The next thing that we're going to be discussing are a variety of clips used for closure. All right, and so we have a variety of clips here to show you today. Many of them you already have used, and I guess this is another question for the audience. What's your most commonly used through-the-scope clip? So the first clip that I'm going to be showing is the Boston Scientific Revolution 360 clip. And this clip is great because it has really nice 360-degree rotation. And so what I'm going to do is open this clip up and try to keep it as still as possible for the audience. You can see that by turning this orange component, we're getting really nice one-to-one rotation. Okay, so I'm going to close this. And the other thing that's nice about this clip is you can open and close it several times, and it won't deploy. All right, so if you want to—have you used these clips at all, Shifu? Yeah, the 360 ones, yeah. I believe, if I'm not wrong, these are the ones that the endoscopist can rotate as well and the tech as well. Yep. So I kind of like that about it sometimes because the two mucosal defects here, we can use the clips for that because sometimes it's not always easy to translate what exactly you want to the endoscopy tech, so I kind of like that about this clip. All right, so you're the boss and I'm your tech. Oh, that's new for me. I'm not used to that. So we can try—so what I would probably try to do is try to go to the upper margin of the defect first so we can probably open it at like three and nine o'clock to start with. Okay. So I'm going to open. And I'll see if I can—and maybe I can try to see if I can rotate it. Great. So that was all you. Now, another key thing when you're getting ready to deploy this is you want the mucosa lax a little bit, right? So you want to suction out some gas to make it a little bit floppier so you can get better and deeper purchase onto the mucosa. And you want to carefully—see, you got all the—you got both edges, kind of suctioning it down a little bit. Yeah, that was a great tip. I'm trying to see if I can get more of the upper margin. And she was just pushing forward a little bit. I think this is where I would like to start. A little bit of suction. Okay. Close slowly. So I'm closing slowly. So I do feel that I have both ends and, like, I wanted to start from the upper margin. I think I'm okay with—I just want to see the other side a little bit better. So maybe pull it back into you a little bit. Yeah. Great. You'll be able to see on the other side. Push forward. Yeah. And what I also noticed about this, Shifa, is that even though you're just on the upper aspect of it, the bottom part, the second half of the defect is already coming together, which means that your subsequent clips are going to be very, I think, pretty easy to place. That's the hope. I think we can deploy here. All right. So what I'm doing is I'm squeezing down on this and opening back up, and the clip has been deployed. Oh, so we did easily get both margins. Yep. You sure did. Real life. All right. So that's the Resolution 360 clip. Again, I would say that was a successful clip deployment. Thank you. Pretty efficient. The next clip that I'm going to be demonstrating is the Quick Clip Pro, and this is from Olympus. And so, now, we haven't used this clip at our institution for a while. They recommend keeping the sheath on this clip in order to help protect the internal channel of the scope. I'm going to leave this on, actually. Oh, I'm going to leave this on, actually. So the plastic sheath remains on while you're passing it through the biopsy channel? You're supposed to keep the plastic sheath on. Oh, I see. Yep. And actually, you're supposed to keep this red thing on, this red piece on, until you're ready to get it in position as well. All right. And so, the way that we reveal this clip is get yourself in position, and then when you're in the air, it's going to come out, and it's going to come out in an open position. So you want to be ready for that. So it's advancing, and there it is out in the open position. So bring your catheter in a little bit closer, because it's always better to work a little bit— Now, is this something that the—is it a clip that an endoscopist can rotate, or is it all— Yeah, I'm able to rotate it by rotating the entire handle. But I don't have that. Right. You won't be able to do that. I don't have that functionality. Correct. Great. Yep. Doing great. Trying to go as close as I can. Mm-hmm. Trying to do some— Yep, and push your catheter out a little bit, maybe. Yep. A little bit of suction. Okay, I think this is a good spot. I think it looks great. Yep, I think it looks great. I'm going to close this and deploy. And make sure that we're off. Great. Take a look at that. Great. Looks terrific. Yeah, both ends. Yep. So also, pretty equally easy to use. Again, you know, being prepared for it to come out in the open position, you want to make sure that when it does come out, you're not, you know, kind of hitting anything or, you know, pushing the arms into any defect or anything like that. But overall, pretty easy device to use. It does seem like it's like the stem is smaller than the 360. Mm-hmm. Yeah, the stem is a little bit smaller. All right. Now, this is another one where you can open and close it, right? So if we had closed and you weren't happy with that position, this one you can also open again and reposition a few times before it gets a little bit wonky. What's, I mean, as a fellow, I've misdeployed a few clips here and there. Sure, sure. How do you, like, what's your approach to that? Like, let's say if I misdeployed it and it's not at a location where it is, do you normally snare it off or? So sometimes I'll just leave it because as long as it's not obstructing my view, I'll leave it in place. If it's causing trouble, I sometimes will just snare it off. But then you get a little bit of bleeding, but that's usually mucosal and not a big deal. One of the ways that I have found to try to prevent, you know, misdeployments or, you know, miscommunication is I really take the time to discuss with my assistant, so the technician who's working with me, the nurse who's working with me. Okay, this one works like this, and I would like you to do this in really clear communication so that you're saying, okay, open, rotate it, and sometimes I'll use my hands like this to show them where I want it to be rotated. I also sometimes will use the clock numbers. You know, I would like it at 12 and 6, and that goes really well. And you'll see that as you're working with your technician and nurse more and more, they know how it's supposed to be, right? It's usually very clear to them how it's supposed to be. And when you have a really experienced nurse or tech, sometimes they'll put it in position without you even saying sometimes. So the third clip that we're going to be using is the Steris Assurance Clip. All right, and this is a nice clip. It has a larger opening. The opening of it is 18 millimeters across, and so it's one of the larger ones. All right, so it came out of the package, and when I took the sheath off of it, it popped open. And so I'm just very gently applying pressure to the plunger here. Okay, open. Yes, I'm going to open. And you can see this is a little bit wider than the other two, at least it seems like it. Again, maybe a little bit more towards three and nine angle. So I'm rotating this by rotating the handle here. Looks better. Thank you. Yep. And suction a little bit of air. Okay. Close. It's closed. Deploy. And it's deployed. Okay, great. And you can see what's nice about this is that it has a large arm. So it has wide arms, but it has a very short nub at the tip, which is great. You can see, I think, if you can kind of show all three of them, Shifa. Yep. Great. You can see the difference in the size of the tail. Okay, excellent. I would say that that defect is well closed. All right, now we're looking at some of the other devices we have. Let me see. Oh, great. So this is another Boston Scientific clip. This is the Resolution 360 Ultra clip. And this is a little bit larger than the other, than the Resolution 360. Its opening diameter is 17 millimeters. And so we're going to give this one a shot. I'm going to see if I can aim for this area between... Actually, with this large clip, I'm wondering if you can just close the middle of that other defect. Like right here? Or I was actually kind of thinking about that other one. If you could get across that. Like this one? Yeah. You think you can get across that? Okay. Let's give it a try. Let's give it a try. Let's see how wide this is. And this looks very similar to the Resolution 360 in terms of the packaging and the way that it's formulated. Here we go. I'll push out a little bit and suction some air, see if you can get it to decompress. You like it? Yeah. Close. Closing. Good. Deploy. Deploy. Great. So let's take a look at that defect. It looks great. You got across the widest part of it with just the one clip. Nice. Looks good. Pretty easy, right? Yeah. Yeah. Okay. And then the next thing, maybe why don't we shift gears and use some of the over-the-scope clips. Perfect. All right. So I'll pull out the double-channel scope. Well, I think we don't even need the double-channel scope. Yeah. Maybe we can switch to a regular endoscope. Oh, yeah. Just switch to a regular endoscope. Yeah, sure. For the OTSC. All right. So bear with us while we switch out our scopes. If there's any questions, please put them into the chat. Okay. Great. And then if you can just pass me the Ovesco. Okay, great. So the next thing we're going to be demoing is the OTSC over-the-scope clip. There's a variety of sizes that are used for this. And it typically comes in a package that contains this feeding device, which is very similar to the way that we use the Cooke banding system. This device is very similar to that. And it has a mechanism that this will go onto the scope and fit on here really tightly. And then this cap is fitted with an over-the-scope clip, sort of like a bear claw type clip. And you can see how this is fitted. And this will go through the working channel of the scope. This will be fastened on the tip of the scope in the same way that a banding device is. Have you used these before? Oh, yes. Yeah. Okay. So the first thing we're going to do is put this cap on, yep. And so we're doing this by opening up the biopsy cap, but leaving the cap on. And then we'll fasten that tightly. Thank you. Okay. So that's on nice and securely. The next thing we'll do is use our feeding device here to go through the working channel of the scope. All right. And then I'm going to use this right here at the tip of the scope to hook it up to the string that has a knot. And then Shif is going to pull back on the catheter, and it just comes off this little sponge here. Great. And then that knot will go into this little here, that little area there. Yep. And we push this down. Oh, sorry. This knot goes into the hole, and then we kind of push it down so that it's caught. And then we'll tighten up this string. Great. Now it's getting tight. So it's very important to avoid putting your finger on the edge of this in case it does deploy. And so what I did here is I just placed it on the table and pushed down. And now you can see the catheter is securely, or the cap is securely affixed to the tip of the cap, or the tip of the scope. And endoscopically, you can see the teeth coming over this cap. All right. Great. Okay. So now our device is ready to use. We use a little bit of lubrication because the width of this is actually quite wide. Do we have suction? We have suction, right? Yeah, okay. All right. So you also want to make sure that when you're doing this technique that you've tested your suction and that your suction is up high because you're going to be suctioning either a vessel or a fibrotic device or a defect into your cap. And you want to make sure that your suction is optimized. I'm just going to find a defect. Great. And so we can identify your defect. I feel like we may have targeted most of our defects and I can just pick a location if you're okay with that. Absolutely. Maybe we can try to aim for this area. Right. Now, with these, it's very important that you're very meticulous about where you choose to deploy this clip because once it's deployed, there's really no going back. And so you want to make sure that these are used for a variety of indications. Some is perforation closure to oppose the tissue. Some is these are also used with bleeding vessels. Right. So an acutely bleeding large duodenal bulb vessel in an ulcer bed, OTSC has been used for that. And so you want to be certain of the indication for your use of this device and be very precise with how you're suctioning things in and almost practice before you finally deploy, if that makes sense. Practice with suctioning. Let's give that a shot. Some suctioning, suctioning, suctioning. Right. And so with these, you know, we're not aiming for the red out that we typically get with, you know, variceal banding, but we're aiming to make sure that the defect or the vessel or whatever we're aiming for is really within the cap. And there are a variety of other tools that can be used. There are two devices that are oftentimes used with this. One is a similar kind of tissue helix where you can screw into the tissue and pull it into the cap. And it's really important that when you use that, you make sure that you've pulled your device into the cap so that it's not outside of the cap because it could get caught in the teeth and it could get, you know, jammed up that way. There's also a individually opposing forceps where the two arms are independently articulating. And so you can use one to grab a piece of tissue and then close it and then use the other one to grab a piece of tissue and then pull that into the cap and then deploy your clip. And there's also a third type of tool where you can actually put it through a defect, say, for example, and it springs open. And it has kind of arms that you then pull into your scope and that helps pull that defect into your scope as well. So while you've been demonstrating that, I feel like I'm able to suction it pretty well. I was just practicing suction. Right. And very similar to a banding device. You're just going to... So I'll just do the wheel away from me. Right. Great. And let's see what it looks like. Great. So you've got a nice piece of mucosa up in there and a very secure OTSC deployment. It looks terrific. So there are a variety of sizes associated with the Ovesco. And so there is the... I think there's overall three. And you have to kind of order all the different kinds. There's kind of the short one. There's one for gastric closure. And then there's sort of an intermediate one as well. So depending on the level of intensity of the sharpness and the depth of the teeth is kind of how you determine which one you're going to use. So what's your preference with using APC around the closure area versus where it doesn't really matter to you? So in terms of like fistula closure? Yeah. So I think that anything that you can do to help promote kind of tissue, overturn of tissue or tissue generation will help close that. And so if I'm dealing with a fistula or say, for example, somebody who's status post-gastric bypass who has a GG fistula they'd like closed, sometimes APCing this and then putting an OTSC clip over that defect can sometimes be an effective way of closing that fistula. There are a variety of, as we were mentioning, there's a variety of cap options. And there's actually this mini one that actually fits over a diagnostic EGD scope. And so I'm just going to show this table here. If you can zoom in on this. So you can see the different types as well as the overall diameter of them and the type of scope that they fit on. This is pretty important information. Because the one that we just used, this is on a standard gastroscope. But there's also ones that will fit on larger scopes as well. Have you had any occasions where they've been misdeployed and needed to be removed? So I've been lucky in that. And we don't use a ton of over-the-scope clips, but you can. There is a scissors to cut them now. And then, you know, I'm also kind of curious if you use, you know, cryotherapy, if that would open things up. Because the nitinol is bent in such a way that when you put it on ice, it opens. And so I've been kind of curious about whether or not spray cryotherapy would be an effective way to open it. But I haven't actually tried that. We had a case with a diodinobulb outside the posterior wall. And it kind of got the pyloric shell as well. So we had to remove it. And there's like a generator that Ovesco comes with, you know, that can help remove it. It's a little cumbersome, but just an option out there. Was it effective? Yeah, yeah. Actually, it was surprising. I've had two occasions where, yeah, in that one, it was effective. And then we used it for a fistula closure. And later on, we got in a soft program that showed the fistula was not closed completely. So it had to be removed. The second occasion, we couldn't get it off. And we had to use Bi-Cap and everything that may not be FDA approved or appropriate. Yeah, sometimes I've also found that treating the side of the clip with thermal therapy can sometimes loosen up the tissue behind it. But it's always a little bit dicey when you're doing that. That is kind of something that we have in the past used for like enteral stents. If we're trying to get vulnerability access with enteral stents, use APC. And that's kind of what we tried with our Ovesco clip. Somewhat effective. Awesome. Well, I hope this has been an informative overview of some of the closure devices. I think that a few key points from this session are that you have a variety of tools at your disposal. It's important to gain familiarity with them. And really try to figure out the ones that are most easily adoptable into your practice. Right? So what are some of the things that you think that would be beneficial to your practice that would get a lot of use or be good to have? And those are the things that you should consider stocking in your endoscopy unit. There's also a variety of additional resources for training. I certainly don't expect anyone to be able to go out and use the overstitch device after just watching a little bit of a virtual demonstration. But fortunately, there's many online videos. There's courses from our industry partners on a lot of these devices. And there's also additional training on these at some of the ASG hands-on courses. So thanks for your attention. And we're going to be restarting the final session at 3.30pm.

endoscopy procedures

Boston Scientific Revolution 360 clip

Quick Clip Pro

Steris Assurance Clip

over-the-scope clips (OTSC)

Ovesco clip