The Apollo OverStitch device is a device that requires a two-channel scope, a double-channel therapeutic scope. And so right now it looks like we're using the Fujinon scope, and it's been... The device has been kind of put in motion here, so the device has been applied. The first step that we're going to do is load the suture. As you can see, this is what it looks like. And when you're setting this up, it comes out of the package in this form. And the way that this fits on here, there's really only one way for this device to fit onto the scope. And so you can see it fits right into this channel, and then it's nice and secure. So the first thing we're going to be using is one of the stitches. Oh, it's loaded. Oh, okay, great. So even better, this suture is already loaded onto the scope, so that's one less step we have to do here. This is a larger device, it's a larger scope, and you need a little bit more clearance in getting around the upper esophageal sphincter or through some tight corners. Now when you advance the scope, you want to have it in the closed position. And so what we just did is it was in the open position, like that, and this controller closes it up. So we're going to do that one more time. You can see that's open, and then this closes it. So we're in closed position, I have the scope moved, okay, I'm just going to switch on the lamp. So we're just firing back up our tower, we'll be right with you. All right, we have endoscopic visualization now. So, Shefa is going to find a place that needs suturing after a large imaginary deep defect from a gastric ESD that was done. She expertly performed. All right, so we're going to find a good location. There's a defect right here. All right. So this needle driver, that's what we call that, that needle driver is already loaded with the suture. It's not loaded. All right. Okay. So what we're going to do is I'm going to open this up and I want you to stay in the air kind of. And I just want to see where this is. Okay. So it's about right there. So I'm going to pull back a little bit and then I'm going to close it. Okay. And then now I'm going to push this in a little bit. Good. And then I'm going to press the button and pull back just like that. Now when you open it up, Shefa, your needle is loaded with your suture. Okay. Great. I should just close it and try to grab a bite of the mucosa. Yep. Exactly. Or. Yep. And we can also use the demonstrate the use of the tissue helix, right? And so I think for the first one, that would be fine. Yeah, absolutely. So you want to, you want to nuzzle it in there so that you're really getting kind of a deep bite. Yep. Pushing my scope forward. I think I'm still just getting mucosa. Yep. So you want to get it into an area where you can really catch an edge. Nope. Even if you come back a little bit and get that bump. Yeah, I'll try to find a different position where I can. Now if we can't grab it without it, we can always use the tissue helix. This time I got mucosa. Good. So depress it all the way. Good. Done. And then the next step, you're going to advance your catheter there until you feel, you should feel a click. Click. Okay. And then just pull up a little bit. Hold. Good. Great. Now undo. Yep. So you're going to open that up and now your suture is through the tissue. You're going to back away and I'm going to give you a little bit of slack. Great. Very nice. Great. Excellent. Okay. Try to grab the mucosa adjacent or... So now we have to load up our needle driver again, right? So the same step that we used to load before is what we're going to do again. So I need you to kind of come into the air so you're not on any tissue. I'm going to push my catheter here. I see where it is. Okay. Close. Not into any tissue. Yep. That's right. Good. Okay. Now I'm going to push this forward until I feel a click and then I'm going to depress the knob and pull up. Good. Now it's loaded again. Yep. Let me see. What area should I go for next? Maybe try for this fold? Sure. Yeah. So open up your device. Great. So now you're connected and that'll give you a little bit better sense of where the next tissue will be. For this next bite, I think we ought to use the tissue helix. Okay. And that's going to go through the second channel. So when you're doing this, your suturing device is going to be through the channel that's closer to this larger channel and the secondary channel is what will get the tissue helix. Do I need to open it? I can try. There you go. You got it? Yep. I got it. Great. Is it similar to the helix that we were using before? It is similar to the helix that we were using before. Oops. Okay. Great. And so I'm going to push down on this, right? And that's going to push it up and then I'm going to screw about five times or so. So five revolutions. All right. And you've got gentle pressure on that mucosa. Okay, good. So now pull it back into you a little bit. Put your big wheel forward. Yeah. So, yep. Good. Great. I'm going to pull this in. So pull back on the secondary catheter, right? So pull back on this. Good. I see how it's coming in. Yep. So now you're going to pull all that in just like that. And you can see the nice purchase you have here. Okay. So that's about as far as we can go. So you want to hold that. Holding it. Okay. And then what we can do is... I'm kind of on the wrong side. Yep. If you can do that. Fire. Try to orient it a little bit. Yep. See if you can get a little bit more meat. Good. Excellent. Yep. I'm just going to pull this back a little bit more. Okay, great. And then I'm going to unravel this. Great. I guess we'll fire this. So we'll go forward with this until you feel that click. Can you just push? Make sure it's there. Okay, good. And then I'm just going to pull it off. Good. Okay. Great. Now I'm going to unravel this to release the piece of tissue. Yep. There we go. We're off. And did it catch? Let's see. Tough to tell. It almost looks like it may not have caught there. Yep. So we can reload our catheter, our needle driver, right? So back into the air, right? And so you're going to close. So I'm going to pull this back. Close. Yep. Okay. Back in here. Hold on. Let me just push this forward so we can see it. There we go. We're right there. Okay. A little bit of tension on this. Okay. Close here? Yep. Okay. Okay. I'm going to advance this. Right. And open. And so we're reloaded. Yep. All right. And so if you want to grab that sort of edge of tissue over there, yeah, you may be able to just kind of position yourself so that you're nice and through it. Okay. Great. Is this a good spot? Yep. That looks like it could be good. And I'm just going to make sure. I'm just going to... Yep. Go ahead. Wire. Good. And now we're going to push that forward. Yep. Advance that forward until you feel it. Click. Okay. And then pull it back on it. Yep. Just pull back. Pulling back. Yep. And then open. Great. And so now what we could do... Yep. So now we have two bites. So we could just do a simple cinch here. We're still loaded. Okay. All right. So the suturing device did not transfer. So we're going to try that one more time. So you're still loaded. And I just want to make sure that we're... Would you like to give it a shot? You have all this? I'm just going to advance here. I'll do this part for you. Yep. So I'm just going to pull back a little bit on this. Okay. And this, we're going to get out of the way. Great. Okay. And so what you can do is try to take another bite. Okay. Yep. Good. Yep. Okay. Now I'm going to push this down. Okay. I felt a click. Now I'm going to pull back. Okay. Okay. Yeah. Yeah. It doesn't seem to be transferring. So we may have... Maybe a little bit bent up. Okay. So what we can do is transfer in the air. All right. So in order to troubleshoot, we're going to reload the wire, right? So I'm going to push this forward. I'm going to give a little tension on this. All right. I feel that. I'm going to just pull back. All right. Open. All right. So open. All right. So now we're going to reload our suturing device or our needle driver. Okay. So I'm going to advance this. Okay. Close. All right. I'm going to push forward until it clicks. And open up. And now our suture has transferred to our needle driver. So that's great. That seems to be working well. So now we're just going to try to take our second bite here. Yep. That looks good. Okay. I'm going to advance this. Okay. I'm going to advance this. I feel it click. I'm just going to pull it off. Okay. Good. Open. All right. Great. Oh, nice. Yeah. So now we've got our two bites and a simple stitch here. So now we're going to switch to our cinch. And so what we do now is we pull this out. Okay. And so the way that we do that is I'm going to push out this catheter to leave our anchor behind first. Right. And so there, that's going to drop that. So we're off. Right. Good. And so you can see up at around 2 o'clock is our T-tach. You can see that's in place. And now we're going to use our cinch, which is very similar, if not identical, to the cinch that we used previously. So we're going to find our end of our thing. Good. I'll give this to you. Oh, you're going to give the hard part to me. Let's see how good my eyes are. Maybe I can help. Oh, maybe. There we go. Through there. Then we pull down. Ten on ten. Pull down on the cinch device. Great. And then we make it like an ERCP wire. So gentle tension. I'll trade you. Great. Thanks. You want to advance that down? I'll introduce it. Great. And so here you can see our very simple two full thickness bites are going to be cinched. And this is kind of the most straightforward way. There's lots of patterns you can do to suture, you know, a figure eight or a purse string. But the simplest is just two interrupted or, you know, an interrupted suture here. And that's what we're aiming for. Is this a good location for cinching? Right. So the first thing you want to do is you want to — one of the key things that requires a good bit of feel is determining how much tension you need on that suture. So you want to be able to close your defect as much as possible without having any of the tissue tear or any of the — and have your sutures not break. And so I'd like you to kind of pull back a little bit. And we'll — it's a little bit of a dance between that catheter. And pull back on the wire a little bit. Right? So, yep. And kind of work that in. Good. And then just kind of push it out again. Great. Yep. And a little bit more tension on the wire. Good. And at this point, we should be able to deploy this. And the way that we do this, again, I'll open up the cinch. This will fall out. And then I'll deploy crunch. Oh, nice. Great. It's completely approximated. Yep. And so it's really nicely approximated. Well done, Shiva. Thank you for walking me through this. Absolutely. I'm going to pull out the scope. So we're going to answer some questions from the audience. So do we use an overtube to get the scope down? So I haven't tried that. But I don't think that the overstitch device can really all that readily fit through the overtube. If you use the Apollo overtube, it's designed. Some of the other overtubes that are frequently used for food boluses or other types of indications, it's a little bit more difficult to get down. But the Apollo overtube can be used to get this device down. What if you do if you don't have a 2T scope? So that's a great question. So there is a single channel suturing device where this apparatus is basically set up alongside the scope or on the outside of the scope. And that's also manufactured by Apollo. And it works in a similar fashion. The angles are a little bit different in terms of your approach. But if you don't have a 2T scope, that's a good alternative. So I think the question is, when do you use this device to anchor stents? And I think that it depends on the location and the indication. For example, and I will point out that a lot of the times that we use sutures to anchor stents, we're using the stents in an off-label manner. So we're using, for example, lumen-opposing stents in the middle of a benign duodenal stricture. So typically, stents in benign areas tend to migrate more. So I will typically always suture that in place, usually with one or two sutures. And I don't make them super tight when I'm suturing the stent in place. I leave a little bit of room for laxity. Have you been suturing any stents in place, Shifa, at the University of Chicago? Yeah, that's the only place where I've used the Apollo suturing device for stent fixation, yeah. I would say that, yeah, we've sutured axial stents and your traditional enteral stents as well. We're also kind of moving towards the stent fixation device more so now. My experience, my limited experience with using suturing for stents, it has worked great for enteral stents. But for axial, I've seen it migrate both for even with edge and, like you said, for gastrogynostomy strictures as well. Right. And again, these are off-label uses of some of these devices. Again, even in a post-bariatric population, so sleeve gastrectomies that have had leaks, we've stented across those and sutured those stents in place that way because, again, these are benign indications. We want the stent to not migrate. And so this has been helpful in that regard. Any other questions from the audience? Awesome. Great. Well, thanks for your attention on this. And thanks for bearing with us as we troubleshoot as we go. And that's kind of how a lot of times you have to be able to think on your feet and figure out what the problem is and where things may be not functioning as well as you may want them to and kind of find the solution like you did and move forward.

Apollo OverStitch

suturing device

endoscopic procedure

two-channel scope

Fujinon scope