Esophagogastroduodenoscopy (EGD) with Placement of a Bravo Probe for pH and GERD Symptom Monitoring

CHAPTER 1

Hi, I'm Charu Paranjape. I'm the Chief of General Surgery and Acute Care Surgery at Mass General Brigham's Newton-Wellesley Hospital. I'm also the Medical Director of its Heartburn program and a surgeon in the Mass General Hospital's SHED program. So today we're gonna do a procedure called endoscopy and placement of a pH probe. Earlier, many years ago, this used to be done with a catheter that used to stay in the patient's nose and used to stay for days. And obviously, that was very painful for the patient. Today we are gonna see a technology where this is placed during the procedure wirelessly and it kind of attaches to the lower part of the esophagus, and with the Bluetooth device, it talks to a pager that the patient will be wearing and this way we can monitor the patient's reflux symptoms as well as the entire pathophysiology of the patient's reflux over the course of typically either 24, 48, or 96 hours. In this case, we're gonna monitor for 96 hours. In this study today, we will be looking at the anatomy of the patient and then secondly, we're gonna be studying the physiology of reflux. So the capsule stays there and records two important things. One is the constant pH at that level, but it also records how much of the reflux is happening over time. In other words, how many reflux episodes? How much during sleep? How much during the supine position? How much during upright position? How much during the day and night? Along with this, the patient keeps a diet diary and also presses the buttons on the remote that was given to the patient. Then there is a software that correlates all this information and there is something called a symptom associated probability score, that gives us an exact profile of the patient's reflux and we're able to very clearly, not only profile the reflux of the patient, but also tell if the particular symptom was due to reflux or not. So broadly, there are two separate parts of the procedure. One is first doing the endoscopy and sort of marking where the GE junction is. The second part is actually placing the capsule and confirming it. So at the time of endoscopy, we mark the GE junction. Dr. DeMeester did multiple studies that have been the benchmark of this kind of procedure that we are gonna see today. He showed us that six centimeters from the GE junction is the magic placement distance, and that's where we are gonna place the actual Bravo probe. And then the third part or the subsequent part, we're gonna do another endoscopy to confirm that it's there and it's talking to the remote device with the Bluetooth technology. So the great part about this is that we don't have to remove it. All our linings of the esophagus, stomach, and the intestines, they shed in about seven to 10 days. And so around that time, as the mucosa sheds, the capsule also gets detached automatically and then the patient just passes it through their stool. We don't have to retrieve the capsule and that is the most patient friendly part of this procedure.

CHAPTER 2

So the first part of the procedure is just doing a routine endoscopy. I'm going down the back of the throat here, entering the scope. The most important thing in this patients is that they're awake and the intubation has to be very smooth without them coughing. As you just saw, going into the esophagus here, this is a mid-esophagus, a little bit tortuous. Here you see a little bit of mucosa protruding into the lumen. I'll be biopsying that while I'm coming back. I'm entering into the distal stomach here. So far, everything looks okay. I'm gonna enter, this is the antrum. I'm going through the antrum here. There's a little bit of curvature here, which is expected. I'm trying to open and this is the first part of the duodenum, going into there. And here we have to turn all the way so turning into this junction of the first and second part of the duodenum to see if we can see the lumen here of the second part. There it is. So here is the duodenum, second and third part. Everything looks okay so far. I'm coming back slowly. So far we don't see any abnormalities here. We're coming back, curving at the duodenum. This is where the C-loop of duodenum. Now we are back into the stomach. The distal stomach looks good. I'm gonna retroflex here. So this is a retroflexed view. As you can see, she's had previous sleeve, looks like, and the stomach is narrow. You're looking like a candy cane or a elephant's trunk looking backwards at the GE junction. And you can see that the GE junction opens up with the respiration, which is normal. The main thing to see in this case is, as you can see there's a small hiatal hernia there as she breathes, is there enough reflux going back into the esophagus? And the way to know that is we're gonna place a Bravo capsule, six centimeters above the GE junction.

CHAPTER 3

Dr. DeMeester did a great study that shows that six centimeters is the magic figure to sort of look at the number of acid refluxes coming back into the esophagus. This is an antegrade view, this is the previous staple line. We are coming back into the stomach. This is the GE junction right there. And we are gonna biopsy that and also mark the GE junction. So the GE junction is at 35 centimeters from the incisors. So six centimeters proximal would be 29. So we are gonna place a marker at 29 with a tape. While she does that, I'm gonna biopsy the junction here. I'm also gonna look at it with narrow band imaging so that it's a targeted biopsy. Looks a little irregular. Open. Open. Close. Close. See if you're happy with the bite. Otherwise, I can give you another bite. The following biopsy needs to be big. Correct, at 35. 35. I'm happy with where it is. It's right at the junction right there. But we gotta make sure she is happy with the bite. She's not happy. We'll take another bite. Thank you. Yeah. Remember, it's all about you. If you're not happy, it's not good Trying to do it from the other side. Open. Open. Close. Close. If you're happy...

CHAPTER 4

Slowly coming back. But we will be putting the capsule next and then going back again. So we have another five, six minutes to go. This is where she needs to be deep. Just coming back. You happy? Yeah. Perfect. All right. We want to just make sure, we're checking again. Perfect. So rule in surgery as usual, measure twice, cut once, yeah. I'm just sliding this on the back of her tongue. I'm just gonna give it just a very gentle jaw thrust and then stop there. Then now she applies the suction, and the suction goes up. And we have to wait all the way till it goes to 650 and now we start measuring. I wait for one full minute. Different people wait different times. Here is where the mucosa of the esophagus is being suctioned into the capsule. So the reason we wait one minute is we want the mucosa completely sucked in into the capsule. This is a little safety check here so that I don't accidentally push this. I'm gonna - closer to one minute, I'm gonna take this off and give it to her. Then when I push this button, that's when the prongs of the capsule go into the mucosa and get attached. And then there's a mechanism where I twist the entire thing and then pull it back, that's where the entire apparatus gets disconnected and then we take that out. As soon as that's done, we can check if that is talking remotely with the Bluetooth chip to this monitor. Three, two, one. Great. I'm gonna give you this. Thank you. This is a safety thing. I have to hold this straight like a line. Then I deploy this, that stops the suction, but as a double safety, she stops it. In addition, we wait another five seconds for this. And then we twist this, and then take this out, twist side to side, and then slowly take this out. There's no capsule here.

CHAPTER 5

Slide this back. And as you can see, there is the capsule right there. And now we are gonna come back. She is gonna check, make sure the capsule is wirelessly talking to the monitor already and we are all done. Thank you. That was great.

CHAPTER 6

And here she is gonna check, make sure it's talking and she'll give us a confirmation. Yep. And it is, perfect. So this is already talking wirelessly to this. It gives us a thing here and it says the pH of 5.3. This continuously monitors not only the pH at that level, but it will monitor how much reflux she has in terms of how many episodes during the next 96 hours, how much during supine position? How much during upright? How much during the day? How much during the night? And then she also keeps a diet diary of the entire thing. And then we correlate all the numbers. She also has buttons here. So when she has symptoms, she pushes the button. And then there is a software that integrates the symptoms along with what's going on here. So that correlation is very important because then we will know that her symptoms, when she pushes the button, is it due to what's happening at the real time at the GE junction or it's not? So that will give us the value, so thank you again.

CHAPTER 7

So now that the procedure is done, we talk to the patient again about all the instructions. The patient, like we discussed before, will keep a diet diary and also press those buttons when they have symptoms. In about four days, which is beyond the 96 hours, they will return this pager to our department. Then we download all the data, and that's where all the correlation happens. And the next time, in about a week or so, when we see the patient in the clinic, we put all that information together, in this case, to determine whether the patient number one does have abnormal reflux. And number two, which is most of the time, most important, is the correlation between their symptoms and what is happening here. And so if that is so, then we can discuss what else can we do both medically and surgically to improve their symptoms. So in this procedure today, we saw two slightly abnormal things than normal. The patient has had a previous sleeve gastrectomy, so in the video you will see that the capacity of the stomach is not complete because the patient had a sleeve gastrectomy. So we will see that anatomy. Secondly, you will see that the GE junction and the classification of the valve where the esophagus meets the stomach is slightly open. We call it Hill grade III, and that's what we are gonna see where it's wide open. So most likely, the patient does have a lot of reflux, but the point is it'll be proven with this study.