So, first, we're going to be starting off with Band EMR, and Dr. TJ is going to take it from here to kind of get us started. All right, so we have a Fuji 1T scope that we're using for this, and we're actually using a pig model, so I think you should be able to see the endoscopic view, if I'm not mistaken. So, we're just advancing the scope down, and our light is not on, so we'll put our light on. Excellent. And so, everyone should know this is just a pig's upper GI exam, a little bit different than a human's, as you can probably tell, but also very similar. So, Dr. TJ is going down the esophagus right now, and we're about to encounter the G-junction, which is coming up real soon, right here, and Dr. TJ and I were joking that this pig has probably some grade C, maybe grade D esophagitis right there, but unlikely. But now we're entering the stomach, and you can see the rugae, and we are going to do some resections within the stomach. We're going to try our best on a pig's stomach when it gets preserved. It doesn't tend to, I guess, be as elastic as a human is, and a live human, but we're going to do our best here, and I think we can get some good resections for you. So, Dr. TJ is going to just tell us what he's seeing right now, as far as his exam. Yeah, so common indication for band EMR in the foregut is a nodular lesion of the foregut, particularly in the field of Barrett's, where you can't really exclude deeper dysplasia. That's sort of where we want to be doing band EMR or ESD for resection of those defects. I mean, here we're sort of going to imagine, and Eric, do you think we're doing the EMR in the esophagus here, or will we do it in the stomach? We can do it in both. Whatever we can get a good bite on. I feel like, for our audience, you know, as a trainee, you're going to be really doing a lot of band EMR in Barrett's resections. You can do a little bit of it in the rectum for, say, like a carcinoid, or you want to ensure that the scar has no residual underlying neoplasia. You can band EMR that, but for the fellow's perspective, you'll probably be doing this more often in an upper exam, most often in the esophagus, so if we can try to do it in the esophagus, we will. If not, we can just go down to the stomach and try to pretend, see what we can grab. Right. Okay. That sounds good. Yeah, so sort of like Dr. Eric was saying here, yeah, like common indication for band EMR in the lower gastrointestinal tract is for resection of rectal nets or carcinoids, but in any case, we'll pretend that this pig has Barrett's esophagus, which, you know, the pig very well may have this degree of esophagitis. Well, I guess we'll need to take another look after a few months of PPI, but we'll sort of convince ourselves that there's Barrett's esophagus here and perhaps a nodule that needs to be resected. So usually in the setting of Barrett's, you know, if we have dysplasia, we ask ourselves what sort of endoscopic eradication therapy can be undertaken and band EMR is sort of what we do for nodular lesions or ESD. RFA is fine for flat dysplasia, but not for nodular dysplasia. Yeah, I completely agree. Really for nodular dysplasia, you really need to be looking to cut this out. For your general gastroenterologist, this is probably one of the resections in addition to EMR that most people can get pretty skilled at pretty quickly. It's overall has a pretty low risk profile. So why don't we start getting this set up for you guys? All right. And seeing what we can do. So we're just going to pan into our instruments that come in with the band EMR. We are currently using the Captivator EMR system. Dr. TJ, you want to go ahead and walk them through each part? Sure. Yeah. So this is the Boston Captivator EMR system. There's also a Cope Duet system that's commonly used. There are variations of the same. Basically what this involves, it's sort of like banding varices, if you've ... I imagine most of you have done that at this point. You go up to the tissue of interest that you want to resect, and you use this cap that we're going to attach to the tip of our endoscope, and suck the tissue into this cap, and then put a band on it. And there's actually preloaded bands in here. And the way we do that is by turning this wheel, which I'm going to try to get into view here. There you go. Yeah. So there's a ... There's a wheel. Yeah. There's a wheel right there that we sort of turn, and you'll see us do it in a moment, to actually deploy the band once we feel like we have a good amount of tissue within the cap. And then we then have a snare that we use to resect the tissue that we've banded. And we are actually able to put this snare through this device, and we'll illustrate that for you in a second. Yeah. And typically these come with a hexagonal snare. This is a 15 millimeter. It can run hot. So in band EMR, you really are going to be cauterizing these lesions off, okay? Here's where you hook up your cautery. So today we're working with a Steri's electrocautery system, but all Erbys also use this, have typical EMR settings, okay? All right. And then the only other thing is we will be, to enter the snare into the actual band system, you will be just having a blunt tip needle that you can just puncture right here to facilitate passing the snare. Makes your life a little bit easier. Okay. So we're going to just get this now set up on the 1T. You can use this on a standard gastroscope, but we have a 1T with us for a couple other demonstrations that we'll be doing. So you want to... Okay. So we're going to put this sheath through the instrument channel and it's going to come out the tip of the endoscope that Dr. Eric is holding there. And we want to just pan in right here and we'll see, actually, can you guys go ahead and just switch to the camera? There you go. I'm going to turn off that light so we can get the audience to see the device come out. And it's going to be coming out of the working channel. It just takes a little bit of time. You can tell your tech some jokes or a nice little story, how your weekend went. There we go. Okay. All right. So we're going to bring this, keep pushing it all the way in, pushing it in all the way. Good. Keep going. All the way. And we're going to mount that with the... The important thing is when you're trying to set this up, is just to remember blue dial is out. Yeah. Okay. Important point. Yeah. Blue dial is out. This comes with a... All the way down? Yeah. I don't believe it. There we go. There we go. So there's a little latch here that goes around the endoscope. I don't know if you see that here. This latch that you turn like this and it clicks around and then it's attached there. Yep. And then once we have that attached, then we can... Remove. Yeah. Remove this... Plastic. Yeah. The plastic sheet. So you can see I'm pulling this out. And the other thing about this latch is that it's kind of like the seatbelt for the device. And I'm just pulling this plastic tubing off. And you'll see real closely here, this is very fine threading, but we have two little holes or we have, I'm sorry, one little loop here and we have one loop right here. Okay. You want to go ahead and show us how we thread these out? Yeah. So this is by far the most challenging part of the procedure. Sometimes you need your glasses. Yeah. You need your glasses. You need like someone to hold the thing when you're trying to thread the needle, but no, it's all good. So we've got plenty of practice by now. So you're trying to get this through the smaller loop. There you go. Yeah. You can see that on the camera. That's quite impressive actually. Do we have the bifocals on site for us, please? And then once that's through, you sort of loop the cap around and you create a knot. Yes. Yeah. I mean, I would say that's what the most like thing that general GI fellows and faculty will remember is this is very similar to how you do a peg tube. Yeah. When you're pulling a pole peg tube, I should say. Yeah. Good. All right. What you'll notice right here also is that there is this plastic film around the bands right now. And what's important is, and Dr. TJ made a really good point earlier, is we don't want to take this off until we're ready to have this snug. These bands are meant to be fired off so it can easily deploy a band if you're futzing around with this. So I just want to make sure you know that this doesn't need to come off until we're ready to go. Okay. Okay. So there's a little wheel on the back of this device that we can actually rotate and I think it's forward that we rotate it to bring the cap towards the tip of the endoscope. Go ahead and bring it in towards my hands real quick. You'll see it kind of coming in. Yeah. Other hand. Other hand. So I'll let this go over here. Yep. Real quick. Yeah. You'll see this coming in. And it's pulling me right now. Yeah. So we're sort of, as I'm putting this on. Just keep going? Yeah. And it just needs a little bit of care, TLC, to go through there. Yes. And you can just help facilitate until it's nice and snug. Yeah. Okay. All right. Now. Let's get the light on. What I like about this also is the positioning of where that thread is on the scope. That's in a good visualization for you when you're trying to see the tissue. I like having that thread, that little pulley, in the bottom left corner. It just facilitates throwing the band and being able to see well. All right. Go ahead. You want to show them how to take this off? Sure. You want to show them your scope real quick? Yeah. So basically, like Dr. Eric was saying, there's a little piece of plastic here that you can sort of, sort of like opening a bottle of wine, I think you said. A wine bottle or a bottle of... Yeah. A bottle of whatever. Yeah. So you sort of yank up on this, and then you just pull around. Okay. Good. And you remove that. Okay. Do we want to fire one real quick? Oh, yeah. Okay. So I'll hold this. Yeah. And so... Let me just demonstrate what that looks like. Yeah. So let's put scope in picture in picture. There you go. And put the other one at my hands. There you go. And what you can see is as Dr. TJ goes and starts cranking, that pulley is going, and it's firing... It's firing a band. And almost, almost. There it goes. There it goes. All right. So that's what we're doing. It's as that band fires, you're suctioning up the tissue beforehand, and that band will fire around the tissue, and then we'll see a nice puckered up specimen that we're going to resect. All right. So let's do this. Okay. So normally you would apply some lube at this point, because this can be difficult to sort of intubate when you have this captivator EMR device on. But I'm told we don't have any such issues with this pig. So we're just going to go back down to our GE Junction. So you can tell the visualization is good, but not as good as when we didn't have the device on. So that's why it's so important to do a really good optical examination before you actually put the device on, and know exactly what your target is. So sometimes when we're doing these resections, we'll actually sort of mark the area that we're going to resect just using snare tips off COAG, similar as you would for ESD, anywhere else I suppose, but we also do it for EMR sometimes just to help with our visualization and to ensure that we've been successful in resecting all of the tissue. So I suppose we can go ahead and... Let's just play pretend, see if we see something we can suck up, and we're going to pretend that that's a nodular piece of Barrett's. Okay, so we're going to pretend that this is a nodular piece of Barrett's here, and we're just going to sort of suck up, and there's techniques that we can use to help with tissue capture. Sort of gently pushing in and out, and we're not really getting great capture there. I mean, normally your esophagus would collapse really well into this, but again, like I had said before, you don't get as good of elasticity with these preserved pigs, but let's see what we can get. Okay, we may have to pretend that the stomach is the esophagus if we're not able to really... Yeah, let's just try the stomach, see what we can get. Okay, so we'll go down to the stomach here. I mean, something that you could do is you could put a little submucosal injection in that would also facilitate the tissue capture, but we'll sort of pretend that this is a nodular area of Barrett's and try to suck this in. So see how it's coming into the cap, and we're going to try to get as much in there as possible. I apologize about the squeaking, that's just our suction in this room. And then now, as you look at Dr. TJ's hands, he's going to fire this band. Okay, so we're just going to fire this band. Did it go? Did not see it go. Okay, let's try again. Okay, we'll try that one more time. Yeah, in real life, the tissue capture is better than this, but yeah, we're actually getting... Yeah, we're getting good suction right there. We're getting decent suction right here. All right. So we'll try to fire a band here. Keep firing. There we go. We got a band to fire. Yeah, there we go. Now, it's really important here that you have a tech or a nurse or a fellow that's ready to go with your snare, because these bands, just like a varix, can fall off. The other thing is you want to do is, and I'm going to help feed this down for Dr. TJ, is that you don't hit that band with the cap, because that can fling this off. This is very stiff. And you will see now, in a second, the hex snare going on over through the working channel. There we go. All right. And Dr. TJ is going to tell me when he wants me to open. Yeah. So we're just going to line the catheter up with the tissue that we want to resect. Visualization is somewhat limited by this mucus. Pull it back. Yeah, we'll pull that back. Yeah. Agreed. We don't want to knock off the band we just placed, which... Where is our band? Yeah. I sort of lost track of it. Okay. If we have to put another one down, that's okay. Yeah. It might have fallen off. It may have fallen off. Yeah. All right. Even though we didn't really disrupt it with anything that we did, I think it may have fallen off. Okay. That's okay. We can put another one down. We got our snare ready. Okay. So like I said, in the pig's stomach, it's kind of not as elastic, so it's going to push off these bands. Normally, these bands stay on pretty well. All right. Go ahead, and we'll try right here. Might work better if I have the... Yeah. With the snare out. Snare out. Yeah. Suction might be a bit better. Okay. So like I said, this is a timed sensitive instrument. So again, it's not getting great tissue capture here. Normally, you'll get more tissue sucked into the cap, but let's see what we get here. I don't know. Yeah. It's very similar to when you get almost like a red out or pink out when you're doing a Let's see. Can I irrigate here? Yeah. Try to put another irrigator there. We should have tested the irrigation before we started. Take a second. A little bit of priming. Yeah. Oh, it's because we're out of water. Oh, okay. No worries. No worries. We can make do with this mucus. We'll just come up here. Yeah. Yeah. Oh, it's because we're out of water. Okay. No, no worries. No worries. We can make do with this mucus will just come off. Yeah, there was our other. Yeah, I saw the other bag. Oh, did you? Okay. Oh, came off. Yeah, the other. Oh, no, I think the one from our first one. The first one is fired. Okay. I mean, you know, one option here is we could do a submucosal injection. Yeah, let's try to create a bit of a lab and then sort of use that. Come around over here. Okay, so this is, you know, we're all just improvise here and we'll we'll do a submucosal injection. We'll sort of demonstrate what, you know, the appropriate injection technique is when we're doing a submucosal injection. And that will also, you know, how Oh, actually, we have it. Oh, good. We have a founder band. Okay. That's okay. Yeah. So just want to try to get this at six o'clock, which is generally the way we like to resect these. And we'll put our snare down, as we did before. And generally speaking, I like to cut below the band to ensure we're capturing as much tissue as possible. I don't know if that's your practice as well. Dr. Eric. Yeah, it is. For multiple things reasons. I mean, you want the whole point of this is to get a curative resection you want me to go ahead and open? Yeah, you can go ahead and open. So opening up slowly also because the snare can Yeah, knock this off. Below the band, don't be afraid to cut below this band. A lot of times these, you know, start closing, starting to close slowly. You want to make sure that you're getting a good curative resection with this. Okay. So we are now below the band below the band. And you can see that there you can see that our snares actually closed below the level of the band. And that's very important. Yeah. And now the other thing is you want to make sure you're not grabbing the rubber band itself. Yeah. And so sometimes that can happen, it'll prolong the actual amount of time you're doing cut. So we're going to go ahead and hit our coterie. Okay, and we're Yeah, we are ready to go. We're ready to go. Okay, so cut through there. Sort of trying to help. There we go. There we go. Yeah, that's nice. A couple, couple of pulses there. But yeah, got it through. So first thing we do is we check the defect. Oh, beautiful. So and it is it Yeah, it is a nice looking defect. You know, sometimes we encounter a bleeding vessel here that we can just treat with snare tips off coag. And you can you can help with use your cap to sort of really isolate the vessel and, you know, treat it. And also look for any evidence of deep neural injury, which, you know, you typically shouldn't get with band EMR. And then, after we've done the resection, we obviously want to retrieve, you know, once we're confident that we've resected everything that we want to resect, we want to retrieve the pieces. So typically, the way you know, we do this is, you can either, like, fire off the rest of the bands and suck the piece. If you have a single piece into the cap, and then remove the piece, or you can just put a some sort of retrieval net, like a rock net down and retrieve them as well. Yeah, I do recommend patients be intubated for this procedure. If you are. Yeah. Last thing you want to do is drop a specimen in someone's trachea. Yeah, no, that would be poor form. Also, this is just a big device. Sometimes these require lots of back and forth going in and out with a scope, we want to minimize any type of aspiration. Right. But what I was getting at was, you know, when you are on that on the specimen, or on the the polyp or the nodule, and it's underneath the band, you want to make sure you're not getting on the rubber band itself when you're going because it you're going to spend more time cauterizing. And it's just going to take time to get through the rubber band. It's okay if it goes through it. But generally, you want to avoid it, it just puts you more at risk for any type of thermal injury. Totally. So I don't know if you want to try to get one more in there. Yeah, so I yeah, we're just gonna say, you know, sometimes like we talked about before, you'll actually have marked the area of interest with little dots with your snare tip. And you'll see if your resection actually captures all those dots. And if it doesn't, you may decide to take an adjacent piece. Or even here, we can pretend that, you know, we don't have it all. And we want to take one more piece that's so sort of overlaps with the resection that we've already done. And just to ensure that we are, you know, really capturing the resecting all of the pathologic tissue. So it might be a little challenging, because it's because it's sort of fibrotic here, it's not really coming out. Go to the left a little bit more puckered up. Yeah, that looks more promising. Agreed. Agreed. All right. So we're gonna be suctioning the whole time bringing in as much as you can. And then now we're going to go ahead and fire cranking the blue wheel. Boom, fired. We're slowly easily back up. Nice. Nice. Well, that's a perfect. Yeah. Now you actually have your snare already down. Yeah. So go ahead. And again, this is the most important part. Make sure you don't knock off this band. Yeah. One little tool or trick I've done is I've actually opened the snare distal to the band and kind of just slowly come back. Right. It's really what your practices and how you're able to get what you feel comfortable getting in that best position underneath the rubber band. Totally. Yeah, I think yeah, that's that's like a very reasonable approach. But the important principle is you want to make sure that the snare is not knocking the band off. Yeah, that you are getting underneath the band. So now Dr. TJ also mentioned about like doing injection in this. You don't necessarily have to I feel like sometimes if you've had some type of thinning of the histologic layers, so like say your patient has had prior radiation, or prior section, etc. And you want to give it just a little cushion, but underneath, that's totally fine. You can definitely do this in the setting are with an injection underneath. So it's won't you can't. The point being you can still lift this away from layers still get a good resection. I think that's actually is that where our other one is? Yeah. Okay, so we have a couple specimens. We have a few. Yeah, we can go after. Okay, this is good. All right, let's take this one. Okay, so we'll get this snare out here. So we're opening. Awesome. Yeah, perfect. See how nicely you got it around. And we're just going to slowly ease our way out. We're gonna push out our snare, get it nice to the bottom. Tell me when you're ready for me to start closing. Sure. Closing slowly. Then we'll sort of pull the catheter in a little bit and look up to make sure we're under the band. Yes. Yeah, right there. I need that band to see the blue. I don't know if you can appreciate that on your screen. But you can see the blue of the band there. And you can see that we're just underneath the band. Yeah. So we should be okay here. I feel good. It feels good. Yeah. All right. We're ready to rumble. Okay, ready, set, go. Again, this will come through a lot faster. Yeah. On a normal human. But let's just examine. So you saw if you go to the left, you can see what it looks like when it falls. When we cut away from it. It might have fallen into the fundus. But yeah, there it is. So you can see the resected specimen. That's a resected specimen. And look at that. Yeah. So now we have two very nice adjacent pieces. And you see this what we're seeing here, these, these cords are, this is submucosis. So yeah, it's, yeah, no, it's, it all looks very good. All right. So now we're going to play pretend. And we're going to pretend one of these is perforated. So we're going to try to close this up. And go ahead and come on out. And we're going to go in and try to close this perforation. So let's show them how we can take this off. So the easiest way is just to go ahead and fire the remainder of the bands. And that's it. And then you just kind of take this guy off. And that's it. And then you pull this guy, you unclip. Yank it out. Yank everything out. Okay. So that is, was like actually a really nice band EMR. Anyone has any questions on this, please feel free. We'll watch your step. Just to patch right in on our Q&A. Looks like there is a question about can you do EMR with just a cold snare? I think that's from the last session. Right. 2.41 PM. Okay. All right. So I'm going to, if you want to go back in, I'm going to go ahead and we're going to go over to scope view. I'm going to go run across and grab the mantis clip. Okay, great. So we have a nice, we're going to play pretend. We're going to say that's the muscle layer. We see a little defect. Right. Okay. So if you want to go ahead and take a look over on the table again, this is zoom in closer to my hands. Okay. We have a question. Let's I'm seeing a question right here. It's from 2.22. 2.22. Can you use any, do you clip the defect after band EMR? No, you don't always have to. My practice, especially with nodular Barrett's is you do not need to clip this. I think it has to do with the depth really of how far down this goes into the submucosa. You're not getting too many deep exposure or larger vessels being cut with this type of resection and the deeper you are, you're going to get those larger vessels. Now it's, it's to your own practice. If you don't, if you're going to sleep better at night knowing that this is closed or the person's on, you know, a lot of anticoagulation or is currently taking an aspirin or any of these things that it's going to make you feel a little bit more anxiety. I think it's reasonable to close it. You're still making a defect, but you do not always have to. Sometimes I close these when I'm doing a rectal band ligation, particularly because a patient may get some stool that has blood on it. They're going to get a little more anxiety, come to the ER, just cost them an ER visit. That's probably cheaper than the cost of a clip. But the short and dirty answer is no, you do not have to. Now, if you had to cauterize a bunch of bleeding vessels, you may feel a little bit better at nighttime with a clip closure. Yeah. Okay. So if we look over at my hands, we have a mantis clip. This is an opposing or an apposition clip. It is meant to really bring together two sides of a defect and then quickly be reinforced with other clips. It is not necessarily like one that you would want to just leave on by itself, but I find it to be incredibly effective in my practice to use this as a primary closure and then quickly reinforce it. And if you'll see, it's got some teeth on it. I like to think of it almost like a snake. And what's going to happen is you're going to grab the one side of the defect and you're going to start pulling it over to the other and open up the jaws again. And you'll notice that only one side is then connected to the tissue. And then you can take your second bite and close them together. And it kind of, the kind of term we use, the little buzzword for this is like a jacket button. You're going to be bringing the jacket together with a button, in this case, the mantis clip, and then quickly use different clips to really reinforce it. Okay. So we're going to go ahead and feed this down, our working channel. And the nice thing I like about the mantis clip is just like a Boston 360 clip, it's physician guided. It's really, they're the one who can do the easy one-to-one feedback with rotation on their own. They don't necessarily need the tech or the nurse spinning the plunger or the piston. So you're seeing here just like the resolution 360, there's good one-to-one movement just as we're rotating the clip on the outside. We see that reflect in the luminal view. So we can sort of get the orientation that we want. And let's go ahead and just show them the jaws. So go ahead. So see those snake bites right there? Those teeth are sharp. So it's meant to really hook on to one side, but the way the clip opens, it's going to release the opposing side. So you can take that second bite. So we're going to pretend we have this perforation here and go ahead. We're going to get nice, good, healthy tissue. Tell me when you're ready from there. So see how on the left side, sort of the anterior stomach, let's pretend, collapse the stomach a little bit. We're sort of retroflexing here. Okay. So we'll grasp this. Let's try to get that little lump right there. There you go. All right. Do you want me to go ahead and close? Yeah. Go ahead and close. Yeah. Again, this is kind of elasticity of this is not the greatest. Yeah. Elasticity. And I think the position's also a bit challenging because it's retroflexing right here. Okay. Take a little air out maybe. Push the clip out. Yeah. All right. So we'll start again. We'll try here. Okay. So now you do not want to, if you look at my hands, you do not want to push this all the way up or pull it all the way up because that will fire the clip. So now I'm going to reopen and you'll see on the left, if you lift up just a little bit, we have that tissue right there. You see that? But my right jaw or the right portion of the jaw is not connected. Okay. So now we're going to go back down, pull it over, suction in, and I'm going to slowly start closing and you can insufflate. You see that we have nice closure. We're ready. I think, see how it's like a jacket button. We're brought two lapels of the jacket together and we're ready to fire. Boom. All right. Yeah. There. Look at that. That's beautiful. Nice tissue. Right. And then let's just quickly, I'm going to grab a 360 to reinforce this. So generally speaking, you can place the mantis as your sort of first clip to close the widest part of the defect and then a zipper the rest of it closed with whatever your standard other clip is. In this case, resolution 360. Yeah. This has been an excellent device for our clip for closing perforations, closing ESD sites, particularly in my experience, it's really kind of changing the game as far as making things a little bit easier on the long day of resecting and trying to get things going as far as getting onto the next patient and not having to spend two hours closing a defect that you spent five hours on. Yeah, totally. All right. So open here and we'll see how exactly this opens. I'm going to go ahead and open. Yeah. All right. And yeah, my my approach has always been to kind of go closer to the actual or to the mantis to like reinforce it. Got the clip nice and centered. It's pushing out some slowly. Yeah. Close. Firing. Yep. Beautiful. See works beautifully. Now we would then just continue on with our kind of zipper approach, almost a further closure of that defect. And that would be that. Yeah. All right. So now let's get one more clip out just to do come around just to pretend like that's bleeding. Actually, let's just do actually, you know, since we use the 360, let's try to just show them one more time. The mantis. Okay. Yeah. We'll pretend like that last clip was also taking care of some bleeding. Yeah. All right. So go ahead. Did you want to show them once more? Oh, yeah. Outside? Yeah. Yeah. I mean, it is a very critical point that, you know, how the mantis actually works. So open, you can see the jaws. Only one side will hold on to the tissue tends to be your left side. And then you open it again, come over, close, fire. All right, so we'll open it right there again to show those jaws. Yeah. Jaws are really something. Yeah. All right. So we'll go ahead and grab that guy whenever you're ready. Let's see if I can... Bit of a tricky position here. A little bit of it is also, as you know, with the bossy cliffs, they tend to have a little bit longer tail. Longer stems, yeah. Yeah, so... Always an issue. Go ahead and let me suction down maybe a little bit. Grab that, and we may have just grabbed the right side, and that's okay. Sometimes you can get it from the right and drag it to the left. Right. Okay, so launch back up a little bit. Let's see what we're working with. Pull back. Okay. So we got a nice little bite on the right. Yes, we do. There we go. See how we just brought those together? Now if we push in, close, and we can fire. Boom. Beautiful. Okay. Nice. Excellent. See, now we've essentially closed this. We may add a clip or two between these, and that would be that. Any questions at all, please feel free to kind of put them in. Okay, we do have a question. Would you use a mantis for a smaller defect as compared to a vesco? No, not necessarily. You know, I think it's more the opposite. I think a vesco, sometimes you have a little bit of difficulty closing giant lesions. I know you can get something up to two centimeters with a vesco. At least my practice has been that. With mantis, you know, you can start off with a larger, you know, ESD. You know, I've been in cases where we've done the initial mantis clip in a five-centimeter defect to bring the two sides together. The difference between an ovesco and a mantis is that you just may need a couple clips as opposed to one ovesco. It just depends on the lesion. So I don't think, you know, one fits all or one fits into one category particularly. But I don't know, have you had any experience between those two? Yeah, no, I totally agree. I think, you know, if anything, the opposite because you're sort of size-limited when you're using a single over-the-scope clip. And generally, 20 millimeters is the upper end of where we can use a single ovesco clip. Whereas with a mantis, you can actually use multiple clips and close a much larger defect. Yeah. All right, so we're going to set up for our next demo. We're going to take a second to switch over scopes. We'll be right back.

band endoscopic mucosal resection

EMR procedure

Fuji 1T scope

Barrett's esophagus

snare resection

submucosal injection

cautery

mantis clip