I'm glad the group is a little bit smaller than it was before, as we've just sort of divided it up. So I want to make this somewhat interactive, so feel free to chime in, ask questions as we go. And if you've used some of these things, great, tell us your experience. Well, let's get started. I don't have any disclosures. So just a real quick case, it's not a video here or anything, but this was just a case that I did not too long ago, about six months ago, a 55-year-old gentleman referred after he was found to have a large tubular adenoma in the ascending colon, his BMI is 47, but he's otherwise pretty healthy. Here's the adenoma that we saw. So it's in the ascending colon, just at the hepatic flexure, and it was a lot bigger than was billed. And so it looks like, estimated to be around four centimeters or so, kind of draped over some folds, and nearly hemicircumferential. And I sort of call it Paris classification 2A. I was a little bit worried. We just talked about all this. I was a little bit worried about some of the little depressed areas in terms of where they were in the fold. Once you get the cap nose into that area, it's just really just sort of a depression in the fold. Overall, this is very predominantly granular, laterally spreading, and looked like it would be pretty resectable. This is it injected. Not a great picture of it sort of blebbing up or anything, but it seemed like all the areas that I did inject seemed to fill, although the injectant did dissipate pretty quickly. But at the end of the day, we were able to get a pretty good resection on this. It took a while for various reasons, but I was pretty happy with the resection afterwards. So this was before we got our video technology, and I wish I had it then, because you would see all the issues I had in between, which we don't often see in the nice videos that we show here. But this was really hard. If you had that, and you guys have all must have had this experience of this colon that is long, loopy, redundant. If you look at my pictures, the polyp is on all of them at 12 o'clock. I would love to resect this at six o'clock, but I just could not for the life of me get it at six o'clock. It was one of those polyps, or it was one of those colons where you hub and you're at the ascending colon. You reduce and you drop down just below the cecum, and then you hub again, trying to get into the cecum. And as you come back, you fall into the transverse, and of course the polyp is right at the hepatic flexure at the point of hubbing. And then if you try to reduce past that, you fall forward, and it was just a back and forth, back and forth. And that was the predominant issue in taking this out. I could not get into a good position, and we struggled. So there are some risk factors for a difficult colonoscopy, advanced age, female gender with the pelvic inlet, BMI, both very high and very low. Low BMI patients have a very thin abdomen, and a long colon is sort of looped into that abdomen. And so you get all these tight loops, tortuous colon, sometimes redundant. And then the large BMI, similar. Previous abdominal pelvic surgery leads to scar tissue formation, narrowing, diverticular disease, similar, poor bowel prep, of course. And in this case, this was a long, redundant, tortuous colon with large twists and turns, and looping with the colonoscope, even with your advanced colonoscopy techniques, your reductions, there are some colons that just don't cooperate. So what are your options? Well, we ask our nurses to give abdominal pressure. And those who know how to do it well know the various techniques that they can use. But that's hard to do or hard to ask for when, A, you need your nurses to get you supplies for the resection. And B, are they going to be holding pressure the whole time that you're going to be resecting a polyp? That's a lot to ask, and it's not safe, and they're not going to be happy with you after that. Have any of you guys used this thing? The ColoRap? So it's essentially an abdominal binder. Have you found it helpful? I saw someone nodding their head. I don't know. I'm still a fellow, but on and off. Sometimes it's helpful, sometimes it's not. No. It looks kind of barbaric, but it's essentially a large abdominal binder that you can sort of really get a full compression of the colon. And I believe that's actually a nurse holding it and pulling while you're scoping. And so it eases up on them, and it sort of compresses the entire abdomen. And initial experiences on some people on Twitter, apparently, was that it seems to work. Is this patient in prone position? No, this is left lateral, I think, is what I see. So speaking of position, yes, we can try some positional changes. We usually scope in the left lateral position. We sometimes switch to supine as our first thought, just because it's easy to do. But your other options are right lateral and prone. This is actually a randomized control trial out of China in 2019, where they randomized unsedated screening colonoscopies to either the left lateral position starting or a supine position starting. And they measured cecal intubation time, and what they found was that the cecal intubation time is about 40 seconds less in a supine position as opposed to the left lateral position when starting. And because they were unsedated, they were able to take pain scores, also slightly less pain, and patients had less changes in position overall when starting supine. What about the prone position? There was a randomized control trial looking at obese patients out of the VA in North Texas in 2013. 50 patients were randomized to prone and 50 patients were randomized to left lateral as a starting position. And the prone position had about two minutes less in terms of cecal intubation time for obese patients. But again, most of us are doing our colonoscopies left lateral, and most of our patients are sedated, and positional changes are difficult and, frankly, cumbersome. You've got all these lines, IV, and now you're asking them to turn and the patients are sedated or an obese patient was turning in a small bed, and we're talking about workplace injuries and workplace safety. I mean, you have nurses sort of throwing out their backs, pulling the sheet, and it's overall it's always a mess and very unpleasant. And I don't know about you, but I've generally, if I'm doing positioning, I'm going left lateral to supine. That's pretty much it. I rarely go right lateral and then prone. But those are pretty extreme cases. But if it doesn't work supine, then I'm kind of done with positional changes. So you can also change your scope. If you're using a pediatric colonoscope, you can change the adult colonoscope that has variable stiffness. Or you can try the SIF. That's the single balloon endoscope. Longer scope, but without the overtube and see how far you can get with that. But it's also flimsy, so it'll also take the loops. You just hope that it's long enough to push through that. So here are initial overtube options. So you have your balloon-assisted NRS scopes. This is the Olympus SIF on the left. That's your single balloon and your double balloon on the right. These are long scopes. They're about 200 centimeters long. The working channel is only 3.2 millimeters. Your colonoscope is 3.7. And all of a sudden, with that long length, you're also limited on your instruments that you can insert. So there are some snares that don't go down the longer scopes. Or if they do go down and they're just enough length, I don't know if you've tried pushing down those channels. But once you're looped and once you're in far enough, sometimes it can be a real bear to get those things down without kinking the instrument. The other problem with these is that there's no irrigation jet. And so you're stuck with having to either inject with 60cc syringes, or as we hook up a needle to our irrigation jet and use that, use the working channel. And now you're using the working channel for multiple things. And of course, the setup can be cumbersome and very difficult. In your colonoscopy, you have a hard, long colon. It's not easy to say, why don't we switch out to the balloon-assisted endoscope? Let's switch out to a DBE. That's an entirely different processor. That's an entirely different getting the tubes out, getting the things unpackaged. It's going to take a while. Usually, you stop and say, we'll bring you back and send them off to someone else to do an SBE or a DBE attempt. So nowadays, we do have some options. And these are both. Well, I'll go over two things, the Dilumen and the Pathfinder, which I'll go over in more detail. And both of these things, you'll see in the hands-on session and give it a try. And I'll be interested to see what your opinions are. So this is the rigidizing overtube. This is what I was referring to as the Pathfinder. It's made by Neptune. And so this is an overtube that goes over the colonoscope. There is a stopcock attached to the overtube with two positions. In one position, it's sort of flexible, and it's sort of a flexible overtube that can easily maneuver with the colonoscope. And in the second position, there's suction that's added to the wall of the overtube. And it leads to a stiffening of it. So it becomes inflexible and rigid, and up to 15 times the rigidity of the normal colonoscope. So as a result, you get this sort of stiffened overtube that won't take on a loop. And it comes in various sizes. So it fits both the PCF and the CF. There's different tubes for either size, although we just carry the CF size. The PCF fits through it just fine, and there's not a lot of air loss. And there's two lengths, 85 and 110. With the 85-centimeter one, you can actually fit upper scopes through it. So as I mentioned, it operates in two areas, rigid and flexible. And so what you see here is the stopcock side of things here. So the stopcock is hooked up to suction, and you can control when that suction's on and when that suction's off. And that suction's a different source than the suction for your endoscope, and it's sort of an offside box. So it's not like you're taking up your own suction to do this. It's not like you need some other devices. And it's a tube that's out of the box. You can just come out with your colonoscope, add to it, and attach it, and just go with the same scope. So you're not switching out, and the setup is not that difficult. So here you can see this is the tube in its flexible state. And it flexes with the colonoscope nicely. They turn on the suction, and the tube maintains its form. And this is a video of a colonoscopy using this. This is from GIE. And this is a colonoscopy that was incomplete. And here you see the scope guide image here, and you can see the loop forming in the sigmoid. The tip of the scope would only reach the transverse colon, and that loop in the sigmoid was just not cooperating despite pressure. And again, you can go in and out of the overtube with the colonoscope. And here's the scope guide image here. And you can see that loop, once stiffened, it does not take the same shape. You're able to get around and reach the cecum. So the technique is fairly straightforward. You would basically load the scope onto the overtube, advance the scope and the overtube to the point where you need to reduce to straighten out the scope. You reduce your loops, and then stiffen the overtube by adding that suction, and then you can advance your colonoscope. Usually that's one reduction, and stiffening is enough to reach the cecum. Sometimes it does require advancing the scope, re-advancing the overtube, stiffening again, and advancing the scope through that. But just like we do in a neuroscopy, this is actually more straightforward than that. I have a question. So the overtube is on the very, you place it to the tip of the endoscope, or is it like a regular, like the overtube used for the upper where you back load it all the way back and then advance over? You back load all the way back. OK. Then you reduce, get the scope where you want it, then you slide it over. You get the scope where you want it, advance the overtube, slide it over, and then you can reduce the both together, so you get the loops out of both of them, and then you can stiffen your scope, stiffen the overtube. OK. So big advantages. Well, it's a really straightforward setup for unexpected need and use, and that's what I want you guys to focus on in the hands-on session is not just the actual use of it. Look at the setup. It's pretty easy for nurses to set it up. It's easy to ask for during a case that you're having difficulty with and just say, let's try the overtube. It's not something you have to stop, bring them back, have the overtube ready and set up for a future case. You can use it in real time on the same case. You get all the benefits of your colonoscope. You have your irrigation jet. You have your good, healthy working channel. You have all the instruments that can go down a colonoscope. And then you're also able to remove and reinsert the scope with the tube remaining in place. You're taking out a large lesion. You're taking it out piecemeal. It's not suctioning through. You can take out the pieces, put them away, and go back in with the colonoscope. You can take it out and reinsert a different scope. In the recent case series published from Stanford using this in about 29 cases, there were several cases where long, mal-rotated, difficult, redundant colons for various reasons could not reach the cecum, tried the overtube, reached further, still could not reach the cecum, removed the colonoscope and changed out to an SIF scope, just a longer single blue scope, and reached the cecum in two minutes, right through that same overtube without having to change the overtube position. And so you have multiple options here, and it does not add that much time as any other cases would. And at the end of the day, it does allow for greater depth of insertion, stabilization, and position. So the other device that you'll see today, this is the double balloon endoluminal intervention platform, otherwise known as the dilumine device, it's made by Lumendy. This is essentially a double balloon overtube, and this is very similar, your technique here is very similar to your double balloon endoscope, except this is an overtube that goes over the colonoscope, and it's a sleeve that fits securely, and it has a hand pump on the side that inflates two balloons. There's a forward balloon and an aft balloon. The aft balloon is sitting behind the colonoscope as you're moving forward, and there's a forward balloon as well that pushes up forward and helps stabilize the colon as well. This is what it looks like, the hand pump. There's a forward balloon and a back balloon, and you can change the dial as to which one's filling and which one's decompressing. And the idea here is that you have two balloons, you have your balloon that's near to the scope and a balloon that's forward, and you create this, what they call a therapeutic zone. And in this zone, you've now stabilized the colon, both proximal to the polyp and distal to the polyp. You can stretch out those folds, you can insufflate just that one portion, you can flood that one portion with water and not have the water necessarily dissipate, so you can use all of your techniques while at the same time having stability. And they're playing around with quite a few innovations with this. As you can see, when you see here, there's sort of the forward balloon and two little channels coming out the side of the scope, that the scope's going through the overtube. They've also built in two 6-millimeter therapeutic channels within that overtube, so eventually you can get instruments through and do complex ESD and EMR this way, or even potentially surgery, almost like robotic endoscopy here. But this is not fully out yet, and the reports on this are iffy only that a few experiences that I've heard is that overall this thing becomes bulky, and so getting it to the right colon becomes an issue. Here we go. So this was an ESD that he wanted to do on this sort of complex-appearing polyp. Looks to be at a flexure, and here is that forward balloon advancing beyond the lesion, sort of stabilized. The overtube's already on, and now he's inflated both, and now he can sort of do what he needs to do in terms of marking, in terms of injection, in terms of resection. And he's sort of created, you can see the sort of, he's insufflated here, and there's a decent amount of, the folds are now sort of spread apart. We'll do this a little bit, here we go. It allows for more stable positioning of the scope. You can rotate your scope, 12 o'clock, 6 o'clock, while this holds the colon sort of in position. The insertion is very similar, and again, you'll try this. You advance your colonoscope, advance the overtube over the colonoscope, inflate the balloon to stabilize certain areas, and then you can reduce, advance, reduce, advance, inflating and deflating as you go. So again, this is also fairly straightforward to set up for unexpected needs issues, meaning you can use it on the fly. All the benefits of your colonoscope are still there, you're able to remove and reinsert the scope in this as well, and it allows for greater stabilization position. I would say that compared to the other overtube, this one is designed more for the stabilization of the lesion. And so, whether you're in rectum or stigmata, or if you even need an overtube, the idea for this is to really spread apart folds, allow you to have a therapeutic zone for resection, and therefore a lot of what you see, the videos you see of this, are to facilitate ESD and more complex resection. I think this feels overall bulkier. It's less intended for simply completing a colonoscopy or an incomplete colonoscopy to get to the cecum, versus the other one, I think, the Pathfinder, is more designed for that. So at the end of the day, we now have two good options to aid in difficult colonoscopies, both of which are fairly recent within the past five years, and you'll see today, and I think these are investments that you could consider, especially if you have a population of difficult colonoscopies, and to have in your back pocket. I'm not sure how the finances worked out, but especially with the Pathfinder, it is disposable, single use, and in our institution, that usually means that it can be billed for. Okay. Awesome. Thank you.

devices

Pathfinder

rigidizing overtube

Dilumen

double balloon overtube