This is going to be just like yesterday, except this time we'll do adverse events. So it'll be asking for some input from our faculty who are not on the hands-on right now, but also from you all on how you'd manage some of these things we have to deal with in practice on a thankfully infrequent basis. First, we're talking about adverse events. Really the most common adverse event is something that I would consider an adverse event is really incomplete resection. So although that doesn't fit into what we're going to talk about most of this, a lot of people falsely believe that they don't have polyp recurrence or incomplete resection. So we get referred these polyps after a screening or surveillance colonoscopy where someone says there's a suspicious-looking polyp in the transverse colon or sending colon. And it's true recurrence. That's a big recurrent polyp a year or two years after someone tried to remove it. So it's just another editorial comment that if you're going to try to remove a polyp, try to get it all out, and that these recurrences do occur. It really is important to take all these techniques you heard today because a little ditzel is one thing, but this is obviously a big recurrent polyp you see here. It's got a nice central depression from the area where the polyp was probably removed, and then all the lateral edges were left behind. Makes it very difficult to remove. So again, these recurrences are common, and as everyone's shown, 10% to 15% of people leave polyp behind when they're doing these resections, as you can see from Heiko Pohl's study. But that's not the kind of thing you think about when you think of an adverse event. Most of us think about perforations and bleeding, and we've had a lot of good talks on it today, so we're mostly going to sort of lean on you all to see how you approach these cases. So a 51-year-old female undergoes routine screening colon. Colons perform without difficulty, has a perfect Boston bowel prep score, and has this polyp that was removed. So since we have a nice audience here, is anyone willing to tell me how they describe this polyp in their practice, size and morphology? All right, I would say I'll just do it, because I think it was described as a 2-centimeter polyp, Paris IIa, and this would be a granular polyp. And this is a classic appearance, as everyone knows, because we're all sort of above average here, that this is a classic serrated appearance, right at the mucous cap. So they elected to do traditional EMR injection and try to remove it on block. So gets a good lift. These always get a good lift. As we talked about before, the polyps get bigger when we lift them, they're serrated. Using a braided snare, working their way to the base, trying to remove it on block. So one thing we didn't talk about, and I will ask our panel, when we teach EMR, we do this voodoo technique of opening the snare a little bit at the end, and then closing it again. I'll ask you, Mark, way in the back, do you do that, and do you think that it helps? If you don't mind using your virtual, your microphone, if you... Okay. Yeah, so I used to do that, the thought was that he would, he had to turn it off for a while, and then he had to do it a little bit at the end, and then off for the following. Yeah, the idea is that, Mark was saying, he's getting his microphone for the rest of this, that he used to do it, but doesn't do it anymore. There's no data. I do it, but I don't think it makes any sense. Does anyone feel that it definitely works? I also do it, I also don't know that it's really work. The other thing I do is, the study from, I believe from Korea, if the amount of snare after you close the defects is more than five millimeter, you might be getting muscle. So if I feel the amount of tissue a lot, I really cannot measure five millimeter. But if it's more than usually I feel, I will release and get the smaller piece. So you always feel the snare yourself? Always. Yeah. So what they're saying is they always take a feel of the snare. I do not do that, I just rely on the nurses who tell me this is more than usual. Probably better, I mean, I'd have to do it now for a lot of times to be better than them. But I think just getting that sense is helpful. Let's see if this will work. Oh, this is that thing that happened yesterday. All right, there we go. All right, so polyps come off, and what do we see here? So, I love coming to these things. I'm really bad at nomenclature that has no, you know, basis in anything like we talked about the carcinoids yesterday. So the deep neural injury that we talked about makes a little bit more sense, right? The Sydney classification. So can anyone give this a Sydney classification? Type 4. Type 3. So I've heard 3 and 4. So I'm actually curious what you'd call this. I think, so type 3, you see muscle at the base. I don't see muscle anymore, so this is type 4. That's exactly what I think. I think it's a type 4, because that's through and through perforation. So, small. Maybe Sunil is saying there's a last remnant fiber hanging on. Yeah, so it's a classic target sign, but not like a massive perforation. Sort of a, it's like a 4 minus or 4 plus, whichever direction it's supposed to go now, compared to like the scope is going to be driving through the hole. So for the audience, let's see. I don't want to pick anyone. So if anyone would volunteer, what would be your sort of thing you would do at this point? Clip. So clips? Clip. I think everyone is now through the scope clip person for this. All right. So, you know, obviously they say there's a few things that we always say you should do. Probably, you know, they're irrelevant. One is to check to make sure you're using CO2 and not air. This is probably the time to do that. If you have a lab where they're still sometimes turning CO2 on, or you have physicians that prefer CO2 and shouldn't be, so this is the time we should be checking to make sure it's CO2. If there's a lot of stool around and you were too lazy to clean it up before, maybe suction that up real quick and then close it. But yes, through the scope clips. Roger, if I could say something. Please. When you do encounter this scenario, a lot of the acute kind of feeling in the room revolves around the vital signs and sometimes when you have a perforation, you know, the heart rate goes up, the blood pressure goes down. Maybe not right away, but after a little bit of time. And so what you really need to be comfortable with is doing a needle decompression or just having that in the room. When you do that, the vital signs often normalize completely. You can really take your time and do a good closure and just reassure everyone that there's not a lot of peritoneal contamination here. You're taking your time. You're closing it nicely. But that can really, once the vitals are normal, everyone can kind of relax a little bit. So that's an important trick to have. I'll show you a video of needle decompression in a little bit, but I think it probably depends partly how big the hole is, but also where it is. It seems to be a big factor. All right. So you'll see, I don't remember who's doing this case. We have a lot of teaching cases in our video library at Northwestern. So the quip closure is great, but I can't take credit for that. And they tattooed the polyp, which I still think is probably irrelevant because that was a pretty good resection of the serrated polyp. Definitely a negative deep margin. And so here, what would you do? So that's the easy part. All right. Show of hands. Who would, at some point during the day, actually we didn't mention antibiotics, so I forgot. Antibiotics also. I would give this patient antibiotics, one dose at least. All right. Who would send the patient home sometime during that recovery period that day? Raise your hand. So we have one person sending home, and everyone else is keeping them? So one and a half people keeping them? All right. Or one of the people sending home, everyone else is keeping them? Okay. All right. So post-procedure, patient has some right side abdominal pain upon waking up from sedation, but does get discharged home, and then develops hiccups and chills at home, and because the pain persists the following day and presents the ED. These are the sort of workup that the patient had, some discomfort in the right upper side, a little bit of a, you know, we always, when we want it to be a low-grade fever, we say it's a low-grade fever. Because you run cold, we say 9.2 is not a fever. It's probably a real fever in this case, a little bit of something going on, a little bit of a white count. So what would you do now? Went to the ED, they're going to get a CT. I thought someone said kill them, but that wasn't what you were saying, right? Just like, it's a little dramatic. We'll save them. Don't worry. All right. So this picture right here, what do you all see? The clips are a good marker if you're not good at radiology. So you see anything in the CT? Probably this right here, right? So not a lot of air. It was read as few foci of extra-luminal free air in anterior to the hepatic flexure. So I can't remember if it's Jen or Sri or Sawney who talked about it, probably all of them did, is that this is where you got to communicate and make sure that we have some trigger-happy surgeons and some really methodical, you know, willing-to-listen-to-reasons surgeons. If you get a surgeon on board who is just, it's 4 o'clock on a Friday and they don't want to operate on, you know, Saturday at 2 a.m., they might take the patient to the OR. But this patient almost certainly doesn't need to go to the OR, right? So this is just an example of trying to get the right surgeon on board and at least communicating well to the patient surgeon. So surgery was consulted, IV antibiotics, and as you would imagine, abdominal exam remained benign. Patient was discharged home two days later in good condition. I'm actually a little surprised, the time course here, and my guess is if the patient went home on antibiotics orally, it would have done fine. It's just a hypothesis because clearly that small amount of air was probably, doesn't represent any sort of failure of the closure. It has to just be that there's a little bit of peritonitis, and that's what patient was having symptoms from. And then just a serrated polyp up with the serosa included. All right. For those of you, you know, I don't think anyone's touched on them. I don't think they were in our lectures. There are guidelines from the CGH on managing perforations, so something to read about. There are a lot of very low-level quality evidence because it's really hard to standardize, you know, these sort of things. But, you know, they recommend a viscous agent, which I don't use. They recommend this opening and closing the snare, which we agree there's no data to support, but we all do it. Obviously, we all agree we should look at the resection to look for target sign and then, you know, making sure we recognize these early. Pictures that you've seen, so I'm not going to go over these again, but nice, you know, take the pictures that you saw and the beautiful slide from the perforation talk. Kind of put them in your head because I think it's very helpful. This is one of my favorite videos of all time. I show it pretty much no matter what lecture, even if it's an ERCP lecture. This is our old fellow, Kevin, who did this great resection with me. Very easy, straightforward serrated polyp. And so removed the polyp here, probably a little extra tissue. We're really trying to get good margins. And so here, so what is, what kind of DMI is that? Sunil, what do you call it? Three, yeah. I would say it looks like a three. This is the dumbest video, but I still love it. So, you know, it's like something we see a reasonable amount. And so we're going to clip close it. So I said, Kevin, can you close this? Naming Kevin. Usually I'll take the blame for myself, but this is great. So he takes the clip and he puts it like right in the defect. Like right there. So this tells you why a DMI three is really just a DMI four. They're all the same. I mean, when you're that closed, this is like a three minus. I'm making your system up. But it tells you what a target sign is, right? You're like, oh, it's just a deep injury. But when it's a deep injury, it goes this deep. Then it's obviously something you absolutely have to close because it's holding on by a thread, right? So I don't think we wrote it as a three converted to four during procedure, but that's essentially what it was. But it looks back kind of where it was before, right? So that just tells you when you see a target sign what you're really, there's not a lot hanging out back there. So then we actually closed the defect. And I can't remember if I sent the patient home or not. I've tended to be more aggressive about sending people home. I've only been burned once on a colitis patient where I think they don't heal that well. But kind of using the principles you saw in the lectures before. So sort of emphasizing that. And then that's the reverse target sign right there. All right. Any thoughts or questions about that? I don't know what we're about to do there. Lots of options, as was mentioned. I'm not going to go over those again. But, you know, we can't just obviously rely on through the scope clips. I'm going to show you some videos that have nothing to do with resection because they're fun. And, you know, we're here to learn things. This is a gentleman who comes in, a 72-year-old, comes in for a surveillance colon and takes some steroid creams. It's a good history. That's how I do all my pre-colonoscopy HMPs. That detail. And I guess I didn't do this colonoscopy. I can't take credit for it. And some diverticulosis and three TAs in his prior colonoscopy six years ago. All right. So. All right. Anyone know what's going on? Yeah. Notes. Notes procedure. Pertinoscopy. I've gotten into the peritoneum a couple times by accident. And it's weird how deep you get into it when you get into it accidentally, though. I don't get it. But you think you just pop in, but you're like way, somehow, way deep. I think all the tension and scope. Because look at this guy. This person's coming back for like a while. So what kind of deep mirror injury is that? I'm kidding. So what do you want to do? Actually, it's not a fair question. In the room, what would you actually do as of right now? So call surgery. Surgery, surgery. Is anyone closing this? Sigmoid. I don't know if I'm doing this right. Oh, can you turn on your microphone? Yeah, I think it's working. Is it working now? It's perfect, yes. So I would probably ask my staff to obviously take a good look. And if I'm in the sigmoid, to get an EGD scope loaded over the scope clip and see if I can grab it first. And obviously have surgery on the backup. And if patient's already not on antibiotics, ask the CRNA to give them a dose of something. So you'll do the same, but for X-TAC? I don't know what you call that. So you'll do X-TAC? Yeah. So I have not had any experience with X-TAC with full, through the scope, or through scope perforations. Have any of you used X-TAC at all for, Sunil, you seem to have some comment on this. I've used X-TAC for a large ilioclonic anastomotic leak, and it did not work very well. It just falls right off. That was a different situation. But I'm overall not super impressed with, you know, it's a little bit of a thinner suture than the suture, the 2-0 that comes with the conventional suturing mechanism. But it is very handy. I think it's through the scope. We don't have to do an exchange. I think it's a totally, it's a reasonable solution here. You know, to comment on, I think Ovesco is a great option. But that diverticulosis was so tight and hard. And the last thing you want is to cause another perforation going in with that. So I don't know. It's a tough, tough situation. Yeah, I mean, I would say that in practice, it feels like most people call surgery. We've had now between the interventional skin called in for these, probably an order of six to eight of these. And now people just expect us to close them. And it's going reasonably well, weirdly. I think if you have to, but you have to be quick. So what you're saying is to be quick. And you have to have a good prep. And if you have a compartment that's open as you said, and you're waiting for it, that's when you can get out of surgery. Yeah, so you can get out of surgery. So I'll show you what it looks like. This is one example. So in this case, it's just like we talked about over the scope. This is actually using the steris padlock. But just like with all over the scope clipping, your visualization gets really poor. So this case, I think this one Aziz did. The next one I did, they tattooed it. I put a clip there. Both of them were moderately helpful. So it's challenging, like Sunil was saying, because the reason you perforate is because there's an angulated sigmoid colon. But it's usually perforations right before the real turn. It almost bends right before it. So you have a few different ways you can deal with this. This is the twin grasper I think he was using to grab one end and the other end, pull it into the cap, and deploy the clip. You could also just grab the fat you saw there and pull it into the cap as well, and then deploy the clip. But as long as you get that red out, and you feel like you've got tissue on both sides, it works. So if you get there fast enough, and so usually it's within 15, 20 minutes, if it's a good prep, you're going to be OK. But you can see the fat there, so you feel pretty good about it. And that's interesting. It wasn't the weirdest, tightest turn, even though it should be. And that's been my experience the last few times I've had to do it, and I don't know why. So in this case, the patient actually did very well and actually was discharged, I think, after a day. Actually, maybe two days after the surgeon watched them. But I've had one where the surgeon just didn't care and operated that same day, and then they always say they did something. But they basically, oh, we reinforced the repair, whatever that was. So I think you have to really get the right person on board. So before we get into this needle decompression, there was a question from the virtual audience of how long you continue antibiotics for these patients. I do, if I'm sending someone home, I usually do three days. If they're a real perforation, I do seven days. I don't know if anyone has any actual data. Was there any data you've seen, anyone, on antibiotic duration after perforations? And the other question was, do you always admit, observe patients' target sign after quick closure? So I said I usually send people home, but a DMI-3 mark, would you send them home, keep them? Honestly, I usually keep them. I usually watch them overnight, because I find that I just probably treating my own anxiety. They often do very well, but I guess I'd rather err on the side of that rather than having somebody not do well at home, get sick and get a fever and come in at a later date in the middle of the night. So I do tend to watch them overnight, but that's, again, probably just me being a little bit more cautious. Yeah, I think it's fair to say, and the comment from the audience was, in practice, almost everyone's going to get admitted for something like this. And I would say probably in academics, most people are going to get admitted. I guess it depends on also where the patient lives, how reliable they are. I think it's, again, you're not going to get burned by admitting them. You probably can get burned by sending them home. Let's say you get C. diff in the hospital. I mean, to your point, if you're doing this in the community, in an ASC, I mean, it's a little bit of an ordeal to transfer them to the hospital from the ASC. So that's certainly a good consideration you have to think about. But those polyps didn't look... I would have tackled those polyps in an ASC, you know, they didn't look too... It's just bad luck, yeah, yeah. All right. This is an example of needle decompression. So you should know this technique, as was mentioned. This is a stolen video. I have yet to get a video of myself doing it. I've only done it... I don't do third space, so I'm trying to... I've only gotten to do it like four or five times. It's pretty amazing. I can't seem to get my video over there, but I'll just assume it's going to work. So you see what... I'm going to start it again and talk you through it again. All right. So what you're doing is obviously finding an area where there's unlikely to be an organ. And what you do is you hook up some saline to... I use an angio-cath needle. Basically find that area. You go in, you see bubbles in the saline. When you see bubbles, you take off the syringe. And essentially then you leave the catheter and it decompresses. And I've had to do it at least twice for true... What Sunil was talking about, like true tension pneumoperitoneum, like hypotensive, unable to oxygenate. And within about a minute, the patients... Or within about 20 seconds, quite honestly, the patient's better. Is there any sort of tips from our third space friends, maybe Sal, any tips on decompression that you use? I also follow Dr. Inouye's instruction. That's always a good idea. Yeah. I mean, there's a risk, but usually when you're doing so much air in this tension pneumoperitoneum that the air is coming well before the colon is coming. Only reason to do it... One time I did it to try to reduce pain after the procedure, and that was probably not a useful reason. Because if you have a lot of air, and this was before we used CO2, if you have a lot of air, it can be uncomfortable and it makes it hard to understand the exam later. But in general, you're doing it because it's patients like hypotensive. So in the syringe, I'm not injecting sterile saline in the syringe, but it's not been injected yet. It's just one of those ones that like anesthesia is like 50,000 of these around, just hook it up. But it helps you see the bubbles, and then you can advance your catheter just a touch more and go. So it's just having saline in the syringe. So if you see bubbles keep coming up, you know that air still coming out. If later on you don't see any bubble come out, you can adjust needle to find the air pocket. But that's just a marker that the needle is still working on it, working. Because sometimes it gets stuck in the tissue. Brown bubbles means you're probably in the cold one, so I don't see more of that. All right. And then we've seen a lot of examples of quip closure. We talked about choosing your surgeon wisely. We talked about decompression. You know, you can put a drain in, and so that's the part of this, which if you had some soilage but you don't have ongoing leak, you can manage it. I mean, when the surgeons have like a leak, they don't always go back and operate, right? If they think the leak is going to seal off, they put a drain and it goes away. So if you think you've sealed something off but you have some contamination, putting a drain and getting that stuff out can be fine. And I've done this for duodenal leaks more than anything else, where it sort of seals off itself. And then we talked about maybe radiographic studies. That I've found more helpful for, again, duodenal leaks than anything else. Colon leaks, our surgeons have asked for it a lot, but I think it's a weird thing to ask for. Like they do rectal contrast to see if there's still a leak. That seems like a big to-do. I'd almost rather get surgery than a CT with rectal contrast. All right. So we talked about that. This patient actually did well, pants to clears, after what's discharged on day two, like I told you. And just because I think these are amazing, here's another video of the same kind of thing. You just never see these. This is part of the advantage that we record all our cases. We see so many, like everything that can happen. So this makes you want to be very careful with your endoscopy. It's always the same thing, but both of these were not such dramatic pushing views. Maybe they'll just get to the CECM. Maybe we got the wrong case. I can never remember. So for the fellow, I always tell the fellows that if the tip of the scope pushing on the wall and you start seeing white, like white mucosa, stop immediately. That means you are having a lot of pressure on the wall. Don't keep pushing if you see white. Which is exactly what you're seeing right here. You're seeing some blanching of the vessels. And recall something's going to happen right here. I think a clear cap could work. Could work. Yeah, I don't find the nook off as helpful for me to get around turns. I find the clear cap more helpful for that. Mark, do you use any of the ADR advanced mean devices? I don't. I don't. I just take my time with my withdrawal. Yeah, but I don't know if it's data that helps us, say, getting around these sort of tough sigmoids. ADR. Yeah, exactly. Oh, for ADR. I thought you were saying just to navigate. Oh, ADR? I am not, because I think we're using AI, and I don't know if we know if AI plus endocuff is any better than AI alone. So this is a similar type of case to the last one, although maybe less peritoneum. What about the tick? I still don't know what it was. So this is how we approach this. I don't know if this is going to play correctly. Let's see. Oh, there we go. So that's the hole we figure out with the upper endoscope, like everyone sort of mentioned, using a thin scope to figure out. And then we had marked it after that with a clip. And I found this one very hard to, more like Sunil's idea, which is it was a tight area. It was very hard for me to, and that clip was super annoying then, because even that was giving me some drag and resistance to get to that. And I got to it, and I tried to make it better, and then I fell back again. Anyway, so here's us lined up with the perforation. And I initially had tried to use the twin grasper, and that's when I fell back again. So I did what sometimes doesn't work, is just suction and hope. And let's see here. Here's another example. This is also padlocked. It's easier than the Ovesco for these cases. And so trying to center the perforation in your cap, suctioning the tissue, and I kept trying to make it better, but I kept just making it bloodier. So there you go. So now I'm just going to do some test suctions, and then I'm pulling all the tissue in. And this patient was weird, because had no symptoms. It was confusing to everyone, probably because it was probably contained. It didn't seem like it went into the rest of the world, except the first one. But obviously, it needed to be closed, and then went home after two days as well on antibiotics. So I think it's a helpful thing to know, because these would not close through the scope clips. And obviously, you're saving a tougher surgery, because a sigmoid resection is not super easy on an old person. So does anyone have any questions or comments on those? There was a question about in the audience, a virtual audience, about the size of perforations. I don't know if anyone has any experience on OTSC closure in parallel for large perforations. I've seen more from the ERCP literature with the Bellroth patients, where they get these gigantic perforations. And there's been some studies or cases of closing it, closing another clip right next to it, and actually it working just like through the scope clips would work. But I have not sort of said, I've not seen a perforation that's so big that you think is not going to be closable over the scope clip. Leaks are all different issues. I think these videos are really important. So the sigmoid colon is the most common area where you're going to see colon perforations that are iatrogenic from a colonoscopy for a lot of reasons. These perforations are different than the colon perforations that you'll see after an endoscopic mucosal resection in the right colon. Those perforations are often smaller in diameter, and they're often treated just through the scope clips. These types of perforations are usually due to the scope going through, and they're larger in diameter. And like Raj said, these are probably less managed, and they're tricky to manage with over the scope clip, basically because they're generally larger, and just for a lot of reasons, more tricky to deal with. So it's good to get used to these for the upper jab weeding, so that when you need to use them for something like this, you have some experience. So when will you bring the patient back for repeat colonoscopy, the complete full colonoscopy? I was worried that I closed the lumen, because it was so hard to get by. But the endoscopist that I did this for was like, should I finish the colon now? I'm like, are you crazy? It's like, didn't you read the paper? Screening colonoscopy doesn't help. Sorry. So I think if I were the patient, I'm like, I'm good. I don't need a colonoscopy again, but we'll see. I think it's hard to say, because these clips may not fall off, and it's already pretty angulated. But if you felt you needed to do it, I would feel fine doing it after maybe two or three months. There's time people you might need to do it. So we didn't talk, and as I thought about the syllabus, one of the things I would improve in the future is probably do a little bit more on the duodenal polyps, make a lecture on that, because those are awful, and a lot of us see them. But let's talk a little bit about duodenal polyp adverse events. This is with a side viewer. It says polyp was referred to me, and I think it was referred for an ampulectomy. To me, nothing better than ampulectomy. It's not ampulectomy, because even though I hate duodenal polyps, a giant duodenal polyp that's also an ampulectomy is even more risk. So you can see here, the polyp is actually, was, you almost saw the orifice up there. So it's like really best friends with the ampula, but not quite there. So I was able to separate it out from the ampula. So the point isn't how we manage these, although we could talk about that. This is a tough one in general. I think I ended up able to, see if it works here, there we go. I was able to inject it, probably caused some pancreatitis from the injection, away from the ampula to take it out. But more of a question of, actually wanna get some opinions of when it comes out, there's a lot less known about how to prevent bleeding. So you might see one centimeter polyps in the duodenum, you remove. I mean, duodenal polyps bleed so much. It's so awful. So let's see, Jasmine, you've just joined us. What would you say you've seen in terms of bleeding prevention for duodenal polyps? What do you believe? Well, I agree with you that they're probably, I think my most hated procedure, cause they tend to be very big. And I feel like closing this defect tends to be probably not so practical. So what I've seen is soft coagulation, you're kind of doing a very good survey of the resection bed, soft coagulation treatment of anything that looks like it might be a higher risk, like an exposed vessel and the edges of the margin morpher, prevention of adenoma recurrence. And then if it's a smaller resection bed, obviously we try and close it, but otherwise I think it is a little bit of just hoping that you're not seeing a post polypectomy bleed in those patients. Two questions. One is, any role for prophylactic gels? Is anyone using them? Does Hyde Park have any prophylactic sprays? So you're saying post resection? Yeah. So yeah, we've used Puristat so far. In one of the, not in diurnal resections yet, but for EMR and EST we've been using it. Actually one of the cases, very large EMR did bleed after even Puristat and we had to bring the patient back in. The other thing where maybe mixing your lifting agent with epi for diurnal resections, just a suggestion because if they bleed a lot, yeah. Yeah. I tend to not mix, my personal bias, again, no evidence. I don't put epi in any of my stuff because I'd rather it bleed immediately than an hour later. But that's, I do it, it's not fair. I do it for serrated cold EMR, but I don't have a risk of delayed bleeding there. But in general, I don't do epi, but I don't, do you all do epi in your solutions? I feel like Miami might. I use cold EMR and then that's what I primarily use. I use a very, very thin epi sometimes for rectal ESDs just for the initial incision because I hate, I just, that bleeding sometimes is really challenging, but that's it. Anyone do anything different? So Purostat is, there's some of the newer hemostasis agents have some data to support prophylaxis as well. There's actually people out there who believe you should not clip close these as well. I think that it's more risk and those clips, first of all, it's a side viewer, so clip closure is very challenging with the duodenoscope. And second of all, is there some concern because the traditional clips have a very long tail and then it's just causing a lot more irritation of that whole area. So at least a year ago, Australians were saying don't close them. Yeah, yeah, so I think they go, I'm saying it goes, I think no one knows what to do, but I think if you're gonna close them with clips, I would use a very short tailed clips or some new ones out there that are much shorter. I switched back to the upper scope to try to close it. These are the worst, but I would say that if you're gonna do it, try to get some of these ones with a very short tail, cause you can see better and they don't necessarily cause some irritation of the contralateral wall. I think the novel gels that might prevent bleeding are very interesting. And then BID-PPI, and then probably keep the patient overnight. Cause my experience is that generate blood within the first 36 hours when these bleed, whereas colon seems to bleed forever. Any other thoughts? So X-Tag is another option. Good point. I think the manuscript has been submitted. So the success rate of complete closure with X-Tag plus minus clip is really high, like 80, 90% in the duodenum. But if you don't have, you can do other technique that we talked earlier. Like the Japanese, they try to close all duodenal ESD with a defect of four centimeter or larger, and they use the suture clip with suture technique. If you don't have X-Tag. That's a good point. And I have not used X-Tag in the duodenum. So if you had good experience, have you used it yourself? It worked okay? Yes, yes. Now I switched back to the upper scope now. Clip or X-Tag? Clip, you can try. Some of them say they're better than others. But my experience is generally, especially if you're trying to go up with any elevator, it deploys the clip. But some of the new ones are less so. But it's much easier with a four viewing scope. I won't let you see my awful work here. I have to have it underwater since everyone makes fun. I'm not even that big of an underwater fan. But it's a nice example of what it's like to bleed. To me, this highlights more the principle that was mentioned a few times of actually positioning the patient so the blood is not dependent. So even though we show the bleeding underwater, it's not really the underwater that's kind of pretty, but it's not the underwater part. It's the fact that it's not collecting on the defect. And so if you can just turn the patient to where the blood is going the opposite wall, it's really nice. But you can get a nice, pretty picture of the bleeding when it's underwater. And so I use the snare tip. You could argue, you could use anything here. The Coa Grasper. You could use a clip, but I wouldn't. So this is using soft coagulation and snare tip. But to me, because it's showing how it's moving away in sort of slow motion, really hides to, a couple of videos we saw today where there's just blood collecting on the defect over and over again. Maybe that's the one where you have to really think about turning the patient. This is a patient on, and I'll do this as our last case because it highlights the sadness of, I think it's, let me just see if there's another better one after this, hold on. Right. Actually, there's a couple of good cases. I'll do two since we have the time to do it. See how this goes. So this patient comes in for this polyp and is on Eloquus, they stopped a couple of days ago. And during the resection, they encountered this bleeding. So it was just not going well, it sounds like, during any part of the procedure. It just kept bleeding everywhere. Like a lot, over and over again, and then kept coagulating and then bleeding. And it was like that whack-a-mole, you know, the game, those of you who lived your life in arcades, hitting one thing and another comes up, then starts to bleed next to it. I don't know why this, some of these are so vascular, and this was not a cancer in the end. This was just an adenoma. An adenoma. Some of these can be super vascular and just be non-malignant. So kept trying to get hemostasis, then kept moving on with the resection. There's another. Close the snare and take this off. And then more bleeding. It's crazy, isn't it? So much bleeding, look at this, two of them, that's. So I have my own cases look like this, but I use other people's. But so I think then they tried to, I think this is, it just turned into a blood bath, which we almost never see, right? Obviously we do a lot of resections in our institution. I've never seen a video where it just kept popping up and it was never able to get good hemostasis. So actually ultimately they could not stop the bleeding, which again, I've not seen, I think ever, in the time I've been there where they actually had to send the patient for ongoing arterial bleeding. And IR initially said like, oh, it looks good. We don't see any bleeding. And then the fellows like, but there's clips like at the bottom, we're not even looking at the clips where the bleeding is supposed to be. I think it was just late and everyone was irritable. So then they actually went to where the clips were and then you can see still active extravasation, despite all the attempts at coagulation, grasper, forceps and all the stuff that, the clips, everything was done. Yeah, actually I skipped over it, hold on. Fair, fair point. I don't wanna make you think that. Not literally every $100, $1,000 was spent. There you go. Chemo spray was also done. So when we spend money, we spend it. No, just keep going. Which tells you that it works probably, but then it doesn't. And then actually embolized, but then of course the patient then developed more abdominal pain, shoulder pain. Anytime someone gets shoulder pain after an endoscopic resection, it's never like their tendinitis. It's always something worse. Had a little bit of free air and actually had to get surgery with a small amount of fluid, some hemoperitoneum and pneumoperitoneum. Ultimately did fine, but sort of, we show a lot of cases where things go well or we even stop complications. It's good to see that even occasionally that things just really spiral. And this probably perforated because you embolized the remaining vascular supply to an area you just took out. Most of the wall, you've already done soft coag to that whole wall. So it sort of makes sense that this would happen. And it was just a villus adenoma. Big one, but villus adenoma. I will skip the gastric polyp. I think we can get ready for your talk, Jasmine. I don't think there's anything else that we, yeah, we absolutely have to see. I'll show you this, I guess this last one right here. After a gastric polyp removal, after innumerable modalities, it was continuing to ooze. It was bleeding. I'll show you, it was bleeding quite briskly after resection in the stomach. And so lots of soft coag, lots of things, just like the other case to try to stop the bleeding. And sort of more adjunctively than to stop the bleeding, didn't over the scope clip. I'll just show you that. This is the Ovesco over the scope clip. It's good for you to see how it looks. Again, like the other ones, hard to get down the throat. Once you get down, try to find the area of bleeding. Caused a pretty big laceration in the esophagus too when I came back later, which you don't need to see. So because this takes up some of your working channel, you can see I got some bad hemostasis, but hemostasis nonetheless, with just tons of cautery artifact. These definitely limit the flexibility of your scope, but I was somehow able to actually put this on in retroflexion, so you can see the area that was bleeding previously. And so you can try to work your way up there and suction this defect into the clip, but I've not had to do this very much at all. Probably the smarter thing to do would be suturing to try to reinforce it, but I'm a better clipper than a suturer. So this is what the Ovesco device looks like. Suction it in, deploy the clip, and should get more durable hemostasis then. Which isn't super easy to do in retroflexion, I'm surprised it worked. And you see all the tissue in there. So just another example of another modality for hemostasis. Any comments or questions from our experts? Anywhere in the room? All right, well with that I think we're on time to move to our lecture, so thank you all. Thank you.

adverse events

endoscopic procedures

colon polyps

duodenal polyps

incomplete resection

recurrence rate

perforation

bleeding

hemostasis