Jeffrey Ponsky (clinical) [Ep 6 · 17:56](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=1076)
- The speaker has trained gastroenterologists, thoracic surgeons, and general surgeons to perform intramural surgical procedures. — Jeffrey Ponsky (clinical) [Ep 6 · 20:06](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=1206)
- Thoracic surgeons at the speaker's institution have embraced intramural surgery techniques. — Jeffrey Ponsky (clinical) [Ep 6 · 20:22](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=1222)
- In 1973-1974, the chief of gastroenterology at Case Western Reserve refused to train a surgery resident in endoscopy, stating "we're not going to train a surgeon to do endoscopy." — Jeffrey L. Ponsky (clinical) [Ep 4 · 4:49](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=289)
- During six months of training in Canton, Ohio in 1974, Dr. Ponsky performed almost 500 endoscopies. — Jeffrey L. Ponsky (clinical) [Ep 4 · 6:06](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=366)
- Early endoscopy in the 1970s used green soap for scope disinfection with no gloves worn, even for colonoscopy, and no high-level disinfection or washing machines. — Jeffrey L. Ponsky (clinical) [Ep 4 · 10:04](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=604)
- The first PEG procedures were performed in May 1979 on five babies at Rainbow Babies hospital, followed by the first adult cases at Mount Sinai. — Jeffrey L. Ponsky (clinical) [Ep 4 · 15:27](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=927)
- When PEG was presented at the 1980 ASGE meeting in Salt Lake City, Peter Cotton stated "I'm only sorry that I didn't think of this." — Jeffrey L. Ponsky (opinion) [Ep 4 · 16:39](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=999)
- In babies, transillumination during PEG placement showed the endoscopist and surgeon were "only a couple of millimeters away from each other," making the procedure more obvious than in adults. — Jeffrey L. Ponsky (clinical) [Ep 4 · 17:20](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1040)
- Early PEG tubes were fashioned from Pezzer catheters with Bunsen burner tubing cut for side holes and a medicut IV catheter as a dilator. — Jeffrey L. Ponsky (clinical) [Ep 4 · 18:02](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1082)
- The discovery that stretching rubber makes it thinner allowed easier insertion of PEG tubes through the dilating catheter. — Jeffrey L. Ponsky (clinical) [Ep 4 · 18:42](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1122)
- Using a snare around the puncturing needle to grab the suture was more reliable than trying to grab it with biopsy forceps during PEG placement. — Jeffrey L. Ponsky (clinical) [Ep 4 · 19:08](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1148)
- The concept behind PEG is "affixing a loop of bowel to the abdominal wall and creating a tract that was permanent." — Jeffrey L. Ponsky (clinical) [Ep 4 · 20:53](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1253)
- The PEG concept was extended to cecal puncture for Ogilvie syndrome, published in 1984. — Jeffrey L. Ponsky (clinical) [Ep 4 · 21:16](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1276)
- Endoscopic tattooing with India ink was first performed in 1975 using a reusable NM1K injection needle and India ink from a bookstore to mark polyp locations for surgical resection. — Jeffrey L. Ponsky (clinical) [Ep 4 · 29:06](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1746)
- SAGES membership grew from 300 members to 2,000 members during Dr. Ponsky's presidency, driven by the laparoscopic cholecystectomy revolution. — Jeffrey L. Ponsky (epidemiological) [Ep 4 · 32:48](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=1968)
- Dr. Ponsky was the second surgeon to serve as president of ASGE, after Ted Schrock. — Jeffrey L. Ponsky (clinical) [Ep 4 · 34:02](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=2042)
- The first human NOTES procedure in the United States was PEG rescue, where a string was passed through an existing PEG tract into the peritoneal cavity, pulled back into the stomach and out the mouth to place a new tube. — Jeffrey L. Ponsky (clinical) [Ep 4 · 38:54](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=2334)
- The NOSCAR consortium established that experimental NOTES procedures would only be performed under IRB protocol with informed consent. — Jeffrey L. Ponsky (guideline) [Ep 4 · 38:44](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=2324)
- POEM was first performed in humans by Haruo Inoue in Yokohama around 2007, though the tunneling concept was conceived earlier at IRCAD in France during the NOTES era. — Jeffrey L. Ponsky (clinical) [Ep 4 · 53:48](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=3228)
- After POEM procedures, patients report "you changed my life, I feel so great," providing strong positive reinforcement for the technique. — Jeffrey L. Ponsky (opinion) [Ep 4 · 54:51](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=3291)
- Per-oral pyloromyotomy (POP) via lesser curve tunneling results in improved or normalized gastric emptying in two-thirds to three-quarters of patients, performed as an outpatient procedure. — Jeffrey L. Ponsky (clinical) [Ep 4 · 55:32](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=3332)
- Over 300 per-oral pyloromyotomy cases have been performed at Cleveland Clinic. — Jeffrey L. Ponsky (epidemiological) [Ep 4 · 55:15](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=3315)
- For Zenker's diverticulum, the intramural approach involves opening the mucosa, tunneling under it, pushing it off the muscle, cutting the muscle, and clipping the mucosa closed—a "double-sided tunnel, one on each side of the muscle." — Jeffrey L. Ponsky (clinical) [Ep 4 · 56:22](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=3382)
- Current ESD technique is "like pushing a nickel across the room with your nose," but future robotic platforms will allow surgeons to "lift it and cut it just like we do in surgery" with knot-tying and full-thickness resection capabilities. — Jeffrey L. Ponsky (opinion) [Ep 4 · 57:34](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=3454)
- For tight radiation strictures preventing standard PEG placement, T-fasteners combined with a surgical step trocar (which radially expands) can be used to place a standard-sized gastrostomy tube. — Jeffrey L. Ponsky (clinical) [Ep 4 · 58:50](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=3530)
- Dr. Ponsky currently performs approximately 1,200 endoscopic procedures annually at age 72. — Jeffrey L. Ponsky (epidemiological) [Ep 4 · 51:15](https://qa.library.globalcastmd.com/watch/meet-the-master-jeffrey-l-ponsky-md-facs-13683?t=3075)
- Flexible fiber-optic endoscopy as currently known began around 1958 when Hersowitz at the University of Michigan developed a method using glass fibers to transmit images. — Todd Ponsky (clinical) [Ep 7 · 0:12](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=12)
- In the 1960s, flexible endoscopy was used only for visualization of the GI tract without therapeutic interventions. — Todd Ponsky (clinical) [Ep 7 · 0:34](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=34)
- In the early 1970s, Shina, a surgeon in New York, developed the ability to remove polyps from the GI tract endoscopically. — Todd Ponsky (clinical) [Ep 7 · 0:45](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=45)
- Endoscopic polypectomy was significant because it enabled removal of polyps before they became cancer. — Todd Ponsky (clinical) [Ep 7 · 0:48](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=48)
- The speaker trained in endoscopy in Canton, Ohio with Jim Canyon, performing approximately 500 cases over nearly 5 months. — Todd Ponsky (clinical) [Ep 7 · 1:47](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=107)
- The speaker and pediatric surgeon Michael Gauderer developed a technique to place feeding tubes endoscopically through the abdominal wall for children with brain damage requiring long-term feeding. — Todd Ponsky (clinical) [Ep 7 · 3:18](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=198)
- The PEG tube procedure was probably the beginning of minimally invasive surgery. — Todd Ponsky (opinion) [Ep 7 · 3:44](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=224)
- The PEG tube was developed in 1979, almost 40 years before this presentation. — Todd Ponsky (clinical) [Ep 7 · 3:51](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=231)
- Major medical device companies including Olympus, Ross Laboratories, and Eaton Laboratory initially declined to commercialize the PEG tube. — Todd Ponsky (clinical) [Ep 7 · 4:09](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=249)
- The PEG tube was commercialized through American Endoscopy, a small company owned by Marlon Yonker. — Todd Ponsky (clinical) [Ep 7 · 4:19](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=259)
- American Endoscopy was sold to Bard Endoscopy in 1986. — Todd Ponsky (clinical) [Ep 7 · 4:40](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=280)
- The PEG tube is now used and overused throughout the world. — Todd Ponsky (opinion) [Ep 7 · 4:53](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=293)
- The PEG was the first minimally invasive surgical procedure. — Todd Ponsky (opinion) [Ep 7 · 4:56](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=296)
- Current endoscopic procedures include dividing muscles for achalasia, a condition where people cannot swallow. — Todd Ponsky (clinical) [Ep 7 · 6:18](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=378)
- Endoscopic treatment is now available for Zenker's diverticulum, an outpouching of the esophagus causing swallowing difficulty. — Todd Ponsky (clinical) [Ep 7 · 6:26](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=386)
- Surgery is now performed through the endoscope. — Todd Ponsky (clinical) [Ep 7 · 6:33](https://qa.library.globalcastmd.com/watch/ponsky-and-gauderer-invent-the-peg-tube-13724?t=393)
- In earlier days, surgeons had more functionality and flexibility with separate individual ports instead of multi-hole platforms for single-port surgery (opinion) [Ep 8 · 1:08](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=68)
- Current multi-hole platforms have improved functionality compared to earlier versions (opinion) [Ep 8 · 1:25](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=85)
- Multiple puncture holes in fascia was a concern and issue with separate trocar approach (clinical) [Ep 8 · 1:34](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=94)
- Most current platforms have a skin barrier protector sleeve for specimen extraction (clinical) [Ep 8 · 1:39](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=99)
- The mass population is probably not going to adopt the robot for single-site surgery (opinion) [Ep 8 · 2:00](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=120)
- Different types of myotomy have been tried for achalasia, starting from the Levatiti one circular or spiral — Silvanna (clinical) [Ep 8 · 2:23](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=143)
- Circular or spiral myotomies that left both longitudinal and circular layers with only mucosa had complications such as out-pouching — Silvanna (clinical) [Ep 8 · 2:23](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=143)
- Total circular myotomy gives length but the esophagus loses strength — Silvanna (clinical) [Ep 8 · 3:14](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=194)
- Bilateral myotomy is capable of elongating the esophagus while keeping good compliance — Silvanna (clinical) [Ep 8 · 3:14](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=194)
- The LINX device is a rosary of magnets that slide along so when you swallow, the bolus pushes the magnets apart and they lose some attraction force, making it more physiologic — Brian (clinical) [Ep 8 · 4:38](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=278)
- LINX is a potential in-between therapy, maybe more effective than current endoluminal therapies but maybe not as much of a barrier as Nissen, but more physiologic — Brian (opinion) [Ep 8 · 4:21](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=261)
- If you are already suffering what is believed to be a complication of gastroesophageal reflux disease (Barrett's), we should be aggressive about managing that and not just treat it expectantly, similar to a colon polyp — Brian (opinion) [Ep 8 · 5:31](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=331)
- It's not clear whether it's necessary to do radiofrequency ablation for non-dysplastic Barrett's in some people's minds — Brian (opinion) [Ep 8 · 5:51](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=351)
- Buried glands is actually a natural state of Barrett's esophagus — Brian (clinical) [Ep 8 · 6:53](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=413)
- Radiofrequency ablation definitely decreases buried glands and does so more than acid suppression and placebo — Brian (clinical) [Ep 8 · 7:12](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=432)
- If we know ahead of time that there are stones in the common bile duct, we don't send to ERCP but explore the common duct directly, either transcystic or via choledochotomy (clinical) [Ep 8 · 8:12](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=492)
- In a review of 500 ERCPs from 10 different endoscopists, only 68% were able to clean the biliary tree (clinical) [Ep 8 · 8:58](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=538)
- In many countries in Latin America, an endoscopist does 100 cases in 10 years as it's not everyday routine (epidemiological) [Ep 8 · 9:42](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=582)
- It's possible to do exploration of the common bile duct with decreased cost, same morbidity, and probably even less morbidity than ERCP (opinion) [Ep 8 · 9:42](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=582)
- Gastric leaks and biliary leaks have very common closure rates and usually close in about 2 to 3 weeks (clinical) [Ep 8 · 11:08](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=668)
- Most surgeons leave stents in place until about 4 to 6 weeks because it's not a big deal to remove them (clinical) [Ep 8 · 11:26](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=686)
- Chronic fistulas, especially tracheoesophageal fistulas managed for months through drainage procedures, clips, and glues, are left with stents for a much longer period and have lower success rates (clinical) [Ep 8 · 11:33](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=693)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The gold standard for achalasia treatment is laparoscopic Heller myotomy. — The host summarizing the discussion [Ep 3 · 0:38](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=38)
- Blunt cerebrovascular injury (BCVI) occurs in 1.3% of all head trauma in the pediatric population. — The host summarizing the discussion [Ep 3 · 2:02](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=122)
- Nearly one-third of pediatric patients with BCVI will have a stroke, increasing mortality up to 20%. — The host summarizing the discussion [Ep 3 · 2:02](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=122)
- The Memphis score is the most sensitive scoring system for BCVI screening in pediatric head trauma patients. — The host summarizing the discussion [Ep 3 · 2:51](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=171)
- Patients under 37 weeks gestational age require overnight monitoring following anesthesia after pyloromyotomy, even if tolerating feeds shortly after surgery. — The host summarizing the discussion [Ep 3 · 3:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=225)
- Full-term babies over 4 weeks old may be eligible for discharge from PACU after pyloromyotomy. — The host summarizing the discussion [Ep 3 · 3:56](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=236)
- NSQIP data shows only 1.5% of pyloromyotomy patients were discharged on day of surgery, with no difference in odds of readmission or complications compared to overnight stay. — The host summarizing the discussion [Ep 3 · 4:01](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=241)
- ICG (indocyanine green) has become increasingly integrated into biliary-related surgeries such as cholecystectomies due to its hepatic excretion. — The host summarizing the discussion [Ep 3 · 4:46](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=286)
- Technetium-99 requires a special machine to detect and is difficult to control the injection timing. — The host summarizing the discussion [Ep 3 · 5:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=308)
- ICG technique is real-time in the operating room with equipment that is standard or soon to be standard in all laparoscopic towers. — The host summarizing the discussion [Ep 3 · 5:20](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=320)
- With ICG injection into the tumor, you can watch over 45-75 seconds as the ICG travels to the sentinel node with lights off under fluorescence. — The host summarizing the discussion [Ep 3 · 5:52](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=352)
- Recent studies have revealed a lack of firm correlation between anal dilations and stricture development following PSARP. — The host summarizing the discussion [Ep 3 · 6:39](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=399)
- Many PSARP patients have a colostomy and will undergo another procedure for colostomy closure, which is a perfect moment to perform strictureplasty if needed. — The host summarizing the discussion [Ep 3 · 7:02](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=422)
- The surgeon sees PSARP patients 2-4 weeks postoperatively, sizes the anoplasty in office, and discusses whether dilations are needed based on the examination, informing families that strictureplasty may be needed later. — The host summarizing the discussion [Ep 3 · 7:13](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=433)
- Every society emphasizes fertility preservation counseling even when surgery is not planned for children facing gonadotoxic therapy. — The host summarizing the discussion [Ep 3 · 8:20](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=500)
- When a patient has a new cancer diagnosis or is approaching stem cell transplant, the fertility preservation counseling service is activated through an Epic order set, triggering consultation by advanced practice nurse, physician, or oncology team for risk assessment. — The host summarizing the discussion [Ep 3 · 8:36](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=516)
- In a prepubertal child, the ovary is about 2 centimeters in size, approximately the size of a grape, and laparoscopic oophorectomy is the best recommendation for ovarian tissue preservation. — The host summarizing the discussion [Ep 3 · 9:05](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=545)
- Laparoscopic oophorectomy is recommended to reduce the risk of hemorrhage and ensure remaining ovarian tissue is preserved for future fertility. — The host summarizing the discussion [Ep 3 · 9:17](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=557)
- Massive transfusion protocol (MTP) is a multidisciplinary process for rapidly obtaining blood and blood products for severely bleeding patients. — The host summarizing the discussion [Ep 3 · 9:49](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=589)
- Massive transfusion protocol should be activated after administering 20 mL/kg of blood in the trauma bay. — The host summarizing the discussion [Ep 3 · 11:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=668)
- Ovarian torsion often presents with a cystic area visible on ultrasound that may be less visible in the operating room due to edema. — The host summarizing the discussion [Ep 3 · 11:51](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=711)
- If the fallopian tube is black and edematous after detorsion and adequate time, consideration should be given to management of that tube. — The host summarizing the discussion [Ep 3 · 12:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=728)
- It is best to avoid removing the ovary in torsion because it may regain functionality even if it appears black. — The host summarizing the discussion [Ep 3 · 12:23](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=743)
- Doctor Breech advises against oophoropexy (ovarian fixation) and instead recommends detorsion with subsequent monitoring. — The host summarizing the discussion [Ep 3 · 12:31](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=751)
- Chronic pancreatitis causes pancreatic insufficiency and damage to islet cells. — The host summarizing the discussion [Ep 3 · 13:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=788)
- TPIAT involves complete removal of pancreas and spleen, extraction of islet cells in a specialized lab, then injection of those cells into the portal vein. — The host summarizing the discussion [Ep 3 · 13:17](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=797)
- Many chronic pancreatitis patients have gene mutations triggering recurrent attacks, causing the gland to replace normal cells with fibrosis. — The host summarizing the discussion [Ep 3 · 13:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=825)
- Performing surgical resection for chronic pancreatitis without islet cell extraction may result in continued pancreatitis attacks and increased diabetes risk due to reduced pancreatic parenchyma. — The host summarizing the discussion [Ep 3 · 13:55](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=835)
- The American Pediatric Surgical Association (APSA) released revised guidelines for blunt hepatosplenic trauma management including four categories: admission location, procedures, discharge timing, and post-discharge management. — The host summarizing the discussion [Ep 3 · 14:52](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=892)
- For grades 1 and 2 blunt liver and spleen trauma, hemodynamically stable patients can be monitored and considered for discharge from the emergency department. — The host summarizing the discussion [Ep 3 · 15:13](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=913)
- Data shows hemodilution occurs in trauma, and patients more likely to fail non-operative management have initial hemoglobin less than 9.25 g/dL. — The host summarizing the discussion [Ep 3 · 15:43](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=943)
- For blunt liver and spleen trauma, increasing evidence supports treating the patient based on signs and symptoms rather than solely on injury grade. — The host summarizing the discussion [Ep 3 · 16:04](https://qa.library.globalcastmd.com/watch/update-course-rewind-2023-top-ten-key-takeaways-8758?t=964)
- A 2015 IPEC survey showed 95% of pediatric surgeons would perform fundoplication with Heller myotomy — Tim summarizing the discussion [Ep 2 · 5:10](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=310)
- In adult literature, when Heller myotomy is performed, good evidence shows fundoplication is not necessary — Tim summarizing the discussion [Ep 2 · 7:30](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=450)
- The learning curve for POEM is approximately 20 cases, with mastery at about 60 cases according to adult literature — The host summarizing the discussion [Ep 2 · 19:10](https://qa.library.globalcastmd.com/watch/update-course-2023-updates-in-pediatric-achalasia-management-7270?t=1150)
- The American Board of Surgery made endoscopy a requirement for surgical training, which put stress on program directors but is necessary for modern bariatric and gastrointestinal surgeons. — Steve summarizes what Dr. Jeff Ponsky said [Ep 5 · 4:03](https://qa.library.globalcastmd.com/watch/endoscopy-and-surgery-13720?t=243)
- Children account for approximately 5% of all patients with achalasia — The host summarizing a resource [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=6)
- The Heller esophagocardiomyotomy is the most definitive treatment for achalasia — The host summarizing a resource [Ep 1 · 0:20](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=20)
- The four major steps of Heller myotomy are mobilization of the distal esophagus, a long esophagomyotomy carried onto the stomach as a cardiomyotomy, and an anterior fundoplication to cover the myotomy and decrease gastroesophageal reflux — The host summarizing a resource [Ep 1 · 0:30](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=30)
- The most critical part of the operation is the myotomy, where mucosal perforations can occur, typically secondary to burns from an energy source such as hook cautery — The host summarizing a resource [Ep 1 · 1:00](https://qa.library.globalcastmd.com/watch/laparoscopic-heller-myotomy-2252?t=60)
- J Pasca at Hopkins originated the idea of creating a submucosal tunnel in the esophagus to avoid gastric leaks during NOTES procedures, and realized the esophageal muscle could be cut endoscopically like a Heller myotomy. — Jeffrey Ponsky summarizing a resource [Ep 6 · 2:08](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=128)
- Early European studies of 70 patients showed POEM was effective at one year. — Jeffrey Ponsky summarizing a resource [Ep 6 · 6:11](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=371)
- Eric Hungness and Nat Soper reported POEM was effective in an early study of 18 patients. — Jeffrey Ponsky summarizing a resource [Ep 6 · 6:27](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=387)
- Lee Swanström's 2014 study of 100 patients showed excellent POEM results but increased reflux compared to Heller myotomy. — Jeffrey Ponsky summarizing a resource [Ep 6 · 7:34](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=454)
- Marco Patti's study showed less dysphagia with POEM than with Heller myotomy, but more reflux. — Jeffrey Ponsky summarizing a resource [Ep 6 · 8:19](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=499)
- A prospective randomized controlled trial presented in Europe at the end of 2018 compared Heller myotomy with Dor fundoplication versus POEM and found both were effective in controlling dysphagia. — Jeffrey Ponsky summarizing a resource [Ep 6 · 8:31](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=511)
- In the 2018 RCT, POEM patients had higher reflux rates than Heller patients at two months, but at three years the reflux rates equalized. — Jeffrey Ponsky summarizing a resource [Ep 6 · 8:47](https://qa.library.globalcastmd.com/watch/poem-by-surgeons-dr-jeffrey-ponsky-13722?t=527)
- In the New England Journal of Medicine study, there was a significant rate of buried glands in both treatment and placebo groups — Brian summarizing the discussion [Ep 8 · 6:27](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=387)
- The percent of buried glands at baseline before anything was done was around 15% in the placebo group and went up, while in the treatment group it went down — Brian summarizing the discussion [Ep 8 · 6:36](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=396)
- On average, to be able to have 85% success in cannulating and working the biliary tree, you need at least 100 cases — The host summarizing the discussion [Ep 8 · 9:23](https://qa.library.globalcastmd.com/watch/sages-alace-symposium-integrating-new-technologies-old-tricks-and-operative-appr-13727?t=563)

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