All right, well welcome back to the virtual streaming room for the ITT Center here in Downers Grove. We're going to go on with the second half of our demonstration. And so as promised, our next technique that we're going to show today is the endoscopic full thickness resection, and we're going to do it today in a colon model. Now I will start by saying the biggest important step about this technique is correct setup. You do the setup incorrectly, you're going to pay for it during the procedure, and pay for it in ways that will really spend a lot of your time trying to fix some of the messes. So the old adage of measure twice and cut once, this really comes down to good setup of the device on your scope, having your assistants and your technicians fully trained on the device and ready to go so that you have a nice, smooth, easy procedure is critically important. A couple of things that we're not going to show but are important when you do this in real life, the device has challenging visualization when you have the device on the scope. And so I know in a lot of you out there or a lot of courses where we talk about endoscopic resection in the colon, we talk about marking but most people don't do marking of the edges. This is a technique where endoscopic marking using APC or a snare tip before the procedure of all the edges of the lesion is extremely, extremely helpful to help ensure adequate visualization of the entire lesion and capture that lesion when you do it. The second is appropriate lesion selection. So this cap in this device is only rated to get on block resection of lesions up to a certain size. I would say generally the max you're going to probably go is about three centimeters max and that's especially lesions that are soft. If you've got something that really hard, really fibrotic, you may not be able to get a full three centimeter lesion in the cap. You may be talking about something smaller, two centimeters or a little less. And so that's where it's important to make sure you're choosing the right lesion. This key for this procedure is on block voltage resection. If you select a lesion that's too big to fit in the cap, you're not going to get the whole thing and you're going to be doing a disservice to getting that lesion and that patient taken care of. So with that, we'll go ahead and start with our setup. And so as you can hopefully see out here on the table, we have our colonoscope laid out and really the first step of setting up this device is similar to setting up the Avesco over the scope clip. And so if you want to grab the control wheel and so this wheel, very familiar for those of you who have used an over the scope clip, it's the exact same wheel. So we'll go ahead and attach it through the biopsy port of the endoscope and put that strap on around the scope to secure it. Now you can put this flush metal to metal. So take your biopsy cap off and put the control wheel through the working channel and have it metal to metal. Or you can go like we did today and put it through the cap itself. The key though, is just make sure you have a nice seal because you don't want air and fluid loss around that. Next step is I'll show also again, if you've seen once again, very exact same device. It's basically our kind of, I don't know what exactly it's called, but I'm going to call it a guiding catheter. It's the exact same device for the over the scope clip. And what you do is you're going to advance this now through that control wheel and through the working channel of the endoscope to have that come out the other side. And so Shiffa is going to demonstrate that, inserting it through. All right. And while she's doing that, I'm going to now show, if I can without messing it up, the other part of the device here. So if you can see it, so this is the actual resection device and it has several key components. And so I'm going to start at the tip here. And so if you want to zoom up and I'll put it up against something that hopefully you can see. All right. So a couple of key points here. First, you'll see that you have on the very tip of the device is the cap. This cap is what goes on the end of the endoscope. The cap is very complex, several pieces here. One is the over the scope clip itself. This is a unique clip compared to the other over the scope clips that the same manufacturer of ESCO sells. This is specifically designed, this clip, for full thickness resection. It's got different teeth configuration and some additional teeth on it. Second, as you can see this catheter extending from the cap down to this handle that is now in my hand. So this is the actual resection snare. The resection snare comes pre-attached to the cap and the snare is already pre-opened on the edge of the cap. It is pre-opened, hence why the handle has this clear safety on it. And so that is to prevent yourself or your assistant from accidentally squeezing the handle and deploying and closing the snare that is pre-opened and preset on the edge of the cap. You'll have, for those of you who have used an over the scope clip before, you'll see this exact same replica. This is the control string, which we will show being pulled through the working channel of the endoscope. And this string, by pulling on the string, is what will cause the clip to deploy. Another unique feature of this device, you will see this white band on the cap itself. And let me put it up against something like my shirt so you can see the white band there. I'm looking in reverse directions here. So this white band, this is a nice little visual marker that for when you deploy the clip itself, you'll see the white band move from the center of the cap towards the end. And that's a good visual cue during the procedure that the clip has deployed. The last part, which is unique for this device, is this sheath. And we'll show the sheath being put over the entire endoscope and the entire snare guiding catheter, which will be attached to the outside of the endoscope. The sheath is meant to hold the snare and the scope together as one unit to help make sure that the snare is straight. It does not corkscrew or twist or become coiled, hence helping to prevent snare malfunction when you go ahead and do your resection. So this sheath is meant to keep that snare up against the scope and will show how you attach the sheath. So it is one single piece with all your components preset, and hence why really setup is critically important here as we do this. All right. So AJ is here with us. He's got an extra set of hands because this is really a two-assistant technique. And so AJ, I'll have you just move a little that way so you can get the camera. It's all right. So if you want to hold that. So what we'll do is we'll start. You can see the guiding catheter, and we'll insert it in the scope through the sheath. Now we'll go ahead and attach. Oh, let me see. There it is. We'll attach the string to our guiding catheter. Oh, let's see here. OK. And now pull that guiding catheter through and keep pulling, keep pulling, keep pulling, keep pulling. And this is really no different. For those of you who have placed it over the scope clip, this is no different part. We're banding. Good call out. No different setup right here. And we've got it through. All right. So now we'll put this down just for a second and we'll show the handle here. Oops. And if you can see the handle, what we're doing is first we're going to secure that string into the control wheel. There's a little T with a little edge there, and we're going to start wrapping that string around the control wheel and stop right there. All right. Perfect. So we just want it just so we get on there. Next part, what we'll show is putting the scope on the edge of the cap, and let me straighten this out. And so we'll slide that just on there. I think we're going on the key part. The key part there is we want that string that's coming through the working channel of the endoscope, we want that string to be really lined up through that working channel itself. I can't get to it. So let me try to clean your lens so we can see if you want to show the endoscopic image for everyone on the screen there. It's better now. All right, so you can see that string kind of lined up nice and we've got our cap on. Call out, which we didn't show, there are three little bumpers on the inside of the cap and that will provide the right resistance so that when you slide the cap onto the tip of the endoscope you will hit those bumpers and it will stop. All right, okay, so now we have, if we want to go back to the scope, we have our cap on, we have our control string connected to the control wheel, now we have to secure our snare to the side of the endoscope and this is where this sheath becomes important. So I think we take one of these guys off, let's get this thing off here, and then we'll slide our plastic sheath over the endoscope. Now, and we have the most fancy tool in all of medicine, tape. So first part here is we want to get our sheath up to the cap, but we do not want to tape and have this on the cap. So we want maybe about two millimeters or so from the edge of the cap and what I'm going to do is try to get this nice and taut up against the endoscope. So you can see my hands trying to get this nice and taut there because what we want to do is we want this nice and snug, the sheath really air and liquid type up against the endoscope. And so now that I've got it there, I'll ask AJ to help me with that first piece of tape. You want to get that on there for me. And you can see the expert hands on getting that first piece of tape on and wrapped around. Once again, key part, you want this seal up here, air and water tight. That first piece of tape, most critical, not touching the cap one, two millimeters away from the cap, right? But nice air, water tight seal. If you need to put a second piece of tape up there, go ahead and do it. And I think for this one we will. Perfect. Once again, nice air, water tight seal. Now what we'll do is we'll continue to extend our sheath across the rest of the endoscope. The key here is we need to have the sheath covering the endoscope, keeping this snare in the same orientation along the endoscope as we deploy our sheath. You want to go ahead and continue this taping process, maybe about every 20 to 30 centimeters or so, keeping it nice and tight and keeping the snare in the same orientation. You don't want it corkscrewing and wrapping around the scope. Keep it a nice straight line down. For the purpose of today, because we're just using a short model, we're not going to continue the taping all the way down, but you want to ensure, normal human being, you continue the taping every 20 to 30 centimeters down the scope. Exceptions are going to be if you're using this like in the rectum, you don't need to go all the way down because you're not going to have the scope that far into the patient. If you're going into the right colon, probably best to make sure you're taping as much of the scope as you plan on using in that patient. So that's the critical part. You'll extend the sheath all the way down, just like we've done here, and normally we'll be continuing that taping process. All right, so with that, we will go ahead and now do our insertion and we'll get a little surgical lube on the edge of our device because it is a little sharp, just like any over-the-scope device there. We'll get that around there. Okay, I will pass this over to Shefa. You got it? Yeah. Okay, and now the funnest part of this entire procedure, which is to go ahead and I can hold on to that if you want, okay, is to now to go ahead and advance this combined device into the patient. There we go. Thank you. No problem. We're going to advance this to our lesion. Now for the purpose of this, we don't have a real lesion. We'll just use some imagination, but as you can see, this is a straight fake colon and the visualization is challenging. It is a deep cap, bigger than what most of us are used to, so visualization is challenging. Hence, once again, the importance, especially in this procedure, of the pre-procedure marking of that lesion. Trust me, you're gonna really use those pre-procedure markings. You're gonna need to use them and be glad that you did for this case. I think we can pick this spot. Okay, perfect. All right, so now that we're down, this procedure is a little different than most of our other over-the-scope kind of device procedures like banding or over-the-scope placement where we rely a lot on suction in those procedures. Here, especially in the colon, do not rely on suction. You rely on suction, you will grab things from the other side of the colon that you do not want to grab, like a ureter or a big artery or something else that you will be killing yourself over because you do not want to grab that. That you will regret grabbing. Yeah, we regret grabbing, yes. So instead, this procedure is all about using this grasping forcep that also comes with the device. If you want to go ahead and open it, it has several wrapped teeth on the edge plus some serrated teeth running all around the teeth itself and it just has, or the the blades of itself, so it's got several teeth and really just open and closed position. So once you've gotten yourself to the lesion, you're going to use this device, this grasper, you're going to insert it down the working channel of your scope and you're going to use this device to generate, I'm going to say, 90%, if not more, of your traction to get the lesion and the full lesion into the cap. So this is the next critical part of this procedure is to make sure you're grabbing and getting the entire lesion into the cap. And so as you can imagine, imagine doing this real life in a patient and you have the cap on here. It's tough to see. This is where having those markings will help you to visualize whether you have everything you need for the lesion in the cap. Because you can see Shefa doing this right now. She's pulling and pulling. This is where you would see in a human being those markings you saw, you placed, and saying, hey, do I have those markings all in the cap? Do I have everything I was supposed to get in the cap? And you're going to be doing a lot of wiggling and moving around and repositioning because you get one shot at this. Once you deploy the clip, that is it. So we started this whole procedure, measure twice, cut once, maybe measure four times, and cut once here. All right, so Shefa's done an amazing job. She's pulled that lesion into the cap. Now we fully have it in here. One other take-home point, you can see how Shefa has brought that grasping catheter fully back into the scope. And it's good things she did that, because what you don't want to do is you don't want to bring that thing into the scope, or you want to leave that sticking out of the cap and accidentally fire the clip on your grasping catheter. Because once you do that, that will be a problem. And so I will apologize, I didn't do my job of setting up everything here. So let me get the cautery thing set up. Once again, why you do not want Neil Gupta as your endoscopy tech, because you will be yelling at him all day long for not doing his job. All right. So she's got the lesion fully in the cap. And so now we are ready for first step, which is to deploy our clip and close our quote unquote hole. All right. So we got a great question there. But I'm going to show this technique real quick because we're right in the middle of the best part. So before she starts turning, and the way she's going to deploy the clip is she's going to turn that wheel. She's going to turn it clockwise. It's nice because the wheel has some numbers on there to remind you this is step one, which is to turn the wheel and deploy the clip. We talked about the white with the band on the edge of the cap. Hopefully you can see that white clear band or not white clear, but white opaque band below the clip on the edge of the cap. Yep. So as she deploys the clip, watch that clip and especially watch that white band move. All right. Let's go ahead. I think I'm also trying to hold it very snug with the scope. Yes. Perfect. Keep my tension. Yes. A lot of tension. Use those extra fingers to hold tension on the grasping catheter. Exactly. Perfect. All right. She's going to start turning. She's turning and she's going to keep turning that control wheel until beautiful. Right. And she saw that white band move. That means a clip is deployed. Now that means my next step, which I took the safety off and I'm going to close the snare and I'm closing the snare. I am snug and now she's going to cut and cut, cut, cut, and we cut through. And so now you're going to go ahead and start pulling the whole device and scope back with the lesion. Everything's going to come out and let's take a look and let's see what we got. So we can open that up and we can see this is, this is what we got here. So I'm going to open this up. You can see we got this large thing out and you can see here I've got the one side of this colon wall. I flip it over. I've got the other side. So I've gotten a full thickness resection there of the colon wall. If we can, I'm going to try to show over here. Let's take a look at where we deployed this, which I believe is right here. So if you can see that here is our external side, that full puckering is from the other parts of the colon wall coming in together, being that perforation that we intentionally caused being fully closed and sealed by this clip that I can feel sitting right there, closing off that part of the colon wall. And so there is our full thickness resection done right there. All right. And so yes, I'll let her go back. And while she's going back and showing our work, good or bad, however it was, question, what kind of submucosal lesions are candidates for full thickness resection? It's a great question. And I think a lot of these really come down to things like carcinoids and just in the lumen of the GI tract that you're worried about malignant potential and are in locations that you can get this device to. And last part, are small enough that both the lesion and what will be the mucosa that comes with it can fit into this cap. So I told you initially about how this cap, you can get two centimeter lesion, maybe something up to three into the cap and fit. This is where it comes to how hard and soft that lesion is. And if it's in the submucosa, you're gonna have to grab more mucosa with it. So a three centimeter carcinoid, you're not gonna fit in this cap because it's submucosal and it contains a bunch of extra mucosa that you're gonna have to get with it. A two centimeter carcinoid, maybe, maybe a little bit something smaller than definitely one centimeter, a centimeter and a half, I think you can definitely get it in there. So that's where it's important to judge that size. One thing you can do is use another cap to help go to that lesion first and give a feel for can you suction and can you grab and pull this lesion that you're planning to do a full intersection on, can you pull that and get it into kind of like a sizing cap before you go ahead and open up and intubate the patient with the entire device fully set up and attached to. But really that's the key part is you gotta find something that is gonna fit in this lumen of the cap. As you can see here, there's our clip closing off the whole lesion. It's a pig or this pig colon, so it's a little narrower than you'll see in a human being, so you don't see as much expansion around here and see kind of this nice little closed off area. All right, so hopefully everyone enjoyed that demonstration. I know I did, Schiffer probably did not since she did all the work. But obviously we want questions, anything else that you want us to demonstrate, we'd love to have that. And so please let us know what you want to see, what you want us to kind of tell you about.

endoscopic full thickness resection

colon model

correct setup

training of assistants

endoscopic marking

lesion selection