1. AATS General Thoracic Skills Course Esophageal Disease Endoscopic and Minimally Invasive Techniques Thomas Varghese Jr, MD, MS tkv@uw.edu @tomvarghesejr April 25, 2015

2. Topics Endoscopic evaluation of Barrett’s Endoscopic evaluation of Barrett’s Endoscopic staging and Rx of Esophageal Cancer Endoscopic staging and Rx of Esophageal Cancer EMR, RFA, Cryo EMR, RFA, Cryo Minimally Invasive Treatment of Benign Disease Minimally Invasive Treatment of Benign Disease Endoscopic Endoscopic POEM, Linx, Endoscopic Anti-Reflux POEM, Linx, Endoscopic Anti-Reflux Laparoscopic PEH Repair Laparoscopic PEH Repair Stitch, Stents and Clips Stitch, Stents and Clips

3. 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

4. Barrett’s Risk Factor for Esophageal Cancer Risk Factor for Esophageal Cancer Most will not develop cancer Most will not develop cancer No way to risk stratify at present with exception of degrees of dysplasia No way to risk stratify at present with exception of degrees of dysplasia Biopsies unreliable Biopsies unreliable Expense of surveillance very, very high Expense of surveillance very, very high

5. Esophageal Cancer HGD to T1a Esophageal Cancer HGD to T1a Esophageal Cancer What is the ideal treatment? What is the ideal treatment?

6. Achalasia PerOral Endoscopic Myotomy (POEM) PerOral Endoscopic Myotomy (POEM) Laparoscopic Heller Myotomy + partial fundoplication Laparoscopic Heller Myotomy + partial fundoplication J Laparoendosc Adv Surg Tech A. 2015;25(2):123-9 Wei M1, Yang T, Yang X, Wang Z, Zhou Z. No difference in complications, reflux, symptom recurrence

7. Reflux LINX™ System LINX™ System Endoscopic Anti-Reflux Procedures Endoscopic Anti-Reflux Procedures

8. Magnetic Sphincter Augmentation (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/m 2 No strictures No prior esophageal surgery No metal allergy

9. Paraesophageal Hernia Laparoscopic Approach Laparoscopic Approach Now the most common Now the most common

10. Esophageal Tears Stitch, Stent, Clips Stitch, Stent, Clips