All right, well, welcome back. We are now going to talk about some of the devices that we have in place. I think Dr. Neil Gupta will be talking with Dr. Shifa Umar about a few of the different devices we have available and we've been talking about today in separate lectures. We're going to be going through some of the EMR concepts, hybrid ESD, the devices we're using for full thickness resection, and the fibrotic polyp. Good afternoon, everyone. Welcome to Downer's Grove. I'm here streaming live to you from the audio visual room of the IT&T Center. My name is Neil Gupta from Loyola University here in Chicago. Hi, I'm Shifa. I'm the advanced endoscopy fellow at the University of Chicago. And today, hopefully over the next two hours, we're going to try to bring to you the same experience of getting to see the various hands-on techniques and tools that all of your colleagues who have attended in person are getting to see in use right behind me in the IT&T Center today. So a couple of housekeeping things as we get started. So we're going to go over a couple of things and we're going to try to demonstrate to you a couple of different tools and techniques. One being kind of the standard EMR, second being a hybrid ESD, third, we'll be going through a couple of ESD devices, including some over tubes and lumen fixation devices. And then also we'll be going through to show an endoscopic full thickness resection device and procedure. So before we get started, two rules. If this is your first time coming to the ASG virtual hands-on club, first rule of the virtual hands-on club is ask questions. We're here to answer and give as much information as possible. So you can ask questions on the chat. So please let us know what questions you have and we'll try our best to answer as much as we can. And second, tell us what you want to see. So we've got some things here on the agenda, we'll demonstrate that, but really tell us what you want to see. And if we can show it, we'll try our best to demonstrate that for you today. All right. So with that, let's go ahead and get started. Shifta is going to go ahead and grab the scope and we're going to go on down into our pig stomach and we'll start with an EMR technique. All right, we got the light going on. Perfect. So as Shifta is getting things down, I'm just going to go ahead and open up just a standard injection needle. So if you can see that, nothing special here. This happens to be a 25 gauge Olympus injection needle, but really nothing unique about this needle has a certain gauge. This one 25 describes kind of how far out from the tip of the device the needle comes out. And so I'm just going to go ahead and open that up, because really, as we get down one of our first steps of doing an EMR is going to be our submucosal injection to separate out the lesion from the muscularis propria. So I'm just getting this out and I'm clearly a very bad tech because I can't get things open. But all right, so I will pass this over to you if you want to go ahead and get that down. And if it's all right, we'll have you switch over to the endoscopic image so we can show you what Shifta is seeing. Now, as we do our lift, hopefully you heard a lot about this morning and already is a lot of different lifting agents out there. We're going to show one here to start with, which is a kind of a more of a thicker agent, so not just a normal saline. But this is the O-Rise gel, which is a Boston Scientific proprietary submucosal injection solution. There are a lot of other ones out on the market. I think every major company has one now these days, all with their proprietary substance used to lift the agent and a inert dye. And so this one you can see already prepackaged in a syringe, has a nice kind of blue tint dye to it. And so you can see the each package comes with two syringes here. And so we'll just go ahead and use this one to kind of start with. One thing you can do is you can kind of see the viscosity in the syringe. If you want to mess around, all of these have different viscosities to them, slightly different, but they're all meant to be pretty thick. And it's a pretty viscous one out there. And there's kind of pros and cons to viscosity. So I think I'm going to go for this spot here and try to lift it. So needle out. OK, needle out. Inject. All right, injecting. Oops. Injecting. Nice. All right. And you can see that nice submucosal blob that we're generating. All right. One through one syringe, let me get you another one. Injecting, injecting, injecting. All right. How's that? Is that good? I got 20 in there. Needle back. OK, needle back. Let's see what we've done. I think we have a good lift here. OK. Give me a snare. Snare. Would you like to lift some more or? I think that looks great. You know, for our first one, we'll go ahead and snare that out. We're just grabbing a snare real quick so I can get that from you. As we're waiting on getting a snare, a lot of different snares out there. Now, if you've heard me speak before, this is going to sound repetitive, but, you know, my approach to snares is they're kind of like samurai swords. You know, you don't have to master all the swords, but you got to find one that you're really good at and like master that one. So for me and my practice, I've used the same snare for almost every one of my EMRs over the last 10 years. It's extremely, extremely rare that I've switched to a different snare. You do want to find a stiffer snare. And one challenge that you'll have is you'll look at packages. So here's just a package that we just grabbed. This is a Boston Scientific Captivator snare. And if you see on the top, it does say some things. You know, it says the diameter here, 15 millimeters as a length of device. And it happens to say, what does it say right here? It says 15 millimeter rounded stiff. All right. And so it says, oh, yeah, it's a stiff snare. You know, and that's the case. But one thing to keep in mind is that there isn't a rating system for stiffness on devices. And so really what you got to do is you got to go out and feel them. So get them out of the packages, open up the snare, see what they feel like. So I'm going to open this one up. I'll let you feel it. I don't know if you've ever used this guy. Yeah. Kind of feel that. Yeah, it's pretty stiff. All right. Probably not the stiffest thing that you'll ever see on the market, but you'll have to kind of take a feel for it. So let's go ahead and use that. And so, Dr. Gupta, do you have a preference for a size of a snare that you use for your EMRs? Great question. So, you know, I try to go as big as possible when I'm doing my EMRs. I'm looking at a lesion and I'm first making decision right up front is whether I want to try to get it on block or whether I'm intentionally planning this resection as a piecemeal resection. And so generally, if you get something on block, I try to do it. And so I'm using at least a two centimeter snare, sometimes a little bigger. And that's the snare I'm using. If I'm doing a piecemeal resection, I go a little smaller, especially when I start doing subsequent bites and you're getting cleaning up edges or other parts of it. You'll often need like the bigger snare doesn't help you. You need to go to a smaller snare. So, yep. Thank you. So I'm thinking to go over this distal margin and start from there. Start my resection on the distal end right here. OK, I think that's a great thing is important tip that you just saw or demonstrate, which is to kind of plan through your resection, plan through where you're going to place your snare tip and how you're going to go ahead and try to grab this lesion. Very important to learn over time to visualize how to do that. So. And we're set up, we're set up and we're ready to go, so. Open. OK, so I'm opening. I'm opening. All right. Open all the way. Close slowly. I'm closing, closing, closing. I'm snug. Cut. Cut. All right. Very nice. And this is a good demonstration. You can see here that nice blue tint of that proprietary injection substance, similar to anything else. He's kind of staying with methylene blue. Shows you that nice blue tint of the submucosal layer. And so you can see you got a nice rim of submucosal still sitting underneath your resection base, meaning that you've got a nice, safe resection there. And so obviously didn't get the whole lesion. And so we'll just keep on resecting here. Open. All right. So I'm going to go ahead and open. Open all the way. And great demonstration, she's showing how to using that edge of that snare to place right in the resection base of the first piece. So that way we get a nice overlapping resection. Snug. Cut. Beautiful and perfect. So I'm going to have you show you can show that nice resection, two pieces. Right. That nice blue all the way through the base. Right. And so that way you've got a nice, clean resection with no residual stuff in there. All right. We got a great question. When doing band EMR, do you prefer to cut above or below the band? So there is no right or wrong answer to this. I will answer with my personal approach, which is I always try to cut below the band. Part of that reason is I also want to try to make sure I'm taking out lesions on block or taking them out in as few pieces as possible to make sure I get a nice, full, clean resection. And so by going below the band, you get a little bit of a bigger piece. I also find a little easier to go below the band because that wall of the lumen and then the band, that separation, it finds itself a nice little ridge there. So you can basically put that snare there and it kind of seats itself right in between the two. And it gives you a nice feel, gives your tech a nice feel right when you're when you set your snare right in there and you can cut off completely safe to do below the band. Remember that rubber band, the strength of the rubber band is not strong enough to hold the muscle. And so your muscle there will always be underneath that band. All right. Just, you know, a follow up question. In which locations, the GI tract, do you prefer using band EMR? Fantastic question. So esophagus, band EMR, probably the most widely used technique in the esophagus for doing resection is the band EMR technique. Also can be safely done in the rectum. It's retroperitoneal, it's thicker, the muscle layer is stronger. And so a band EMR, you know, a safe technique to do there. If you're going and using the band EMR technique outside those areas, you have a little higher risk of being able to pull the muscle layer into the band and get yourself into a perforation. So doing a band EMR, let's say in the right colon, you do that, you should be prepared that you're probably going to have a perforation there doing it in like the fundus of the stomach. Also very loose, very easy to pull the muscle layer, you know, into the rubber band when doing a band EMR in that location. Duodenal bulb is kind of like a hit or miss location. You can do it. You can do it safely. But it is a little easier to perforate than the rectum or the esophagus. So if I had to rank my safety in my use of band EMR, esophagus number one, rectum number two, duodenal bulb, kind of my third one. And then everywhere else, I'm preparing myself that if I'm doing that, I should be ready to close that perforation. So perfect. Thank you. All right. So when do you add epinephrine to your lifting agent? It's a tough question. Once again, no right or wrong answer, I think, to epinephrine use. I think it comes down to picking your poison on bleeding. So epinephrine, it will be great anytime you add it to your solution or you use it during the resection. It's going to be great to prevent and reduce the immediate bleeding you get during the procedure, whether that immediate bleeding is severe. It's like a spurting vessel or a lot going on. Or if that immediate bleeding is just a lot of oozing. And if you've done resections, you know, in a human being, often you'll see a lot of oozing going on. And it just makes your life a little less clean. You know, when doing that resection, when you got a lot of oozing there. So adding the epinephrine to the injection solution will reduce those things. But as soon as that epi wears off and you start talking about day two, day three, day four after your resection, you're going to have a higher risk of delayed bleeding when the patient is home and no longer in your unit. And so that's where I say it's kind of like a picking your poison, adding epi makes your life a little easier, reduces your risk of intermediate bleeding, but it will increase your risk a little bit of delayed bleeding later on. So the times when I've used epinephrine is sometimes when I'm having to do resections on patients who have a higher risk of bleeding up front. Right. Maybe they have a platelet count of like 60,000 because they're cirrhotic or they have a bone marrow problem or this patient just had a cardiac cath and a stent. And their cardiologist says they have to be on platelets. You cannot stop the platelets while those patients are going to have a higher risk of immediate bleeding because of those other bleeding factors. So I'm more inclined to say, well, I really need to use the epi. But at least in my practice, if I'm using epi, then I'm at the end of my resection. I'm trying to take some additional efforts to try to minimize that risk of delayed bleeding when they go home. And that may be like things like prophylactic placement, prophylactic closure of the resection base with sutures or the extract or these are now these proprietary gels and solutions that are out there to cover up a resection base to help reduce the risk of delayed bleeding. I see. I mean, in my limited experience, sometimes with cold EMR, it helps with visualization. No, it's a great question. And that's that's one cold EMR. You have no cautery to help with you that immediate bleeding effect. And so the epi helps make your life a little easier while you're cutting away and have all this oozing going on. So, yeah. Yeah. Excellent. Yep. Yep. You move along here. Yeah. Let's take some more pieces. Let's have some fun with this. Open. All right. I feel like I've lifted it a little too much, maybe. Yeah, so it's kind of a funny thing. So just try to close here. I'm going to start closing. Oh, it's going to slide over. It's a funny thing. I always used to tell my trainees, if the question is, should I inject or should I inject more, the answer always is yes. Are you snug? I'm snug, sorry. Oh, nice. All right. So I always say, if you're not sure if you should inject more, the answer is yes, you should inject more. But you can make your life a little bit more challenging by over-injecting, by turning something that's flat and raising it. And instead of just raising it to be a nice little mound that you can snare, raising it into a giant flat thing that now is just raised flat. So instead of creating a little mountain, you've created a giant plateau. And that plateau has the same problem with it being flat again. Flat again. And it's harder. So sometimes, if I know something I'm going to take out in more than one piece, I've gone to more of an approach of saying, let me lift for that first piece. Let me create a little mountain. Cut out that mountain. And then let me create a little mountain right next to it. Cut out that next mountain. So that way, I've always got these little bumps that I'm cutting. And I have not created this raised plateau that is entirely flat again. That's a great approach, Dr. Gupta. OK, we'll try to open here and see if I can get this part. All right, so I'm opening. Yep. And we get another question. So any tips on directions in which you have to inject the lifting agent? Oh, this is injection itself is an art all of itself. And so I would say a couple of things about how to inject. I always try to plan out my injection by looking at the lesion and thinking about how I'm going to cut it out. And I would say my first word of advice is don't use the same method of injection for every lesion you do. Because then you will always run into problems. Each lesion is unique. So sometimes your injection solution and approach also has to be unique and tailored to the lesion of what you're approaching. So I think in the example we just discussed, some large, flat lesion that you're going to take out in multiple pieces, if you know you're taking out in multiple pieces, create yourself multiple bumps. Create yourself a bump, cut it out. Create yourself a bump next to it, cut it out, and move along that way, preventing that plateau effect. Some lesions go over a fold or have parts that are hard to see. That's a great opportunity to then use the injection on that part that's hard to see. Use the injection to make it more visible to you. Cut that part out. Bring it closer to you. Lift it and push it away from that fold. Get it out of that diverticula. Bring it around a turn so you can see it better around a turn. Get it to be visible. Don't lift the whole lesion. Just lift that hard part. Make it visible. Then cut it out and be done with it. And then move on to the rest. So those are some things about injection planning. You'll see in videos and on lectures, hey, do you start injecting and then stick the needle in? Or do you stick the needle in and then start injecting and pull back? I think it's about where you want to create a mess. You're creating a mess somewhere. You either create it in the lumen or you create it in the peritoneum. So you can pick where you're creating the mess. I don't know if anyone actually knows the difference about where messier is OK. It's the same. In follow-up to the technique you explained about injecting part of the lesion, one of the things that tells us that could this be a deeper invasive cancer is if it's not lifting. What if you partially lift it and then you realize that it's not lifting any further? Yeah, it's a great part. And I think one thing often to not get confused about, these pseudodepressions that you create because you lift and then you miss a spot and you think it's not lifting, but it really would lift had you just lifted additional in there. So my first approach is anything that doesn't seem to be lifting. I just try to make sure I've given it really good injection there to make sure it just doesn't lift. And then often, you'll start injecting and focused on that area, it will lift. And then you've realized that was a pseudodepression, not a real depression. I think you've underscored a part which is before you start cutting out anything using any technique, you need to really do a visual inspection of that lesion both with white light, potentially with chromoendoscopy, whether it's chemical chromoendoscopy or electronic chromoendoscopy. You need to take a good look at the lesion itself and make sure that you have not seen an area that is concerning for malignancy. And if you're worried about an area, then you have one of two things. Either one, you go ahead and identify that that is a high-risk area. I'm pretty confident it's a high-risk area, in which case you should not be doing an endoscopic resection unless you're planning to do something more advanced that we're going to show a little later, either an ESD or a full thickness resection. Or you can go, if you're not sure, you should focus on injecting that spot first, lifting that spot first, and cutting out that section first. Because that is your highest-risk area. That's the area you want to make sure you got on block. And everything related to the resection of the rest of that lesion is dependent on your success or failure of getting out the cancerous or the concerning area. OK, can you describe your technique for angling the injection needle into the right position? I'm going to pause on that question because I'm going to have Shefa show you this technique once we cut off another section or two and we move to our hybrid ESD. Because I think it's a critical part. I will answer one part before we get to it, which is the key part is going tangential to the plane of the mucosa and the plane of the lumen. So if you do not go perpendicular like this, you want to go as tangential or parallel as possible. And that gives your needle the best chance of finding the submucosal space. All right, let's take out maybe another bite or two here, and then we'll start having some ESD fun. All right, closing, closing snug. All right. Yeah, we could probably presume that the central part is not this island. Yep. I don't think I get it all. Very nice. And I just want to say, now I don't even know I've lost count of how many pieces we've taken out here. But you can see this really nice blue surface across all the pieces. And that's really what you want to see when you're doing a piecemeal resection. You want to see that nice surface, one smooth surface at the end of your resection. And really, it replicates what you would do had you done an en bloc resection of the entire lesion. Right for this area. Yep. There you go. Very nice. Close. OK. Open. Opening. Close, close, close. Closing, closing snug. Cut. Cut. All right, beautiful. So I think you can really see that now, how we've gotten this nice blue surface all the way around. All right, so we've got another question here, also about injecting. Well, while injecting a larger lesion, I have been noting that the lifting agent dissipates over time and has become flat by the time I've gotten to snare it. Is that your experience? And how do you troubleshoot that scenario? So I don't know if you want to take a stab at this one. I think this is 100% the reason right here of why all these novel proprietary lifting agents have been created and have come out in the market. When you inject with saline and saline mixed either with epinephrine or saline mixed with epinephrine and some dye, the dissipation time is very quick. And you will 100% see that phenomena happen that you will inject. And sometimes, even by the time you've taken your injection needle out and you've gotten your snare down and you're ready to cut, that lift is gone. All of these proprietary agents that are now available have much higher viscosity. And they're specifically designed to help navigate this problem of dissipation very quickly during an EMR. So you can see here that we injected with the single solution of 20 cc's of, what did we use, O-Rise gel. And that area is still lifted, even though we've been talking for I don't even know how many minutes, right? It is sat there. 25 minutes. Oh, has it been 25 minutes? OK, all right. Well, it's been a long time. And it's lifted and stayed that long. So the thicker the agent, the more time it will stay in the tissue, right? That's more viscous. And so generally, I think if you're using one of these thicker agents, these proprietary solutions, you're going to see this different effect on the tissue that will allow you more time and ability to snare out multiple pieces, deal with a larger lesion while not having to inject so much or re-inject and lose that lesion. It is, though, a real challenge, especially once you start cutting. So the more and more submucosa you expose, it leaks out of that cut submucosa. And so you've popped the balloon a little bit, right? Once you've taken that first bite, and now it starts leaking out more and more. And so it does get more difficult to maintain a lift as you've cut out more of a lesion, hence even the greater importance of using a more viscous agent, whether it's one of these gels or you can make your own. If you have head of starch, which is a colloid resuscitation agent available in many hospitals because it's used by trauma surgeons and anesthesiologists for volume resuscitation, you can make your own. You take a bag of head of starch, you put some methylene blue in it, and you've created your own proprietary gel just, I guess, on your own. That's pretty interesting. Yeah, so you can do that. So you can make it anywhere you want as long as you have that stuff. All right, so we've done a nice job here. What we'll do is we'll switch over to showing some ESD techniques. How about that? I was kind of thinking that these islands, they seem to have not lifted. If we can try something to help with that. We can. That's a great question. So before we move on, let's demonstrate one way of dealing with little residual strips of a lesion that can be hard to take out. Maybe you can't snare them out. You can't lift them. You can use coagulation forceps. So this is one example of a hot biopsy forcep. This is a coagulation forcep. This is an Olympus product. And so what we can do is we can use this. And just give me a second while I open up the box. And we'll use this to demonstrate kind of a hot avulsion technique of grabbing some of the tissue and then using a combination of coagulation and traction to avulse that tissue. So I don't know if you can see this. Try to demonstrate as best I can. So this is a very, very tiny, maybe no glove. It's a little white because it's dark. Very, very tiny forcep with some teeth on there. That's it. It's very simple. All those years that we kept telling you hot biopsy forceps are bad, well, they're back. And they're back for this indication. Dr. Gupta, what coag settings do you use for your hot biopsy forceps? Yeah, I think you'll see the most common setting is to use a soft coag setting on your generator and use anywhere from 40 to 80 watts. I'll just leave it on this force coag because it's a pig and it's not going to make a difference and save us some time. And so the technique here is you're going to go ahead and grab that tissue. Close. We'll close it. And then you want to pull it away as you use your cautery to deal with it. Perfect. So it's a combination of traction and coagulation. And that's what makes this a little safer. So we'll close, you pull away, and perfect. And do you tend to use these, when you send it to PATH, do you send it separately as compared to your other specimen or do you send it together with your? I usually just send it all on the same thing because remember, you're dealing with something that you've taken out in piecemeal. The orientation is no longer valid on the pathologist's side anymore because they can't orient the specimen. They're just going to look at all the specimen to see if there's any areas of invasive cancer. All right.

endoscopic resection

techniques

EMR

snare

lesion resection

injection technique

coagulation forceps