All right, welcome back everybody to day two of the ASGE Advanced Endoscopic Lesion Resection course here at the IT&T Center. I have the pleasure of introducing Dr. Jennifer Marenke and Dr. Shifa Umar. Dr. Marenke is coming to us from the Penn State University Medical Center in Hershey, Pennsylvania. And Dr. Umar is one of our local advanced therapeutic fellows at the University of Chicago. And they're going to be going through several different skills today, looking at both hemostasis, endoscopic suturing, X-TAC, and a few different clips. So I hope you can enjoy. Thanks very much, Adam. I'm Jen Marenke, and I'm here with Shifa Umar. And we're going to be demonstrating a few endoscopic techniques today related to endoscopic resection. We're going to start by demonstrating two different types of hemostatic sprays. And a question for all of you virtual participants, what is your biggest issue with using hemostatic sprays if you've used them? Please respond in the chat. So Shifa, have you had any experience using hemostatic sprays? Yeah, we've used the Coq hemo spray during my fellowship and advanced endoscopy fellowship. We actually frequently use it in patients post-large EMR, even as to prevent bleeding, not only just to treat active bleeding. If you would ask, I think the most common problem that we accomplish is visualization and it getting stuck on the skull. I see. Yeah, I also have noticed with certain types that it can be difficult to close a defect after hemo spray has been applied. So we're going to start first by demonstrating the endoclot, which comes in this type of package. This is a polysaccharide hemostatic spray. And it comes in a few components. It also comes with an endoclot air compressor, which will be your insufflation source. So even if you're using carbon dioxide insufflation, you'll switch to this air compressor that will, you can keep your CO2 insufflation on, but this air compressor will be what's delivering the hemostatic agent through the scope. So we first start by using this powder and we hook it up by using sort of a 45 degree angle to screw this in. And then with that, you'll take the tip of the catheter and push it down. Once your air compressor is on and ours is already on, you'll put that through the working, channel of the scope. All right. Would you like me to introduce the scope into the model first or? Um, actually it would probably be best to, um, either, either or is fine. I think really. Okay. I'm going to intubate this big stomach. All right. And I'm just going to untangle this. All right. So we'll introduce this through the working channel of the scope. Got it. It's definitely bending a little bit, but I'm able to advance it by holding the catheter closer to the biopsy channel. All right. Now, as the, um, as the catheter is being introduced through the working channel of the scope, it's important to keep this at a 45 degree angle so that we're not dumping the hemostatic powder into the catheter. We'll wait until we've identified our bleeding source, and then we'll, we'll, um, I'll show you the technique for applying the spray. And so we're going to use our bleeder here. Let's see how well our bleeding model works. Maybe get back up a little. Oh, got a bleeder. The vessel is right here, spurting vessel. Okay. And so what we can see here is the way that this is applied is we gently tap so that some of the, the spray definitely bends. The catheter bends a lot while you're introducing it. I don't know if you have any tricks to help with that. Um, I don't, I feel like once it's bent, it can sometimes be difficult to use. So sometimes just backing up a little bit. All right. And can you advance that through there? Yep. It's, it's just coming, it's just coming slowly. There you go. Right. So I may have jumped it up a little bit for you. So the, it's important once your catheter is down to then use to sort of tap this device and you'll see that the hemostatic spray is coming out. That's very controlled as compared to the cook device. And you can see you have really good visualization here. Is this compatible with all endoscopes Dr. Marenke? It is, and I think that it, I'm pretty sure it comes in a longer device to work through a colonoscope as well. I'll have to check to confirm that though. Great. And so that's how that works. Switching gears we can also demonstrate the use of another hemostatic spray, which has been on the market a little bit longer I think there's more clinical experience with that. Right now we do have some leftover. Can this be reused or is this like one application only like most other hemostatic spray? This, I don't think this can be reused at another setting in another setting, but in the same session, this, this bottle can be reused. Thank you. So I'm just going to wrap this up. And then we have, we'll need insufflation. We use the insufflation through the scope for this next type, and you all may have used this device, which is the Coquima spray. This has been on the market for a number of years now, and it works in a similar fashion. One of the key aspects of the use of HEMA spray is that you must keep the channel clean, right? So I would recommend doing whatever suctioning you'd like to do to kind of clear your field as much as possible before we put our catheter down. This comes with this type of device that is the gun with the hemostatic powder here. And we'll start by, Dr. Moran, you mentioned that it's important to keep the scope channel free of any debris. Any tips on how to prevent clogging? Yeah, so what we typically do is we hook up this catheter to our CO2 insufflator, and then we put it down through the working channel of the scope. When this first came on the market, we recommended flushing the catheter with several rounds of a 60cc syringe of air to sort of dry out the catheter as much as possible. And then additionally, it's very important to avoid suctioning while you have the catheter down there, because you want to keep it nice and dry. It's oftentimes difficult to do. So we found a little bit of a workaround that was actually published in Video GIE involves setting up the CO2 insufflator to this device until you're ready to deploy. And so I'm just going to grab this. Where is our garden scope insufflator? This is what I have, the classic. Okay. So what we'll use instead is air. We have 60cc syringes of air that we can do to make sure that it stays. Okay. And if you just want to suction that down a little bit, that'd be great. So suck out all that you need. And then in terms of actively bleeding source, we'll find another, yeah, suction that if you can. Good. Great. So decompress the stomach. Okay, you're finished suctioning Shiffa? Okay, so now you can put this down. This is definitely more firm and easier to get down the previous catheter. And the whole while that you're doing that, I'm just going to, typically you'd use a larger syringe. This is what we have to kind of keep the catheter dry from any debris, and this can be difficult without an insufflator because you get a lot of clogging and it's difficult to avoid having some of that liquid or blood, whatever debris is in the stomach, go up into the working channel and through the catheter. Let's see if we can find our bleeder. All right, so you've got that through. Okay, great. Let's see if we can find our bleeder. There it is. Okay. Okay. Now we connect this to the catheter here. Push this to on. And then we activate this. And then we apply hemo spray. And it's in short bursts, doing a great job keeping the channel nice and dry. We make a deliberate effort to stay far from the mucosa. So the interesting thing is that I do avoid avoid getting near the mucosa, because there's a greater likelihood that you'll. There's a greater likelihood that you'll make contact with the liquid. And so I, the hemo spray actually can be effective, even without, even without really a direct spray on things on the bleeding source. And so in the general area it's been shown to be effective. Now you can see the overall effect that this has had right this is a large amount of hemo spray. It's hard to not to not want to suction it. And your view can get obscured rather quickly with this. The other thing that I found with hemo spray is, if you're, if you've used it in the setting of of mucosal resection and you want to suture the defect closed, the hemo spray can make it a little bit firm and it can be difficult to, to close that defect. In terms of, in terms of troubleshooting you know tips for keeping the catheter dry. My main go to is really hooking up my co2 insufflator to the catheter, until I'm ready to deploy the hemostatic spray. Right, so I hook up the, the co2 insufflator to this area until it's just about time to go and then I switch things out, hook it up to the hemo spray gun, and then deploy, and that's been very effective for me personally have you used that at all what do you do, Shifa at the University of Chicago. We currently. That's a great tip but yeah I do have like, like you described previously like we've seen our techs would help out with like with a 10 cc syringe. While we're driving the catheter down but not use that particularly hooking it up to co2. Right. I think you need to make a constant conscious effort to avoid suctioning. And also recognize that the hemo spray can be deployed in the general area so even when you can't see all that well, you can be confident that it will likely be effective, as long as it's in the general area of your bleeding source, and that's, I found I have found that to be true. It sounds like some of the main issues that you all have encountered are similar to what we've encountered which is that the hemostatic spray can clog your view, it can obstruct the probe. And oftentimes these devices aren't used frequently enough to really develop a system for doing it but I do agree with the co2 insufflation and really just trying to keep the channel as clean and dry as possible. Do you have experience with like you know if you've used hemo spray and going back in and taking a look like, you know, 48 hours after, and what does it look like. Sure. So, the. We have gone back, gone back one day later and 48 hours later and usually by 48 hours, all of the hemo spray has has dissipated it's it's kind of all gone. And what we typically see is a healing ulcer bed or whatever source was bleeding that will be healing that will be, you know, starting to heal over, and, you know, have a decreased risk of free bleed, you do have visualization for retreat men, yes, definitely at 48 hours that is that material is gone. And so you're able to reassess and readdress. I think that one of the, my. to be helpful is in the setting of an acute bleed, whether it be from a post mucosal resection defect, or a peptic ulcer bleed. If we haven't been able to achieve hemostasis using our standard techniques meaning, you know, possible epinephrine injection with hemoclip or electrocardiogram like the bicap probe, or even if it's not suitable for an over the scope clip, we've deployed hemo spray, even for the purposes, knowing that this may read lead knowing that he must pray will dissipate dissipate within 48 hours or so, but to buy time to allow that ulcer to heal with proper acid suppression. A lot of times that's enough that that's enough of a temporary fix to prevent a read lead. Thank you. Any other questions. I think, I think that's pretty much it for the hemo spray. Okay, great. I don't know if you have any other questions from the audience. Alright so we're going to shift gears after this we're going to change out our models, and we'll be back with some endoscopic suturing devices. Thanks very much.

endoscopic resection

hemostasis

hemostatic sprays

Endoclot

Coq hemo spray