Welcome back everyone, I'm here with Shifa again and we're going to be demonstrating the use of the X-TAC device, which is the Through the Scope Endoscopic Helix Tacking System by Apollo, and this is the package that it comes in. We have one set up. Just a question for the audience, have any of you used this X-TAC device and have any experience with it, or any input about it, please note in the chat if you have. I find that we have mainly been using this device for mucosal defects that we'd like to close up, similar to the way that we would use endoscopic clips. This device has a little bit of a thinner suture compared to the Apollo overstitch device, and it doesn't cause a full thickness stitch or suture through the full thickness of the GI tract, but it does provide a very firm, solid mucosal suture. And so first we're going to start – have you used this at all, Shifa? Yes, I've used it in practice models. Okay, great. So the first thing we're going to do is attach this device to the shaft of the scope. We'll go like this, like that, yeah, this goes up and over. So you need a lot of upper body strength to put it together. There we go. So the strap goes on like that, and then next we will – yep, the cap needs to be open, so this is important. Is it better, I think, that just the biopsy cap on with an open cap? Yeah, just like that. That's great. Okay, and this will go through the working channel, so you can advance that. Does the sheet have to come off? This goes through. Yep. You could advance it just a little bit, so that'll help me introduce it. So we're just advancing the helix over the sheet so it it's easier to advance through the biopsy channel without bending the catheter. Right. Do you want me to introduce the scope into the model or? Yep, once it's at the tip you can do that. So I've reached the point where the plastic is in the biopsy channel. Excellent. So now we're going to advance and we're going to find a defect to close here in our in our model. And we're just going to attach this and that will come off. There we go. And then this goes on right like this. Seats in there really solidly. I guess we can pick a spot here and start. And so what you're going to do is you're going to advance the catheter. Great. And what will happen is I'm going to close. So apply some gentle pressure to that. I'm going to slowly close this and you can see I'm very slowly closing this device or kind of closing this knob and it should be spinning clockwise. And what it's doing is it's basically helixing itself into the tissue. Okay. And so once I've completed that and I've gone as far as I can go, we'll pull back on the catheter a little bit to see if we're fully seated in there. All right. It looks like we were pulled back a little bit more. Good. And what I'm going to do is an additional few turns of the device. Turns of the device. Yep. Just like that. Okay. Now pull back again. Good. I'm wrapping the tissue around it. Yep. So pull the catheter into the scope. Okay. Does that feel like it's pretty well seated? All right. And so what we're going to do is I'm going to depress this and we'll advance it. And that's our first our first tack. So that's great. Good job. Thank you. So we're going to take this catheter out and we're going to set it up to have the the second tack applied. When I pulled it out the switcher, I think it came undone. Okay, it's just the we can try another one. Yep. I think it's just having difficulty catching the mucosa for the model. Okay. Right. So then I'm going to and this will go like that. So now the catheter very importantly, the catheter is reset to take a second tack. And I did that by pushing down all the way on this by depressing this blue button. So that's down and then the handle is also down at the bottom. So now the catheter is ready to take the second suture. The second tack. And what you do these are numbered two, three and four. And so we'll go to number two. So that goes right in here. It should click, push into that system, it should click, feel it and then you can lift it up. Now you're free. Right. And now we'll do is just give a little bit of tension here. Now that I've got the tag, I'm introducing the catheter. I was wondering if this this that's deployed in the stomach would be a problem for us. You know, just and then we just need tension on this. And right now we're just pulling back on our suture wire. Is it coming? Yeah, this is why I'm having difficulty advancing the catheter as well. It's important as you're doing this to kind of have a little bit of almost ERCP wire tension on the wire so that it stays nice and straight. No, yeah, we just need tension on the wire. Yep, good, excellent. This will be nice and straight. We did kind of troubleshoot through that. This is a forgiving device because you can see even when there's a lot of embedded in the tissue. Okay, and so once you've got, you're in the target area, Shifa, are you happy with that spot? Yes. Okay, so what I'm going to do is I'm going to depress the catheter, or I'm sorry, depress the plunger sort of very slowly so that it screws into the mucosa. And this will go about the depth to the muscularis propria. That's the idea. You just hold tension with the catheter or with the scope itself as well? Yep, so just kind of push on that. Now, I'm finished pushing that plunger down, and so what I'd like you to do is just pull back a little bit to make sure that we have adequate purchase. And then I might screw in a little bit more after that. Okay, so you're in there, and I'm just going to do a few more turns here. Doesn't seem to be turning despite my turning. I do see some movement, yeah. Yeah, it looks like it's delayed a little bit. All right, and so the next step is we're going to, I'm going to push this button down and release the suture. Great, I'm going to pull out the catheter. Excellent. I'm going to reset the plunger once it's out, so we don't want to damage the inside of the scope. So we don't want to damage the inside of the scope. The tip of it can be a little bit sharp. And we'll do our third tack. Again, it looks out, feel for a click. Click. Good. Seated, and then I just need some tension on the wire. Coiling in the stomach like we faced the last time. Right, right, exactly. Could you finally help me with the flap? Totally off. Totally off. And I just want to make sure I can see my last, or that kind of lost position like most fellows do. Yeah, it's okay. All good. Advancing, so now that you're holding tension, I'm advancing very smoothly. Very smoothly, yeah. Alright, and so find your second spot. Presuming that the defect is right here, maybe I can go for this area? That sounds great. Alright, so you let me know when you... I'm ready. I think I have good tissue acquisition. And so I'm going to slowly depress this. Now it's important when you're selecting your spots, you want to be perpendicular to the tissue that you would like to seed yourself into, right? And so that's perfect. She has done a great job of that. I'll pull back on the catheter a little bit, make sure that we're embedded. Yeah. Okay, great. And I'm just going to give a few more turns. As I pull back, I can see that the tissue is coming along. I'm just getting a little bit deeper in there. Great. Okay, are you happy with that? Yeah, I think it looks good. Okay, so now I'm going to deploy this. Pushing this down and pulling it out. Great. Nice. Excellent. Perfect. So now we'll do the final tack. Okay. Alright, so I'm going to reset our catheter. Okay, I'm going to try for the click again. Good. And we just need some tension on the wire. On the switcher. Yep, great. Yeah. And then you'll advance your catheter. And then I'd like you to be on the side across from our imaginary defect. Would you prefer me aiming for this area? Yeah, that'd be great. More of like a triangle? Yep. I'm going to try to triangulate that because we lost our first one. So triangulate that. Again, be perpendicular. A little bit of tension on the wire. Tension on the switcher, please. Yep. Great. Let me clean my lens a little bit for better visualization. Yep. Do you like this spot or do you want me to be a little bit more… I think that's great. I think that's perfect. And do you think I'm perpendicular enough? I think that looks great. It looks terrific. So I'm going to slowly depress this as you give gentle pressure in. And it's really important to be slow and deliberate when you're doing this spot to make sure that the catheter kind of catches up with your movements to be able to screw it into the mucosa. Okay, still have a little bit of ways to go. Good. Now if you want to pull back on it, Shifa, to make sure that you've got purchase. Yeah, I can see tissue coming along with my catheter. Okay, so now I'm going to just give a few more turns. Three more turns. Okay, you happy with that? Actually, I… It broke free? Yeah. Okay, that's fine. Do you think we can go in again with the same… So I'm just going to gently… Before you do that, Shifa, I just have to gently slide myself back. Okay. Yep. Okay, great. Yep, and sometimes it's difficult with the animal models. I'm going to… You ready for me to start screwing it in? Right, so I'm going to use this helix to screw into that tissue. I agree, it's difficult with animal models sometimes. Maybe decompress a little bit if you can. Make the mucosa a little bit thicker. Okay, good. Now pull back a little bit. I do see more. Seems like you've got some purchase there, so I'm going to screw it in a little bit more. Okay, you ready to deploy this? Yes, let's do that. I'm going to push down on the button and pull back on this. Looks great so far. Yep, great. So I'll pull out the catheter now. So now you've got sort of a triangulation here. Yep, so you can pull out the catheter. Pulling out, there we go. And we want to keep that suture, kind of avoid it from getting tangled. All right, and next we're going to use the cinch. Cinch device. All right, so you also want to take this. This is the introducer out? Just a question about the introducer. Yes, because the cinch won't go down. Okay, so we need to remove that over the suture. So this is important. The introducer that was used, we need to remove prior to advancing the cinch down. Yeah, I see. Just with a little bit of tension on the suture, it's already like the defect is coming closer together. So we've got some great questions about the use of the X-TAC. It can be good for difficult locations, and it can supplement or be used in combination with clips. So as you're doing this and you realize a certain part you weren't able to reach with clips or they're not able to stay on, so now this device is the cinch. And so we need to thread this wire through this, through one of these holes here. Your eyes are better than mine. Yeah. Okay, great. So that's good. And now I'm going to pull down on this. Okay. Seems like it went through. Right. Good. Great. All right. So similar to an ERSP wire, and you're doing such a great job over there. It seems like a better angle than what I've got over here. You're going to advance this over the suture. Okay. Make sure it's not tangled. A little bit of tension on the wire, on the suture. Great. Okay, perfect. All right. So this is the last part, and I'm going to get to some of these questions in a minute. Yeah, so a little bit more tension on the suture. Yeah, so it's coiled a little bit. So a little bit of tension on the suture. Nice. There you go. Thank you. Okay, so that's good. It's important to keep a dot on the suture. So you're going to go where your first tack was. I feel like, well, you know, we've already cinched it a little bit while getting the equipment down a little bit. Yep. And so once your cinch is advanced, we're going to really be aiming for the place where we placed our first tack. You want to go adjacent to that spot. Right? And so see if you can aim yourself to that spot. A little bit closer. A little bit of tension. Yep. And so we're going to get a little bit more tension to close this a little bit. You see how just a little bit more tension. Yeah. Right? Yep. And so let's push this out a little bit more. Yep. Okay, so now that everything's come together, the next step is for me to open this up, and this will fall out. And then a big squeeze with two hands will deploy it. Oh, wonderful. Oh, look at that. And so you can see how effective that was, even with just a triangulation of a defect. It closed things up really well. So the X-TAC device isn't available everywhere. And so that's, you know, currently something that Apollo is addressing to improve the availability of the X-TAC device. But I think that it definitely has a role in through-the-scope maneuvers. It can be used in conjunction with a variety of clips. So each kit comes with four tacks. And that usually is good for about a two-centimeter defect. If you have a defect that's larger than that, you can probably traverse about two centimeters of it with these four tacks. If you need to close the rest of the defect, you can either use an additional kit, which is another four tacks, or you can supplement those tacks with hemoclips. The key is to really have adequate closure of the mucosal defects. This device may have a little bit less functionality in the stomach because it is a superficial suture. And the sutures that are used with this device are thinner than the sutures that are used with the overstitch device. And so it's not a full thickness closure. The stomach is usually a thick-walled organ. And so we typically may have a little bit less functionality for deep defects in the stomach. Really, this device, compared to some other endoscopic suturing devices, is actually pretty straightforward. What do you think, Shifa? You think it's pretty easy to learn? This is my second time using it. I did feel like, yeah, the first time we had some troubleshooting with the suture being lax and kind of our tack didn't really hold up. But I think the last two, I started to feel more comfortable with what we were doing and getting a better sense of it, yeah. And the best part is you don't have to withdraw the scope out if you're closing a defect. You can introduce it through, like I said, you don't need, like previously, and what we'll demonstrate later with the overstitch, you need a double channel. So it's definitely easy utility to use, yeah. Great. I feel like you just have to keep, like, practicing just like with anything else to get better. I completely agree. I think this is something that everyone can learn. I think that it does not require a lot of intense training. I think that doing this a few times, practicing, you know, on some of the models would probably give you enough training to be able to use this clinically. And so I think this is really applicable and a great kind of in-between between endoscopic suturing and hemoclips. I think that this device has a lot of future utility. So we are going to switch gears to the overstitch device.

X-TAC device

mucosal defects

mucosal suture

defect closure

clip attachment

overstitch device