All right, hi, my name is Wasif Abadi, I'm one of the gastroenterologists at Baylor College of Medicine. And hi, I'm Linda Ho, I'm one of the interventional and general GI doctors at Kaiser Permanente at Panorama City in Southern California. All right, so we are here, we're trying to show you some of the equipment. You guys are advanced, you guys are kind of senior fellows, you've seen a lot of this equipment, you've worked with a lot of this equipment. But there are some nuances that you will continue to learn and learn as you work through this equipment. You'll see us doing this stuff. Some of these things we're actually not as familiar with, you'll see us struggling with it. It's a lot of, it's actually good learning for you from a lot of these things because you'll get to see what we do and what we do when we have trouble or when we need help and what's going to go on and troubleshooting things. With equipment, I always tell people, know the equipment really well, play with it, mess with it, know what its failure points are. You're not exactly an engineer, but you kind of have to sometimes think like an engineer and really know what these things are because it's going to screw up and the tech is going to look at you and be like, I don't know, I was just told to do this, something like this. And you have to start figuring out what to do, how to fix it, how to get things kind of working again. So without further ado, let's get started. I think we're going to start with just a polyp snare. And so I'll let you take over talking and I'll do the endoscopy. So generally most everybody, depending on which practice model you end up going towards, a lot of times we always end up doing some form of general GI. So this is bread and butter GI. This is about polyps and whatnot. So we're going to go ahead and start with our scopes, our cameras. A lot of the equipment you end up using in your practice may not be the same as you used in training. So I always tell people, try to continue to learn about different types of equipment depending on which practice setting you go to. And that will sort of determine kind of how familiar you are with equipment and whatnot. So we're going to go ahead and take a look here. One of the tips I have for senior fellows is if you guys don't already, if you guys are ever in the same room with each other, to try to tech for each other. That's where you learn about some of the equipment, like failure points and what it sounds like. Because you may not get techs that are as well trained as you have currently in your academic centers where they're used to doing a lot of this more complicated stuff. So here is our artificial polyp. So we have different types of snares here. We have cold and hot snares. Cold snare is at this revolution. I remember back when I was in training, we didn't use cold snare as much, right? Lots of like- No. And I don't know. Yeah, absolutely. Yeah. And so, but now a lot of our flatter, more set style lesions, they do better with cold snare. A lot of the smaller lesions that we used to do, like multiple jumbo, forceps, biopsies, we don't do that anymore. It's just one cold snare out, we're done. Whereas hot snares, we tend to use for pedunculated lesions, very bulky lesions, that kind of stuff. They're made stiff so that you can really get around something and burn it. And the cold snares aren't really made that way. We'll talk about some of the details, but the wires are made to really cut through things as easily as possible. So what snare do you want then? So this is a little bit bulkier lesion. So I would tend to pick a hot snare in this situation. Okay. And you're looking at the size. This one should be, the smallest snare should be fine. Usually- So these are actually nice because this is, so this is Captivator 2. This really is a lot of times my go-to. It is 10 millimeters, so it's smaller than a normal hot snare that you do, but you can connect it and get hot snare with it. A lot of the Snare Master Plus from Olympus, you can sometimes, you can use them both hot and cold. And so it works either way. But Captivator, you're okay with it? Or you want a 15? You have a 20? Sure. We'll open what you got. Snare Master, okay. I think a 10 should be just fine for this particular lesion. All right. So we're going to use a 10 Captivator. Thank you. All right. I can give that to you. Oh, let's see. I'm already being a bad tech. It's all right. We're all good. There you go. All right. And then a little bit about hot snares. Know your coagulation setup, your current setup. We have our, let's see here. So while she's getting that down, let me, if you, I don't know, it's a little bit behind here, so I don't know if you can move over a little bit, but we have a sterist system and there are multiple. There's Irby. There's ConMed. There's a couple of other systems that you can use to try to, for cautery. Now it's either cautery or cut is the usual way that you think about it. But the fact of the matter is that all of these currents are actually both different blends of cautery and cut. And when I'm talking about a blend of a cut, it's not that, that kind of like what you hear at burr, burr, burr, where it's kind of like, okay, there's a cut and then there's a blend and there's a coag and a cut and coag. No, this is the actual like electronic wave is actually blending and cutting sort of in the same thing. Yes. So one noise. Yeah. Yeah. So it should be one noise, but that's what, and there are interval ways of doing things, but we're going to use, what do you want to use for this polypectomy? So we'll use our blend of cut here. It's on a monopolar setting, blend of cut here. Perfect. Yeah. So go ahead. So I tend to, one of the tips I learned was I tend to open my snare a little bit in channel. So a lot of people will, will tell you to open it out here, but the closer you are to the scope tip, the better control you have for your snare location. So a lot of times I'll barely have the tip of the catheter out before I tell them to open. So it lays flatter. So go ahead and open for me. Let's hope it's. Is that the right way to open? Nice and slow, boss. All right. Yeah. Okay. So we'll do it nice and slow so that she doesn't hit something that she's not supposed to. So here, and then it usually ends up laying a little flatter than if you open it, say, way the heck out here. So, so we'll go do that. And then you can close nice and slow for them, please. So we're just going to cut here. Close nice and slow, please. Okay. And then if you feel, do you feel tight around it? I have a tightness. I'm resistance. Okay. Excellent. And then here we go. And I usually lean away a little bit from the actual lumen wall. He's going to hook up the cut portion. Otherwise it's going to be a cold situation and we'll go ahead and step on the pedal here and close, close, close. Let's hope this goes through. Ah, there we go. And there's a hole. Well, it's not a full hole. It's just, there's the actual polypectomy site here. That's a pretty polypectomy site. I can take that for you. Thank you so much. I appreciate you. So just, so there's a couple of things. A lot of times with these polyps, I tend to, and I don't know if this is something you do Wes, if for some of the very thick pedunculated stocks, I will sometimes inject a little bit of epinephrine or something into the stock itself to minimize any bleeding I have post procedure. Sometimes for flat polyps, we'll go ahead and lift them. There's a variety of lifting agents. There's also just plain old saline. You guys use starch. Yes. Head of starch, we'll use that, but we use, I use a lot of saline, especially the smaller polyps. I have a big ESD center that I'm part, that I'm part of. And so there we have everything available to us. But whatever is available to you, a lot of these things for smaller polyps, it doesn't matter. You're going to really be able to lift it and get it ready very quickly. Yes. Sometimes we will close these polypectomy sites with clips. A lot of my patients who have to go back immediately on anticoagulation, I do tend to clip those sites closed, even though I know generally for the patient who doesn't have any risk factors for major bleeding post procedure, a lot of times you can leave it open. So if you want to go ahead and open one of those clips for me, we can just do, yeah. Clips are going to be the same thing. It's going to, again, be whatever is at your institution. So here we have some of the Boston Scientific clips that have been gracious enough to give us tips. Resolution 360 is a pretty standard clip. It opens pretty nicely. It's rotatable. So you're able to easy rotate. Actually, the physician is able to rotate these, which kind of makes it easier. You don't have to rely on a technician to do exactly kind of the rotation that you want to do. But really, there are clips from a lot of other different companies that are fantastic, that work, whether it's Olympus or Cook. If I'm worried about that this has kind of gotten a little bit too full thickness and it might be a perforation underneath there, I might go for a Cook. That tends to be more reliable for me. If it's a little bit bigger, sometimes there are other clips that you can use, including the Mantis clip. Well, the Resolution Ultra is also 17 millimeter versus 16 millimeter. And the Mantis, and we'll talk about this a little bit later, and we'll kind of give a little bit of more information on the Mantis in a second. So we'll just use the Resolution. Resolution 360. It looks like it's a pretty kind of standard. Standard. Yeah. Smaller polyp size. Okay. So we're going to open it. It comes pretty much ready to go. And so I'm going to give her the clip. Okay. All right. This one. Go ahead. And one of the things, when you start out in practice, is I always tend to take a lot of photos. These days, photo storage is not an issue for a lot of these systems. So here, I can rotate it. I don't know if you can see it, but at my hand side, you can see that I can rotate it here. I can ask our tech to rotate it. Yeah. So right here, you can see there's that orange thing, and you can see as I'm rotating it, it is rotating around. Now, one thing that will happen is if that tech is really close to the physician and you have this kind of loop here, that's going to make rotating hard. So I'm going to try to make it as straight as possible so that as you rotate it, it goes right there. You can see how much the rotation is better now that I'm keeping it straight. Yes. Or I can rotate it at the site right here at the biopsy port as well. So go ahead and open for me. All right. So I'm going to push it forward to open it. Yes. And a lot of times, what I will do is I tend to, again, try to keep it as close to scope as possible. I will pull it back a little bit and then move closer. And go ahead and close. Okay. So I'm going to start closing it. And go ahead. Yes. And so there are actually different settings. You're going to close it. Yes. And then at that point in time, I haven't deployed it. So if she is not happy with it, I should be able to open it again. But she's very happy with the location. So I'm going to go ahead and deploy. Yes. Go ahead and deploy for me. Just go for it. Now, these clips, you have to kind of do the other part, which is you got to release it. You got to open it up. Otherwise, it's going to come right out with everything. That's not necessarily true for some of the other clips. Okay. And we'll go ahead and thank you. All righty. Okay. All righty. Anything else for this that you can think about that we should cover? I think that's about it. So, yeah, that's essentially the thing. That looks good. You come out, you continue looking. If this was a colon, you continue looking for colon polyps. All right, and you move forward. So we'll go ahead and talk a little bit about one of the complications that sometimes you can see post polypectomy and otherwise the bleeding situations. So we can show you guys some new equipment for that. I can scope and you can talk. Yeah. So one of the things is there's a lot of different ways to address bleeding. Most likely, you know, in this situation, we're not talking about variceal bleeding, but non-variceal bleeding. So a lot of times this comes in forms of ulcers, but you can see it in post polypectomy as well and whatnot. So we have multiple modalities. Remember that you always have to do a dual modality type of therapy. There's, you have to, you know, if you plan on using epinephrine at any point for active bleeding lesions, you do have to use a second modality. There is CLPS, like we showed you earlier. There's also APCs, another modality, and also we have bipolar coag as well. So we've already, this poor pig has already been bleeding a little bit. We're gonna identify a site for you earlier. Newer on the market, we have hemostatic sprays. There's more than one company that produces product now. So that a lot of times is used for sort of rescue situations where some of your standard CLPS or injection or BICAP has failed to that extent. One of the other things that you can do, there's over the scope CLPS that we have used for large ulcer bleeds before that have different types of attachments, but those are some of the techniques overall. So rarely, we've actually used suturing as well and overstitch. We've used it for big ulcers that might need to be kind of covered up. That's helped as well. So these are getting a little bit into niche areas, but the idea is that you have a lot of tools available to you. We're not gonna be able to show you everything to you guys today, but let's at least kind of show you a couple of things that we can do for these polyps. So do you want to do a CLPS first and then the hemospray or how do you want to do it? Yeah, let's do exactly that. So we can talk a little bit about Bantus Clip as one of our possibilities. Let's just use, let's use, yeah, sure. Bantus Clip will be fine. All right, so the first thing is, of course, identifying the source of bleeding. This is what I came into. I see a little bit of blood and I clean it up. You might even see a little bit of an eschar or a clot going on in there. And you're like, you know what? I don't really like that because I don't know where the bleeding is coming from. I don't know what's underneath there. The way I've been trained and the way I do it is that if there's a big bleeding spot and there's a lot of blood clot, I try to clean that off as much as possible. Sometimes even snaring off a clot. See what your attending's like to do and kind of do based on what they are. It's a little bit aggressive sometimes, but that actually will show you if there is actually a vessel underneath it. And so you're also able to treat exactly what's going on rather than just kind of blanket treating it. Yes. Okay, so. So the difference between this particular clip sort of are the, they call them like the talon edges or whatnot. The talon edges, yeah. So I don't know if you can see it against my, scope here. It's a little bit different. When you get inside, I'll show you guys exactly where those, how those talon edges are, what they are doing and kind of thing. It also helps with closure. So if you have an area like a big polypectomy site that you've closed down and you kind of said, okay, this needs to be closed down, but it's really big. It's about two centimeters. And you're like, oh, I can't just bring it down with one clip. This sometimes can help. So let's first actually show where the bleeding site is. Do you want to put the pod in there? All right, let's do this one. Yes, because I can't see where the bleeding site is. And I'm just going to wait and I'm going to wash. And then suddenly. Let's see. Hold on one second here. Magically, of course, because we had no idea this was going to happen. Hello. It starts bleeding. Hello, Dulapoi lesion. That's the Dulapoi. Ooh, okay. There you go. I got you. You got the scope. So this is, there's an area here that you definitely want to close down. And this is looks exactly like a Dulapoi. Yeah. It's a full mucosa, but let's say this was a big ulcer and kind of like, okay, this is a big ulcer area. And I want to basically be able to close this area and we'll try to close a larger area than we normally would. This mantis, if you look at it right there, you can see right at that edge by the scope where it's coming out, those talons that are kind of coming out. And when they open up, yep, there you go, beautiful. When they open up, they can kind of get into mucosa and then they're able to pull mucosa onto the other side and be able to kind of cover an area. So let's say this was the edge of the ulcer. I want to try to close it. So I want to have it open. Open. All right. I'm going to try to, again, work close, just like Linda was saying before, we like to work close. And let's close here. Okay, close. So close. I usually close it down and kind of bring the mucosa a little bit over. And what it's doing is that it's kind of pulling tension on one of those talons. So now as she opens, so go ahead, open it again. See how on the other side, you can see just barely, you can see it's holding onto the mucosa. So it's able to kind of cover that area. And I'm able to even pull that over a little bit if I can. And I'm going to try to grab over here. I don't know if I can, but. I'm going to see if I can rotate it a little bit too. I think you'll be able to. Yeah, maybe. No, we should be okay. So I'm going to try to close it there and it's not going to be able to grab it. So what I'm going to do is I'm just going to grab that mucosa and grab it over the actual dulafoil site and we should be able to then be able to cover it. Okay, good. You okay with that? Let me take a look at it first. You deployed already? I deployed. I'm sorry, I'm sorry. This is where communication comes into play. Yep, it looks good. And then we'll go ahead and release. And then the same thing where you have to release it a little bit. Okay, good. All right, here we go. I'm going to look at it again. And so you can see it's brought the mucosa from here where it was all the way further away. It's brought it closer together and it's kind of covered that area. But we also grabbed that area pretty nicely and we're able to kind of close that bleeding. Let's see if that bleeding still happens. All right. Oh wow. Hey, nicely done. We actually did it really well. Okay, it's still dripping though. Oh, there it is. Oh, it's burning again. Oh no. All right, so it still started bleeding. So what do I do at this point in time? I'm probably, honestly, if I was sitting there in a case, I'd probably put another clip on there and see what's going on. But you guys have already seen two clips. So I'm not going to really get you guys to see more clips. We're going to start, and we could also do other things, injecting it, obviously. And then the other thing that we could do is these new generation of powders. Now, I'm not actually on a GI bleeding service anymore. I mostly do panc-biliary service. So I haven't used NexPowder that often. I used it a while ago. Have you used it? I have not used it, so here we are. This is brand new for all of us. Okay, so now here's a system that you guys never used. This does happen, actually. Especially with all the new equipment that's available, this does happen. And you're like, oh shoot, I have a bleeder, I have equipment that I don't know how to use. What do I do? Simple things. Ask the people in the room. Because sometimes the technicians are pretty, have used these a few times, and they might be able to help you. You should obviously know the concept of what you're doing. You have an area, you need to spray it with a device that's going to cause hemostasis of some sorts. So that's the concept of how to do it. You may have watched the videos or something, and seen it before. You might have seen somebody else use it. But at least have a concept, an idea. I wouldn't go into using an item that you really don't have any concept of how to use it. But then it comes up in this box, and you're like, oh shoot, I don't really know how to use this. And maybe the technician hasn't really used it that much. Oh, here you go. So you're like, okay, let me open it. And you're like, oh, okay, this is all this stuff, and what is this, and how does it all go together? So there is a package insert always, and kind of look through that. And actually, equipment that you have used a bunch of times, it's not a bad idea to look at the package insert, because it might give you some information that you did not expect to know. You're like, oh, okay, actually, oh, that's interesting. I didn't know that, and this and that. So sometimes these can be actually quite useful. The PEG kits actually have a lot of interesting information sometimes that you're like, oh, I didn't do that. I don't do that normally. And it's probably because our attendings don't do it that way, but it can sometimes help. But the package insert is helpful, especially if you're not sure if a device fits through something or the other. Do I need a diagnostic scope okay, or do I actually need to pull out the therapeutic scope? Sometimes this will help, too. Exactly, and some of that information's also on the packaging somewhere. You might see it, hey, this requires this device or something, because a lot of times, these will say, hey, this is a 235 centimeters. It opens up to 17 millimeters. It usually tells you the working length and then the working channel requires a 2.8. So if you're working with an ultra slim, it's not gonna fit through there. So you have all that information and it's good to just look at this if you haven't looked at these things just to kind of get an idea of all the information and even the package. But the package insert is great, but it's not exactly 100% and it still can be confusing for you. A lot of times your next source of information is gonna be the other attendings if they're around. That's okay. If this was something that was planned, you can also have the rep for the company come over and help you and show you this a lot of this information. Say, hey, this is how you open this. This is how you do this. And the reps are actually really helpful. They love to be in the cases with you. And they'll be able to kind of give you little tips that'll make it work. And if something doesn't work, they've also been trained to kind of figure out, hey, this isn't working this way. Whereas your colleague might be like, hey, I'm in the middle of a colonoscopy. I can show this for two seconds, but I got to run back and do that patient because they're under anesthesia and things. So that might not be as practical. Do we want to get the, do you want to, let's get them to come here. Let's actually have someone come here and. Tell us a little bit about it. Yeah. In the meantime, we do have a question, I believe. The question is, is the mantis able to grab and drag mucosa even for fibrotic ulcer edges? That's a really good question. And it's meant to be semi-full thickness. And so sometimes you're able to pull the whole sort of mucosa and sort of some of the submucosa and the subfibrosis over. But a lot of times you're going to have trouble with that. And you're going to have to go further out, quite a bit further out to get healthy mucosa that's sort of just able to come over and cover things. Clips in general, you're really just putting, it's really putting pressure on things. And so you really want to make sure, a lot of times, honestly, we're using mostly resolutions and the cook clips and a DuraClip and just kind of putting direct pressure on those things. Okay, so we have trouble because neither one of us has really used this. And so we need a little help. And can you run this through with us before we kind of go through? You want to come around this way? We are going to, so here we go. Come over a little bit, you might be able to, yeah, yeah. We got it, yeah. So this is the NexPowder agent. NexPowder is a hemostatic agent for non-variceal upper GI bleeds. It's built from lactose, so it's contraindicated in patients that are lactose intolerant. And the machine comes in one kit, one kit per patient. It comes in three parts. First, the spray body, second, the catheter, and then the vial of three grams of the NexPowder agent itself. It's 220 centimeters long. It's seven and a half French. It fits through the working channel of every scope. It has wings on the tip. You line it up with the tracks on the spray body. Line it up and it clicks into position. The next thing you're going to do is make sure that the throttle, it says open and it says closed. You want to make sure that it's closed at all times. And then with the powder itself, you screw it in with the gun upside down. That way it doesn't dump and make a little bit of a mess. Throttle again is closed. Then when the tech and the physician feed it into the working channel of the scope, you want to make sure that it is on, on, off on the back. Throttle is closed and on. So with a lot of these powders, what happens is that you do need to make sure that the channel is dry. And we use, I sometimes will push in air with it or just really make sure it's clean. Because if there's any sort of fluid that it really touches, it will start congealing and it'll start becoming obstructed and cause a problem. So what he's doing by turning on that on is just making sure that air is gone and that we don't have to worry about the channel and the catheter getting obstructed. All right. So again, that's here. I'm going to kind of work about one to two centimeters away from it. It's about a centimeter outside the scope, maybe a little bit further, I'd have it coming out and then kind of go right there. And then there's the bleed and you're like, okay, well, I need to go in there. So let's go ahead and start spraying right there. All right. So I'm going to go ahead and open the red a little bit, nice and slow here to about halfway. There it is. Yeah. And then you're just painting it. It's just, it's almost like it's art at that point in time. So I'm going around this and I'm trying to get this not fluid on it, but I have to kind of get underneath there. So what happens if you do get fluid on it? What would you? Well, it might can get obstructed. I'm old. We'll try that. So let's say give you a little bit higher power here. All right. So now I got some fluid on there on purpose and I'm like, okay, shoot. That's actually, it's still working. Look at that. It's working actually better than it was before. Look at that. I turned on the power. Here we go. Okay. But if it does get obstructed and that's good. That's, that's fantastic. You can turn it off now. All right. And then you can always go back and use more, but if it does become obstructed, that catheter, it's plastic. You just go and cut the end of that plastic catheter. And then you're, yeah. Then turn it off. Okay. Okay. All right. And then I'm going to come out with this and that actually looks really beautiful. That's really nice. You should hang that up as a painting. I should. My kids will love it. I know. They're like, you don't put our artwork up, but you put that stuff up. So if it gets clogged, similar to other hemostatic powder sprays, you can always take a pair of scissors and cut this. The other tip that we had was this powder comes, you want to try to hold it or have your tech hold it. So this part is perpendicular. So it feels, you know, it feels different. It's not like holding a gun, but it's sort of, you just want to keep this portion upright. That actually looks really nice. Look at it. It's not bleeding. I love that. Yeah. So. Yeah, we'll call that our own work. Not because someone stopped pushing blood through. It's a Wasif original here. Yeah. All right. If everyone wants to, you know, wants our autograph and take a picture of that, please send it over. We'll autograph it later. So we are going to show dilation. Again, bread and butter GI. There's different indications for dilations. We have peptic strictures. We have eosinophilic esophagitis strictures. A lot of those times we can use balloon dilation. Not as many people are trained in using the old school Maloney dilators and whatnot anymore. We oftentimes in this sort of medical legal situation, rely on balloon dilation as one of the fundamental things we do. So here Wasif has sort of shown this kind of very narrow esophagus. So balloon dilation is one of our more standard things. I'm sure you guys have done it at some point. It's actually one of the, I feel like the techs always tell me it's one of the last things they learn how to do because it takes a little bit of time to set up. So usually there is a gun component. There's the kind of filler component, I call it. You may have heard this name. Yeah. They call it the alliance. So it's an alliance too. That's what it's called. Olympus has their own system that works as well. So it's not necessarily specifically, you need to use this one. But this is the one that comes. It comes just regular without any fluid in there. And then you're able to pull in fluid. There is a fill line. So you get the fill line up. So there is also to it a second component. It only fits on one side here. Just the catheter, not absolutely needed. And then what you do is you attach it in this. All righty. If I can get that going here. And then here you see the pressure gradients. A lot of times, you know what? I always do it backward. This is clearly not my day job. But here we go. All right. Okay. Let me just put that thing on top. So it does have a little clip to make sure it doesn't fall off. Otherwise in the middle of dilating, it suddenly falls off. The gun does have this kind of a lever that'll go forward, neutral, or backwards. And so you're able to kind of fill things in. In terms of what you're filling this in with, you're oftentimes filling it just with water for your regular dilations. Now, some of the therapeutic endoscopists, they might end up using a little bit of contrast in there. And so they'll use it with, well, they'll use it with fluoro, and then they're able to kind of see what exactly the dilation is happening and everything. I don't like to have any air in here. Air is gonna give you a different force than water. These are hydrostatic. So these are pneumatic dilation, different from pneumatic dilation. They're hydrostatic dilation. They're using water to kind of fill it up. There is a pneumatic dilators that you guys might have heard about, the Rigiflex. Again, not many people use that anymore. I use it all the time, but I'm using it on sleeve strictures, sleeve gastrectomy strictures. But those are bigger. Those are the ones that we use for akalasia, and they're bigger volumes. So filling up with those things with fluid just will take a long time. So you fill it up with air, and they're more rigid once you kind of get to the right point. So then you have the balloon catheter component as well here. A lot of times they will come in runs of three sizes, 12 to 15, with sort of three markings for that. Do not have to text throw away the packaging, because the other thing on the package, they also tell you is what it corresponds to, pressure measurement wise, on your gauge. A lot of times, newer techs, they'll throw it away, and then they'll be like, oh no, where do I go up to on this? For a while, they didn't have the actual, that catheter didn't have the labels. I think the labels should be on the catheter itself. Yes, they do, yes. I don't know why. They just forgot to put them on. Like right here, you can see the catheter has that. So it should come on there. There are different types of balloon catheters. A balloon catheter is not just a balloon catheter. This one, if you can see the packaging again, it does say wire guided. And so you're like, okay, this has a wire that we can use inside it, or we can use it over a wire. So let's say I wasn't able to, if you look at the endoscope, if I wasn't able to pass this area, I might say, you know what, it's safer, I'm able to put a wire through it, and then be able to kind of open things up. That would be a safer than me just saying, okay, let me just go put a balloon through this. And so I would put, use the wire guided. There is the, so the purple packaging from Boston Scientific, that's a non-wire guided. And there are some differences. This is five and a half centimeters. The non-wire guided is eight centimeters. So you kind of have to look at it and see if there's different differences. Different sizes will have different pressures that you're going up to. So this one is a 12 to 15. And then you're gonna see here that it's gonna go from three atmospheres to eight atmospheres. Don't always pay attention to the units. And this goes back to your physics class from pre-med, you gotta look at the units because three atmospheres is gonna be different from something else. They're gonna be like, no, we have 680. And you're like, well, what's 680? And then you start realizing they're talking about PSI and not atmospheres, and you have the kilopascals. And so you have to be able to kind of convert those or make sure they're using exactly the right units. Actually, it matters because when you use the dilators that you use on a pneumatic dilator, pneumatic dilators actually go to very low atmospheres. And it's almost like one and a half atmospheres is equivalent to 20 PSI. And so you have to be able to convert that. And if you don't know the difference, you might blow the balloon up or not dilate it enough. And a lot of this sometimes is tactile by feel. If your tech is already a good tech, well-trained tech, if you're already starting to encounter resistance as you are increasing the fill and blowing up the balloon, sometimes they'll tell you, hey, it's starting to feel a little bit tight. You may be able to adjust your dilation that way too. Okay, so we're opening up this balloon. You can see that this is the wire and there's a covering over here. If the tech gives it to you without, just like that, you're like, this isn't going through my tech. You just need to pull that off, okay? Excellent. And you can see that you can play with these things, play with these things, especially if you have one that you didn't use or even if you use it afterwards, just play with it and see what it's like. This is the wire. It kind of goes in and out. You're like, what is this white thing? You've got to do this and the wire doesn't move and it holds the wire in place. So if the tech is kind of holding that and you're like, this wire is not going through, you're like, okay, well, that's what's going on. You have two ports. And so you have that wire port that we just did and then you have the actual injection port, all right? And what if I was using contrast to actually look at the lumen? I can actually pull this wire out and put in contrast through that lumen itself, okay? So yeah, so you're gonna, I'm gonna give you this. I'm gonna go back to the endoscope. Here, give me this, perfect. Okay. Go here. So this is where you attach the port. Here we go. Okay. Okay, now what I do is similar to what you were saying about having the loop come out in the channel. I actually have them put the wire out all the way while it's going in the channel. So if you can, yeah, you know, just leave it as is. Exactly, just push it, push it. And you don't see it. This is the way I do it. I don't think a lot of people do it this way. That way I have control over the wire. I'm not telling the tech to push the wire forward or anything like that. But we're able to kind of go in through here and I can feel that there is no resistance with this coming through. And we had X-ray would be able to kind of look at that. That's what that wire is for. I'm just gonna use that wire because I didn't expect to make this so tight that I wouldn't be able to get my scope through here, but I did. So it is. Here we are. So we here are, exactly, okay? So I have it in exactly the position. You need to be able to see that you're kind of making sure you're going past it. When they're really tight, sometimes it actually pushes the balloon out towards you or it goes inward. So you really do have to make sure that that balloon doesn't go move anywhere. What do I do? I'm holding the balloon against the scope to make sure it doesn't go anywhere. And then I'm holding the scope at the mouth so that I make sure the scope doesn't go anywhere as well. Okay? So that looks like a pretty good position. Let's go ahead. I'm gonna pull it back just a little bit and let's go ahead and start going up. You're gonna say what you're gonna go up to. You don't just say go up the balloon because the tech's not gonna know what to do. So you're gonna go to 12 millimeters. I'm gonna go to 12, which corresponds to 3 ATM. Okay. So I'm feeling a little bit of resistance here, sort of right before 3 ATM. So let's say, let's stop at that resistance. And the reason is that I want to show you a couple things. One is that you can actually look through this balloon. Oh, the money shot. Yeah, especially if I can look through here. You can look through the balloon and you can see further down in the balloon, you can see that it's not touching mucosa, but maybe somewhere around the middle, there's this ring and usually it's blanches. This is pig model, it's dead, so you don't see it, but it usually blanches, becomes white. This is a poor man's endo flip, essentially, because you can see that that area is just doesn't have the elasticity and it wasn't, doesn't open up. And so you need, you say, okay, that's what I'm actually dilating. So that's good. Now you can also see at that point in time, if you cause a perforation or something, you can watch it under direct view and you can see it. Okay, let's go in there, but okay, good. Let's continue, let's go on up to 12. Okay, that is, okay. Because it seems to be okay. All right, there we go. And that's good. Now how long do you wait at 12? Depends at dilation-wise, you know. If I do cause, so they used to teach the rule of threes, you know, you dilate three intervals, so sort of this 12 to 15 interval would be one of them, or you dilate until you tear. That's the, that's when you know you have to stop. We'll talk about that in a second, yes. But that's good, and I wait about a minute between the intervals. About a minute, yes. So I'll wait a minute. If I have fluoro, I just have to watch that waste go away. Then I'm like, you know what? I've done whatever it needs to be done. I don't need to wait any longer and I can go to the next interval. So let's go ahead and let's say that's been a minute. We'll go ahead to 13 and a half. Keep going, and that's four and a half. So we're going up a little bit more. There we go, four and a half. And then let's say we waited a minute there. It looks okay. Let's go up to 15. And then you go up to 15, which corresponds to eight. Yep. The text is gonna tell you this is eight, and they're gonna, don't let them do what they're doing. Okay, good. You can actually see a little bit of a ring still there. You know, there is that ring there. That's the wire that I put on there, but that's the dilation, and I might wait there a minute and say, okay, that's dilated. And I tend to ask them to drop the balloon pretty slowly. That way you kind of get a really good view. Make sure you really didn't cause anything that you weren't supposed to. Oh, that's a good idea. Yes, okay. All right, so let's come down on it. All right, we're gonna go down nice and slow here. Okay, and then we'll have to put it backwards. Yep. Okay. All the way. All the way, yeah. Okay. And then. A lot of times, the other one, you can actually ask them to kind of just pull down. So they're coming down on it, coming down on it. Beautiful, beautiful. Okay. Yeah, nice and slow. So you can kind of see what damage you caused. Good, now we can see. There's that stenosis. Let's see if I can get through it. Stretched it? You know, I did stretch it, but it's still not letting. Oh, there you go. You did it. It let the scope through. All right, good. Now we can see everything else and see everything else that's going on. Perfect. But that worked really well. There's still a resistance. You can see it there. So there is still a stricture there, but let's leave it for another day. Next time. When do you bring them back, Wasif? I actually bring them back in two to four weeks. I don't want to wait too long because they can get scarred down. There's new stuff that you can inject it with Kenalog. Kenalog. And there's a lot of good data, both with anastomotic strictures and regular strictures, peptic ulcer strictures. Right. They help, they help a lot. You put it in and it reduces re-stenosis. And there's some other new studies that are going on about other balloons and other coated balloons that we can use to try to prevent re-stenosis. As you go through your practice, you start realizing how much re-stenosis can be an issue because you see the same patient again and again, year after year. And you're like, really? You're coming back again? What am I going to do with you? Do I send you to surgery at that point in time? And that's a whole different conversation. Okay, good. So let's say we did cause a tear or a perforation and there was a little cut here. And they're like, oh shoot. What do you do? You don't go cry to mommy. You can go cry to your surgeon. Yes, that's allowed. And having the surgeons on board is important. Yes. Any things that you would do just in the procedure immediately as you see the stenosis? So a couple of things, a couple options. If you have fluoroscopy available to you. Sometimes injecting may be helpful to kind of delineate how bad of a tear it was, et cetera. Sometimes we've done that. Another thing's the closure clips we showed before. That's one option to close, either with something like Mantis or one of these bigger clips or even some of those over-the-scope clips. That's one of the options that you can use as well. In the esophagus in particular, stenting is also an option here. Stenting is an option. You do want to give him antibiotics. Very, very good idea to figure out. Yes, always do. But it's very good to figure out exactly what the degree of the tear is. It might look like a nasty mucosal, it looks like a nasty tear. It's really deep. You can see muscle under there, but the fact of the matter is if that area's so scarred down that there's nothing leaking and actually the patient wakes up and they do perfectly fine. You're expecting some mucosal tear. It's those deep tears or you see a hole in there. That's when you start becoming a little bit more worried about it. You see a little bit more of the muscle. Yes. So in the esophagus, stents are fantastic. They can close things or even temporize things so that you're not immediately running over to getting this patient to go through surgery or getting your advanced physician over in there and trying to fix this and help you with it. You can at least temporize it. And I think that it's important that most physicians, most GI doctors be able to use at least a basic esophageal stent, okay? All right, so we have a stent right here. This is one of our Boston stents. This is the Agile esophageal stent. This one is partially covered. I believe Boston's, the coloring on the package will tell you if it's fully covered. It was, yeah. Fully covered are the orange ones, right? Are the orange ones. Yeah, yeah, yeah, yes. The partially covered are green. The reason I asked the rep to bring this partially covered one is this. They have something called a Walflex, which is these long ones, and they have these Agile stents. And these Agile stents, the 18 millimeter, actually can go through your channel. So you don't need to go and get fluoro on board. You don't need to do anything else. You can just kind of get it and put it through. Now, it does need a therapeutic upper. So you might look to that. See a tear. You're using a regular upper endoscope. You switch over to a therapeutic upper, and you're able to kind of work that way. So, you wanna open this one? Let's do it. All right, here we go. I have a therapeutic upper. He's already, yeah. He's already prepped for this one. So this is. That wasn't planned at all. I know. So, there's a, the width that's listed on here is not the flange width, okay? So, make sure you check the measurements and whatnot. As I understand. Yeah, sorry. So this one's a 18 width by 119 length. And then the flange actually itself opens to 23. So, all right. And the idea, so there are covered, uncovered, and partially covered. We talked about this. Migration is a big problem with stents. And if you don't somehow tack it to the mucosa, and this is not a cancer. Obviously, this is not a cancer. And I should say that we are using this off-label. This is not on-label. These are indicated for use of malignant strictures. That's what they're really supposed to be doing. But we're using it off-label to try to help avoid a surgery and get patients to kind of get there. But you do need some kind of, if it's, especially if it is a benign stricture of some sorts, you need something to prevent it from migrating. Otherwise, within a week, sometimes within a few days, that stent is gonna migrate to their stomach, and then they're gonna have the same problem that they had before. Or worse, they're gonna start having stomach pain and a GI bleed because that stent is rubbing around. So, the unpartially covered, they actually have areas around the ends that are uncovered. And those can dig into mucosa, and they will reduce the chances of migration. These will fit over a wire. There's a channel for the wire to come through. But my question is, do you wanna show this on the model, or do you wanna show this in real life? We have it there. I think we're okay. Yeah, you're already there. Right, okay. Yeah, we can get it out if necessary. So, I guess it's 10 French, right? That's what it is? Yes. I do try to wet my equipment just a little bit, or put a little bit of lube on it so that I can kind of get it through. Some people will use cooking spray as well, off-label as well. But if you wanna use an on-label, something they have in the OR, it's a mineral oil that would be used. I do these over a wire. I never do this without a wire. I don't know if I have a wire right here, so we're just gonna- I have not seen one other than the wire. We could probably take the wire from the CR balloon, but in the interest of time, we're just gonna go ahead and- We're just gonna show you, yeah. Yeah, and then you can show the delivery of the device. So, have the techs, I usually have them kind of stand a little farther away, give you a little bit more room, and you kind of hold it sort of towards your torso and one hand on the delivery portion and one hand on the other part. So, I'm not ready yet. I'm gonna put in there. Now, this is a long stent. This is 120 centimeters, right? Yeah, pretty much. Oh, sorry, 12 centimeters. 119. Yeah, 119 millimeters. And so, I have to kind of get it down there pretty much. And plus, these stents are made, they're kind of, they're squeezed down so they elongate as well. So, you're gonna see this looks like a very long stent. You're like, wow, that's way more than 12 centimeters. Just try to get it so that the stricture is somewhere in the middle of that. Also realize as these stents are higher up in the esophagus, it will cause more discomfort to the patient. So, you kind of have to kind of get it from there. All right, good. There is a point of no return that you will see. Yeah, so. It's marked, yes. Go ahead. All right, so go ahead. All right, so we're gonna do it. So, the way we're gonna deploy this is that, like she said, she's gonna pull this back. This is covering, what she's pulling back is actually this over catheter that is covering the stent that you can see in the, on the image of the endoscope. And so, as she's pulling that back down, if I hold it here, guess what? That stent is gonna start moving forward because she's, I'm not allowing the tube that's covering it to come back. So, I actually have to match what she's doing and pull it back while she's deploying. A lot of times I'll say, okay, so deploying, deploying. And then you can see it's moving forward and I don't want that to happen so I'm starting to pull back from the endoscope. Keep going, keep deploying, keep deploying. And now we start to get this rhythm going. Okay, good, keep going, keep going, keep going. Yes, you can watch it on screen. And you can watch my hands here as well. And you can see that I'm pulling back as that's gonna, she's deploying that. And we're trying to work on this together. A lot of times the final deployment, it will move forward. So, I tend to be a little bit further back on some of these stents. I don't know if that's been your experience. Absolutely. The flip side is that if you deploy it further, sorry, I'm gonna stop you, stop. If you deploy a distal, as in distal in the lumen, then you can always pull it back pretty easily. Whereas if you deploy it too far forward, it's very hard to push it back out. Absolutely, okay. All right, so let's keep deploying, keep deploying. Deploying, deploying, almost point of no return here. Okay, good. And point of no return. Okay, and I don't have a good sense of where I am but I know the stricture's further down so I don't have to say, okay, you know what, let's stop, let's redo this. I might pull back just a little bit. It is a very long stent. Yeah, and then we'll put it. Deploying, deploying, deploying, deploying, here we go. And you'll see it actually unfurl right in front of you here. Watch the endoscope image. Going slower, slower, slower, and almost there here. I'm going real slow as best I can here. Should open, I see it opening in the distance. All right, sorry, that was my fault. It's all right. Okay, keep going, keep going, keep going. And here we go. There you go, okay, good. And there it is. All right, and there it deployed. And that's able to cover things pretty good. Now, if this is an emergency situation, I'm using a fully covered Agile stent to go through this. Yes, because you plan on removing it at one point. I plan on removing it. At least it can kind of cover things for right now. Even if it's removed later that night or the next day or something, that's okay as it oftentimes will prevent the emergency, prevent the problem from happening. We do have a question from the audience. Do you typically use fluoroscopy for stent placement? So if I have it planned, I will use the stent. I'll use fluoroscopy because I know, hey, I'm gonna use the thing. I often, I'm very liberal about dilations. I will do them with fluoroscopy whenever I can because I never know when I'm gonna have problems. We're both interventional GIs, so we sometimes will get the more complicated dilations where it's been dilated a few times. Maybe even she's had a perforation in the past. They come to us and they're like, well, can you please dilate again? And I'm like, great, thank you. I will do it though, and then I'll be ready in case there's any problem. Or like in this case where I couldn't go further down, I really like to use fluoro to make sure that I am in the right lumen. I've had to deal with other people's complications where they just went and put a balloon through and they didn't know and they ended up dilating through the wall of the small intestine, and that's never fun, no. So I tend to use fluoro if I know the stricture is smaller than the scope. That's sort of where I'm at in terms of whether I decide to do the dilation in an outpatient surgery center versus on the fluoro table. That's sort of my decision making when I see, encounter esophageal strictures or other strictures, so. If it looks good to you, leave it alone. Don't do what I just did, which is trying to go inside and mess with it because you can start moving it around. Don't, do as I say, not as I do. Take a picture and then. And then mess with it, yeah. Good, any other questions? Any other questions? Okay, all right. How to remove this? We'll just remove it while we're here, right? Yeah, yeah, yeah, we can. We can always reuse it again. So we don't have. We could, you wanna put a mantis clip? Yeah, yeah, yeah. So we don't have a alligator clip, sorry, alligator forceps or anything like that right here. So, and this happens a lot of times as well. Knowing the equipment and seeing what your facility has will allow you to find alternatives to what you might be able to, what the proper thing is to use. So if I don't have the right clip, I could be like, okay, well, what are the alternatives? If I don't have any clips at all, it's like, oh shoot, what do I do? And then you might realize that, oh, you know what? What's, I have an endo loop. Maybe we'll use that. Or a snare. Or a snare or something, just to kind of put some pressure on it and then decide what to do. So know your equipment, figure out what needs to be done. A lot of this ends up being off label. So, and please, please, let me make it clear. A lot of the things that we end up doing here are some of the stuff we're showing here is off label. So please don't, please don't realize that this is not the way it's intended for use, but it works and it helps you. So let's see if this works and then we can get that stent out. And if not, we have a snare too. Okay, so these snares, they have a suture that you can see that. That suture they can see that goes around the end of the stent. It's a drawstring. Yeah, it really is, it's just a drawstring. And so I have to be able to pull that drawstring. That's all I can do. And it closes down the end so that it comes out very easily. Remember that the end part is bigger than the actual measurement as listed on the stent. See if you can open it partially. All right, let's see here. I can't remember if the mantises are easy to open partially. You can open it wide and then close it down a little bit. And I'm gonna try to go right into that. Good, and it's closed right there. And see now we got that drawstring. Let's see if it pulls it down. Oh, beautiful. Oh, beautiful, look at that stitch. And it's able to pull it down. Actually can pull it into the channel even with this stent. But you can see the covered part and the uncovered part right there. Uncovered part close to us and the covered part to this way. But you don't have to pull it all the way through the channel. You should be able to then slowly start pulling it through. Pull it out with the scope itself. And then come all the way out. It'll give you a little bit more traction to do it this way sometimes. Yeah, and plus that drawstring can break. If that breaks, then you're in trouble. That's broken before. Yeah, that's why I don't try to pull it through the channel too often. Mostly for that reason. Okay, good. There are other stents that you can use. You can see it. The Axio stent. It's a lumen-opposing metal stent. It's one centimeter. But sometimes for very localized strictures that have perforated, it can help a lot, right? And asthmatic strictures, I use the Axio stent for. Again, off-label indication. All right, good. All right. Last thing, closure. All righty, so. Okay, so I'm gonna go through here again. There's a little stricture. I can go through it again. Okay. All right. The last thing we're gonna talk about is closure. Now, we're gonna leave that alone. That could probably be, again, use another clip right there. But let's find another. There are some other sites here that we should be able to kind of go in there and find a polypectomy site. Or sites, I'm so sorry. Actually, that one right there, maybe? Yeah, right there. You can kind of go in there. There was another one, big one here, but maybe that's not. It's not, it's right on that thing. So it's right on the fold. So it's not easy. Here's a good one. All right, so we're gonna try to open, try to close that, all right? Now, closure in itself, closure of a polypectomy site itself, it has distinct advantages because you have late, especially with all these more kind of complicated, bigger polypectomies that we're doing piecemeal cold or an ESD or something, it reduces the chances of delayed perforation and the chances of bleedings. And that's great. If your patient doesn't have to come back to you in a week, that's great. And so that's what we can try to prevent. And so this, let's say this was actually bigger than this one is. This is actually, let's say, two centimeters. Very good reason for me to close it. You also wanna close lesions that are in areas that would bleed a lot. So you can imagine where is there a lot of blood flow, where there's problems. Stomach has a lot of blood flow. So if you've taken a polyp out, there's a good chance that it will bleed right there in front of you, but also further later on, it could cause, have a delayed bleeding. There's a lot of blood flow. And then data shown actually in the rectum. Rectum, because rectum is dual vascular supply as well. Exactly. And the benefit of closing these sites is actually much more in the rectum than it is on the right side. There are also more tools on the rectum that we can use versus on the right side, but that's a whole different conversation. Okay, good. So I'm gonna have you scope here. All right. What's, how do you wanna close that? Or do you wanna, we showed clip closure. You want to show it again? Do you wanna show, I think from timing, I think you probably should show X tag. So I'm gonna let Watts take the lead here. He does, this is what he does. I'm actually gonna, yeah. He's gonna walk me through it. So this is a little bit different because I do not do bariatrics. I don't do third space, which is where a lot of these techniques have come in to play these days from that part of interventional endoscopy. So. And it's not unusual that some of your attendings might tell you, you're like, oh, why don't we use this? And you're attending is like, no. No, I'm not used to it. Yes, yes. They're not used to it. They don't know it. It's not a great reason or excuse, but it is important that they need to be comfortable with it in order to know how to troubleshoot it, all right? So the X tag device, you may have, let's step back, closure again. There are multiple ways of closing things. We talked about the clips, a fantastic way to close things, but the clip is really limited by either the size of it or even mantis. Sometimes it's able to pull things over, but it's not able to pull everything together. And it becomes a little bit difficult sometimes. And so there are better devices to close bigger areas, including the suturing device and the overstitch. Guys might've seen it, you might've used it. And I doubt there's anybody out there that touched it for the first time and was able to get it fully properly functional and get a full closure done without crying or having someone really help them and walk them through it. So it's a complicated device. I teach people about this a lot of times and I'm teaching them how to do the overstitch device. It's not easy to grasp all the steps and be able to do it the first time. So the idea of the X tag was to actually, let's make a system that is simpler, that can go through the scope. As you may recall or may know, the overstitch device can only be used on an upper end of scope or a dual channel upper end of scope so you can't really use it on a colonoscope. So if I'm on the ascending colon, a big polyp area, I can't use that, but I can actually use this device. It comes in short and long devices. I have to make sure that this is the actual short. Is it using the shorter ones? I have a 160, yeah. Yeah, 160, perfect. This is how it comes packaged. It has a tab and it has these, I don't know if you're able to, let me take it out first and then I'll try to show the tabs that it comes in here. It does come with very annoying packaging. The tech will be like, you're like, get it out now, and the tech's like, I'm getting it out, I'm trying, it's just. Okay. Yeah. So the first is this part. This is kind of just a holder that you put on the end of scope itself. Put it over the end of scope, put it somewhere that's nice and easy for you to reach it. This goes around the channel and then right back down and then holds that in place so it doesn't go anywhere. All right? So it looks like this. And you'll see right now that there are, the device itself, it has, it comes sort of preloaded so it's almost ready to go. It has an overtube or sort of a tube that, and catheter that protects the channel. So before we do that in there, I'm gonna pull it out and let's see if I can, oops. Did it come out? Yeah, no, I do, but I need to. So let's just show it that way. Okay, so you can see, I don't know how far you're able to zoom in, but it essentially, it's like a helical device. It kind of just burrows into mucosa and the idea that it's supposed to go deeper into mucosa and go actually into the muscle layer. Not full thickness, but at least a muscle layer that it's able to get into. And it comes in with this device. It's a sort of a Persian drill. So you're able to pull it down and you can see that that thing is screwing in, that end piece is screwing into tissue as you're kind of going down, all right? And then you can kind of undo it as well if you go forward, all right? So that's the idea. We're gonna go put in there. There's a suture on these and on this tab, there are four more of those anchoring sites. And so it's gonna take those anchoring sites and it's gonna go one, two, three, four around a perforation site and then we're able to close it, all right? The reason I have this tube is to really to protect the channel. Because if I just put this right now as is, it can scratch the channel. Yeah, so let me try to pull it back and then let's get it in there. So through the biopsy port. Through the biopsy port. Now I'm gonna put it through the biopsy port. A lot of times people might think, okay, this is pretty big, I wanna open it up. You don't have to open it up. Just keep it through. If it fits nicely, so. Yeah. Because it'll allow you to insufflate. Otherwise you may not be able to insufflate. Okay, so it's gonna go, go, go. It should go all the way down without showing. Okay, so it's all the way down. It's all the way in. Okay, great. Now it has this orange tab. You just pull that off. And what that does is that kind of releases it so that now you're able to move everything. Don't worry about that. Don't worry about that? Okay. Yeah, you can take it off, but it's okay. Now I want to get these tabs in place for us. So I'm going to get these tabs, and you're going to put it on that holder, the platform. So it slides in. Okay. It's got sort of that landing strip as well. And then what do I do with this very long string? So your tech, if it was a good tech, would be able to pull that for you, but you can just kind of put it on the side, and you'd be able to kind of go from there. So I'm going to hold it here. Now if you look at the actual site... All right, which one do you want? This one maybe? So whichever one you want to do, but the way this really works is that you really want to put four corners around the NS, around the opening site, to be able to close it down. So you can imagine the four corners that you want to do, and you want to kind of plan it out a little bit better. What do you think? If you look at it, and if you're able to show the screen, I don't know with the camera, because I can't point on it. I think what they're seeing right there. Yeah, but well, you know what? It's okay. If you don't mind, I'm going to grab this. Show this. So for this, I would actually... Let me see if I can pull it. Maybe you can use the helix itself to show. Yeah, exactly, exactly. So I would probably go about .5, so 5 to 10 millimeters away from the site. So maybe right about here, go into the first one, and then kind of go make a box around it. Two, and then three, and then four around here. So that's one, two, three, four in a box form. But you can also cross it. One, two, and then you say, okay, I'm going to go. The next one's going to be here, and then the last one's going to be here, four. Okay. So like a Z shape? Yeah, a Z shape. A Z shape, yeah. Yeah, it's kind of making it, or you can even cross one, two, and then three, four. The beauty about the X-TAC is you can be a little bit flexible with it if it's a weirdly shaped closure that you have to do. Maybe this was a long line that I had to do, so let's say this one. I might even say, okay, I'm going to go one, two on this side, and it's almost like a running suture, three, and then four. So it's kind of a zigzag running suture over around that thing. So you have the flexibility of doing whatever you need to do. I'll leave it up to you how you want to decide for this one. We'll figure this out, yeah. Okay? All right. So, all righty. So let's do this maybe. I'm trying to get a good look. So sometimes, and I think we do this for polyp removal, when we do lifting and injection, we try to get the hardest part first. So that's why I'm like, how do you decide which one to do first? I do like to do the hardest part first as well. There are nuances that you can do. I think you can go to the easiest part here, and the reason I say go to the easiest part is because, in this case, it will pull all of that tissue up, and it will make the hardest part a little bit easier for you. So maybe we'll just do what's easiest. Maybe down here, and then we can go up. Maybe a little bit further away. Just a tad bit further away. Sorry, away from the actual. Yeah, from the lesion. Yeah. So maybe here. Yeah, I think that should be okay. So I'm trying to get a little closer to the lesion. I'm sorry. Yeah, you're retroflexed a little bit. I am. So in the stomach. All right. Here we go. So maybe here we go. There. You'll realize it's right there. Right there? Yeah, that's good enough. All right. So now if you see the Persian drill, and you can watch the screen as well, I'm going in through it, going in through it, going in through it, going in through it, and it's kind of closing things down, and you can see it's burrowing in. I see that. Now, this is a pig model, so you can actually keep turning it manually if you hold this together, just because I don't know how much it's going to be able to go through. So you can see it's already burrowed because I'm pulling on the catheter backward. Okay. So then I'm going to go ahead and deploy. By deploying, I put this button forward, and then I'm pushing it away. All right? All right. What happened? There it is. Beautiful. You did your first one. Yay. Okay. All right. Now I reverse it. Okay. And now you're going to pull out all the way with this catheter. Okay. So we'll pull the metal all the way out. Put the metal all the way through. The reason is that you need to grab the next tack. The next tack. The helical tack. Got it. So let me see if we can keep this one in view. All right. And then you just load this. Mm-hmm. This way. Mm-hmm. And then until you hear what? You hear a click. You hear a click. Okay. Good. You heard the click? Yes. Okay. And we can pull it out. That's okay. So this happens. So, yeah. So what happened is that we heard a click, but it didn't really go in. So it deployed. Let me see if I can show it to you the best way. Are we able to zoom in on here? All right. Can you connect more than four tacks before cinching? So you can't – technically, yes, you can. The problem is that it doesn't come – this kind of – this tack system doesn't come separately. When the company was originally making it, they were going to make it so that you could buy an extra tack system and continue to put through. It doesn't come separately, so you really have to open an entire system. At that point in time, it becomes much easier just to go ahead and tack it down, see where the problem is and where you need to do more, and then bring out the next one and continue tacking along. So you don't use the same suture as well. You use a different suture. Sometimes it's better in case one suture breaks. You're not going to ruin your entire closure. Okay? All right. So I'm going to hold this for you like a wire guided. I do like to push on this a little bit. It's not sharp at the end, so you can just push on it a little bit just to make sure it really is down. Because if you end up losing it in the channel, that's a little bit of a problem. That's not fun. All right. And then we'll go down again here. And I'm holding this straight so that it doesn't get curled inside and cause problems. Okay. So let's do that. Okay. All right. Okay. All right. Fantastic. So let's pick a different spot. So you said – Right there? Okay. Good. There's good. So you need a little bit of slack, I think, with the suture. Let me get a little closer with the scope if I can. It's just that you're retroflexing at that point in time. I know. It is pig stomach. So let me see if I can – This never happens in humans, though. No, never. Never. I always pick the right spot right away. So let me see if I can – Perfect. It should be okay. Yeah. And then we'll just show a basic sense of it, and then they'll have an idea. Too far. A little too ambitious there? Yeah, a little bit too far. I can hold the scope for you. Yeah. Thank you. Okay. This part? Or do you think I should just go across? Whatever you want to do. I think that should be – That's – Go a little bit higher. Here? Right there. Push on it. Push on the catheter. Push, push, push. And I'm going to go ahead and – It's a little farther away, but – Yeah. And I'm going to go ahead and deploy and see what happened there. Okay. Pull it back. Pulling back? That's something. Did it come out? I don't know. There you go. There it goes. Okay. Got something there. That's something. That's not as deep as I wanted it to be, but it's okay. Okay. So let's see if I can get a third one. So you can come out with it completely? Come out with this one. And we'll try to load this third one a little bit better here. Okay. Yes. You got it? All righty. Let's see if we can try this again. There. You hear the click? Yeah. Yeah. See if that just comes right out. Yeah. There it is. Okay. And I do like to touch it each time. Yeah. Okay? Okay. Getting sort of the hang of this a little bit. I'm going to give you a little bit more slack than I gave you last time. Yeah. Yeah. Okay. Let's see. Do you think I should get the sort of 11 o'clock area, or should I get the cross side? Side of the first one? So I would probably go just right here. Okay. The last one you can do over there, and close it down nicely. Sort of a backward C. Yeah. I'm giving you a little bit more slack. That's good. Okay. Thank you. Okay. So kind of here, maybe. Mm-hmm. Okay. That should be good. Okay. Pushing? Yep. There we go. I'm going to continue going, continue going, continue going. This one I'm trying to make it as deep as possible. Trying to give you a little bit more traction. Okay. I'm going to go ahead and deploy. You're okay? Okay. Yes. All right. Good. I'm going to come out and get the next one. Yeah. Yeah. The other beauty about this is that I actually, while she's getting the next tack in, I can show you that you can kind of see what your work is doing as you're coming along, and you can realize that, you know what, it's getting half of the thing down, but maybe I need, that's the area that I still need to kind of address, and so you can kind of go ahead and do that. Got it. So it's sort of top corner there. Yeah. Yeah. And so we'll do that, and then we'll kind of show from there. That's really nice. So I think I've been finding it really helpful to just hold the little plastic thing when I'm loading this, and then. Perfect. Gives me a little traction here. Just right across from all the other ones, if you can. Yeah. This right here, hold on. 11 o'clock where you had it before, yeah? Yeah, right there. Okay. You want me to go there? Yeah, go ahead. Let's do it. Do the Persian Trill, and then I'm gonna continue to go in because it is... Pig stomach. Pig stomach. And then I'm ready to deploy. Okay, go ahead. Okay, pull it back. Good, and now we're gonna come out. Now... This is not gonna be fully closed. I can sort of sense it from the thing. Yeah, and it's not a bad idea. There is an idea of using multiple modalities, and so we might even, if we, well, we barely have enough time, but so, yeah. It'll actually, we'll be able to close some of it. Some of it. Some of it down. We'll see how it goes, okay? So the next thing is that you need to tie it down. Now, unfortunately, I can't tie it down and put it all the way down, so what I use is a cinch. Essentially, it's a device that is able to put a capsule there at the end and then really make sure that it stays in place, all right? So here's the cinch, okay? For those who used overstitch or have seen overstitch, it's the same cinch that you're gonna be using with them. It does now come in a short and long form, so it uses, for the colonoscopy, you can use a longer cinch. This should be just a standard cinch. Oh, final rotation after break. We're doing great on time. Yeah, I know. All right, time wise. So maybe we can put a clip on there just to kind of reinforce it. All right, so the way that this works, you'll have to practice this at home or with your, anytime you use an overstitch device, but it had a little tab in there that it's able to pull the suture through the catheter, and so you put it through this tab and you kind of put it all the way through and you let it go. People have a very big tendency, and I don't know why, they just have a tendency to hold that suture. It's not gonna work because it's gotta pull the suture through, so I just let it go. And if it comes out, not a big deal. I just put it through again and then just kind of get it so that its location is good. Doesn't matter which way you do it as long as it goes through that area, all right? And then what I'm doing, I'm not holding it necessarily, but I'm just kind of holding that and it's pulling, I think people can see it here. It's just pulling that suture down and being able to see exactly what's going on. All right, perfect. It's coming through, it's coming through, and now you're using the wire essentially like a guide wire. Using the suture as a guide wire, I apologize. There you go, okay. So I apologize, we made a mistake. I made a mistake in telling you what you needed to do. And what happens is that if you've done this, and what'll happen is as you're kind of going through, you say, okay, I made it, I made it, I made it, I made it, I made it, and I can't go in here. Uh-oh, what's going on? So we need to take that whole thing out on the last one. And this is recorded, so yeah, some people are gonna make fun of us for this, but that's okay. But this is how you figure it out sometimes. If you know how it works, you'll know what the problems are and how to fix them. That's not that big of a deal if you're like, oh, okay, that's just there to hold it in place. There's no end to protect your scope, so it's not a big deal if you need to put it back out. I'm not gonna show you how to do this without the tab, but it's pretty easy actually. In the meantime, next question. If using X-TAC for closing a fistula in your practice, do you APC the margins of the defect first? And if you do, selectively, when would that be? Okay, I tend not to use X-TAC for fistula closure. And the reason is that it's just not as strong as using overstitch. I'm not able to get as deep of bites, and I prefer not to use it. But there are times when I do have to use X-TAC. Mostly it's because of the location. I'm not able to get it to a location that overstitch can get to. In that case, yes, I still will use APC. And the concept of APC is that you wanna burn the margins so that when it heals, it's not pulling mucosa back to mucosa and never healing together. Like if you put mucosa to mucosa surfaces together, there won't ever be healers. It will always be mucosa, mucosa, and it'll open up whenever you kinda let it go, right? If you denude the mucosa, then it actually heals itself. And you're able to actually close that fistula and get it to kinda cover itself. Great, fantastic. All righty. Okay. So here comes. So now you gotta use, you need your third hand. Do you have your third hand? No. So what you do is, just for ease's sake, I'm gonna take this off for you so you don't have to deal with this. Just hold it up against your chest. Okay. And then you're gonna hold this hand, you let go of this hand and just hold, your wrist will just hold the scope. Okay. Okay, so now you hold the suture. And the suture's gonna come back at you. And this, you need to make sure that the cinch does not come back at you. Okay. I'm gonna suction you down a little bit. Yes. So I'm pulling the suture tight. While making sure that the cinch doesn't come back at you. Yes. And. Okay, now once it all comes back together, there's no way you can pull it any tighter. Those four things are close to each other. I just need to go ahead and cinch it down. There's a little protector here that doesn't prevent me from doing it accidentally. I just push it forward, the protector goes down, it goes away, and then I'm able to kind of cinch that down. And then you hear a click, that's the suture being cut. And once the suture is cut, it should. There you go. And then you should be able to pull it up. There it is. There you go. There it is, nice. Fantastic. All right, so let me get a view, show you the view of it, right here. It's actually a pretty good closure. Sometimes you get surprised. You're like, wow, I kind of actually pretty much closed it down. But perhaps we can use just a clip. At the top portion. The X-TAC brought a lot of the margins together, and then you can use a clip to say, okay, you know what, I can do that final adjustment and cover the areas completely. Any particular clip you want? You think you can get away with the resolution? Whenever it's available. There's another clip that I think is useful that we don't have to demo here, but there's another one that it opens. The two ones that open, the DAT clip, the D-A-T clip. It has essentially, it's kind of like Mantis, where it's trying to pull mucosa together. What it does is that it has two separate openings, and then they're able to then, so you're over the one side and grab the tissue, and then come to the other side and grab the tissue on the other side, and then be able to kind of close it down. The prongs are controlled separately. They open and control separately. I'm just gonna give you a resolution 360 if you're okay with that. That's fine. You use what you have. So. And. All right, no other questions I see in the chat. Let's see here. Okay. Oh, let's see here. All right, and open for me. This is a close or small, we could have used a. Deploy. Let's see here. Can't see it as well. Maybe one more under. Maybe one more. Yeah. Let's use the resolution ultra. That's a bigger opening, so you might have a little bit more success in bringing those two things together. We should have. We should have. There it is, there we go. I was about to say, sorry, doc, that was our last resolution ultra 360. That's our last clip, but it's okay. Come on, why don't you guys order these things? Yeah, usually you will have some, bunch of different ones. Dr. Ho would have been yelling at me. No. I'm like, sorry, sorry. No. We don't yell, we use our inside voices. So. Yeah, I'm just kidding. Okay. And so you can see automatically already that it's different. Open. Okay. Little bit of a wider wingspan here. Okay, close for a second. Let's. So now you got the other clip out of the way, you know, in the way, and that's not unusual. Open. That does happen. Sorry. There we go. There we go. Okay. And. Close. You're completely in. Open. Hold on, open. Yeah. Maybe rotate it. Maybe this way. Yeah. Close. Oh, beautiful. Okay, good. Release. All right. Released. Beautiful. And then you can continue to close. Yeah, you can continue to close it. We'll. Interest of time here. In the interest of time, we'll stop this and kind of go from there. All right. Fantastic. Any other questions from the attendees? Speak now or forever? Hold your peace. All right. Well, thank you for joining us. It's been our pleasure to help you understand these equipment. This is just the beginning, obviously. There's a lot more nuances in this equipment. There's a lot more that you guys could learn from your wonderful attendings who are training you. Ask them questions. My big thing is just look at the equipment. Especially when the attending is like, what are you doing? And takes the scope away from you. Not that they really say it that way. They say it nicer. Right. Let me take a look at this. Yeah, yeah. But then go and look at the equipment or tech. That's a very, very good thing that Linda mentioned. Yes. And you can always ask your most seasoned techs too to go through some of the equipment with you. They're happy to teach you. When you're out job hunting, as you guys are looking, be sure to kind of look around, see what they have equipment-wise, see what vendors, see what type of equipment, see how long their techs have been there. Those are the kind of things you look for when you're out interviewing for jobs out in the practice area. Oh, being in an area with experienced techs. Oh, that's fantastic. You're all like, oh my God, I don't have to do anything. It'll spoil you, but man, it's really nice. But being with inexperienced techs, you have to train them to do everything. So yeah, good point. All right, thank you very much. Thank you guys. Take care. Bye-bye.

GI techniques

polyp snares

polypectomy

hemostatic sprays

balloon dilation

esophageal strictures

fluoroscopy

perforation closure

stent deployment

medical equipment

gastroenterology