So, show of hands, how many of you are using hemostatic powders in your practice? Okay. And how many of you are using over the scope clips? For bleeding. Just out of curiosity. Say again? And over the scope clips for bleeding? For bleeding. Yep. Yes, for bleeding, I should say. So, you know, you can see that there's some varied responses. So, Dr. Christie, what are the opportunities for people who, if these new technologies are making their way into the guidelines, what are opportunities for them to learn via ASGE? What are the opportunities? How can you get trained when you're, you know, out on your own and something makes its way to a guideline in your, now to incorporate that into your practice? Yeah, that's a great question, Manai. So, we have many opportunities as far as, even at the trainee level, so I think a lot of folks are aware of the first year fellows course, at least introduced to a lot of these instruments. And then we actually have an advanced fellows course, not advanced endoscopy, but advanced fellows course where you could learn some of these additional techniques and the technology. And then we also have the STAR program where, in which, you know, you can register and learn specific techniques as it relates to our discussion and also polypectomy and a number of things so that you feel comfortable and certified. And these are hands-on experiences, so I encourage you to do that. And it's important because it's changing every single day. It's difficult to keep up. So there are learning opportunities to incorporate this into your practice. We have a few questions here on the stent that you were describing for the prior video. What do you do with the stent? You put the stent in. Now, in that case, we discussed more definitive therapy in the form of tips. What if a patient doesn't qualify for more definitive therapy, put a stent in, and that's their bridge? When do you take it out? Do you leave it in? What's your approach? That's a hard conversation because that's an end-of-life discussion. If they're not going to be eligible for tips and they had that bleeding, but at least you know that the clock is not at 24 hours, you can wait a little longer, get the family together and talk to them. If you have a Blakemore tube and a helmet on, that's a little bit different, isn't it? And so I think you can take it out whenever you need. Once you take it out, they're not bleeding anymore and they can continue onwards. But the key message is that it buys you a lot more time than the dilation balloons, Blakemores and so on that we have. Yeah. And it's better put in. The number of times I know about you, my experience is horrific positioning of Blakemores, not put in properly, leaking out, sometimes causing perforation and so on. At least you have the control of everything because you're the bleeding person, right? They're not for the severe variceal bleeds. Question, what do you think the learning curve is to deploy TTS stents? And so number one, what type of scope do you need for that? And two, you know, can you just do, is it C1, do one teach one? It's close. It's pretty close. You do need a therapeutic scope to do it. I mean, if you know how to leave the Savory Guidewire behind by pushing it in and pulling back at the same time, it's essentially the same thing. It's essentially the same thing. So it seems difficult, but it really is quite easy. Dr. Das, I know that this is not, doesn't happen to you, but if you misdeploy a clip, say a regular, through the scope clip or an over the scope clip, what's your approach to that? How do you, how do you handle that? After a curse. I think that, you know, once you, if you misdeploy it through the scope clip and then obviously happens, especially in difficult locations. I try not to remove them if I don't have to, because especially if they're in the region of an ulcer base or something like that, the trauma of pulling it off can often be a second problem that you now have to fix. So I would try to go around it and over it. Some through the scope clips make this easier or less easier. So if you have a hook deployment system in the back, say for example, the way a ConMed clip is kind of designed versus if you have a firing pin mechanism, as say, for example, an evolution clip has, I'm sorry, revolution clip has the back end of the clip will be larger, which will make it harder to actually get around the first object to get there. So that sometimes can affect your decision-making depending on what equipment you have in terms of a misfired over the scope clip. As Alan was saying earlier, it's in, it's in, you're not going to necessarily be removing it anytime soon. Okay. And just make a point. The new clips have, you have no excuse not to misdeploy. It happens, happened to me as well, but you can close it and not deploy and see if there's active bleeding or not. And then if it looks good, then you go ahead and deploy. The problem is the moment you deploy, nothing's perfect. Sometimes it slips. You can still misdeploy, but make sure you do that closure first for deploying. The second thing I would say is I should use that to then determine, okay, understand where the bleeding is compared to where that clip is and proceed. Ideally, with less than three clips in the area, you're probably good dealing with it. More than three, good luck. Some troubleshooting tips. So some of these hemostatic powders can clog. Some of them are very sticky, difficult to see. Any tips for how you, how you work through that? Great. Yeah. So one of the methods that I published was just to take a piece of bone wax, which is a sterile paraffin that's used in the OR, orthopods use it in neurosurgeons. You can put a tiny little bead of it over the catheter tip, and that precludes you from having to flush or clean the scope, and you could just pass that down immediately. If you connect that to a three-way stopcock and then the hemo spray gun, the third way of the stopcock, you just place a syringe with an air flush. And like a booger that you're shooting out of your nose, you could just blow it off with one quick push, blows the bone wax off, you turn the stopcock and you can fire. What does that allow you to do? You don't have to, you can still suction if you have a therapeutic scope and using a seven French catheter, you can suction. You don't need to flush the channel of the scope. And when the catheter tip gets out and it has the bone wax tip, it can get wet. And so you kind of overcome all those options. The other method is to borrow the carbon dioxide from your own scope and put it onto the third way of the stopcock. That provides a continuous flow of carbon dioxide that will protect the device. The newer powders, NexPowder, Undoclot, they have continuous room air protecting it from clotting. Room air, not CO2. So you never have to think about the barotrauma consideration of that. But those are much more difficult to get clogged because of that. The only other thing is that's delivery. Once you've applied it, always try and put as little as you have to. So that if you have to do more, you can do it then. But remember, the advantage of these is, and I sound like a broken record, if the powder can hit the bleeding lesion, chances are the bleeding is going to stop 95%. So you can come back another time if you put too much and you can't see. Don't be shy about doing that. That's where second look, and some people do routine second look when they use. I was just, you teed up the next question. When do you use second look? Second look. So it's not recommended routinely. We've looked at this carefully. I could bore you with the data, but I won't. It's not necessary for everybody. I think if you don't feel comfortable with what you've done, absolutely. High risk lesions, remember the ones that came in, active bleeding, duodenal bulb, and or where the left gastric lives in the stomach, you may want to go back and have a look. Maybe, maybe not. What I personally do is if I'm pleased with what I've done, I leave it like that. If I'm not, I come back. If you've used spray alone, I realized that the data from James Lau said you didn't have to. I would go after spray, go back in a pre-planned 12 to 16 hours later, have a look and see where you stand. Yeah. I would agree with that. I mean, it typically, you know, and have a very low threshold for it. Obviously, if the hemoglobin is not holding, you have signs of not, not, you know, sort of the melanin you expect, but sort of ongoing with drop in hemoglobin, I would have a low threshold. We're talking pre-planned. We're not talking patients start bleeding again. Of course, you have to go back. We're talking pre-planned if everything's stable. Yeah. Alan, in cases where you're using hemo spray for palliative malignant bleeding, do you have a protocol? Do you come back PRN? Yeah, I still. What do you, I know that gets you out of the acute jam. We did a randomized trial, a pilot trial of 20, 20 patients, and we since have done this and the group from Bangkok, who's done an amazing study, shows the same. You go in once because then you may have to do it serially. We do it once. Then usually we end up doing some radiation treatment, so on and so on. And we just follow them because chances are you may have to go back. So we do not go back again afterwards. You know that it's not going to cure the tumor. It's not going to heal the tumor. When you go back, you're going to, you could go back every day. You're always going to find more stuff. So we just follow them clinically from the point of view of bleeding. How long do you, I'm sorry, go ahead, find that the hemo spray lasts like on average? We actually did a post-hoc analysis looking at this and our best estimates are between 12 and 24 hours. And next powder, I asked the next powder people how long, and I think it's honestly, they don't have a huge amount of data. It's roughly the same. So you're really looking at it. So we have a couple of minutes. So in peptic ulcer disease, bleeding doesn't really make sense because it takes three days to go from a high risk to a low risk lesion when you do an esophageal therapy, which is to which as usual, I was wrong. I predicted that spray alone will not work for ulcers. And then James Lau came out and showed that this randomized trial worked for the subgroup of ulcers. However, as I said, it was blended with malignant bleeds and so on. So the data shows that if you want to use spray as sole treatment without second look for an ulcer, you can, I have a tendency to go back and look or do multi-combination because of this residency time of the powder with regards to the normal healing time. We're talking about ulcers, very different if there's very low re-bleeding risk, such as malary waist tear. Yeah. All right. We have a few minutes. So I'm going to, I'd like to queue up this lower GI bleeding video that we have stored. We'll go over that for five minutes. So Jennifer and I kind of did this one as a combo team here. Some of these are my cases here. This is a diverticular bleed like the one you see in your career. And then here we tried to do what's called over the top clip closure where you just close the whole diverticulum and you see, this is what I use Allen's method here, close, but don't deploy. Wash. No bleeding. This should work. It looks good. You don't know how deep that tick is though. That's right. You're going blind, right? It didn't work. The patient re-bled. I put another clip on there the following day and that didn't work either. Right. So I'm missing it, but I can't see where it is. And it's very hard to target these diverticular because they're kind of concave inwards and you're not actually getting in there. And so, you know, what do you do in this case? So can we pause the video right here for a second? You mentioned, you mentioned that you can use clips to target so your IR folks can target it. Right. So you have, you, you, you can do that in this option, right? It's very fair. I went a little bit more. Well, and I think everybody knows by now that Andy would go a little bit more. So I think we're, you know, so the, the clips came off. You will know. I took them off. I took them off. Grab them by the back. Right. I didn't feel good about it. You're ripping clips off of a diverticular. This could be bad, but let me ask you this. Have you ever applied heat to the clip? I haven't. And I wouldn't on that one. It doesn't conduct. It doesn't seem to go. The clips, the new clips do not conduct heat. The new ones don't. Actually, we see this for safety reasons as well. So if I can just suggest, if you can see the depth of the diverticular, I will usually inject some epi to try and bring out the vessel. If you don't see this, don't forget, Japanese have done, although I never see diverticular bleeding, to be honest, but I would just suggest that you just go ahead and suction and then do very, very still banding. This everts it to a section and hopefully walls off and cuts off that are so pathophysiologically, it makes kind of sense because the problem is exactly this when we put in clips. And what's the role for Doppler in that, in that situation after you've clipped it? So the only Doppler I know, we did, we did, we, we didn't attend analysis on it looking is in upper bleed. I have not seen the role of Doppler in lower bleeding. It's a very good question. Can we play this again? Right. So I ended up removing the clips and then nuzzling into the diverticular so that we could see the bleeding spot. We'll advance it midway through the video here. Yeah, fast forward to about 66% forward from the, from this video. Right, so don't go back a little bit. I'm sorry. Okay, there it is right there. Yeah, right there. So see You can see the vessel here, and you can kind of get the bipolar growth. I know what you guys are thinking. There's no muscular appropriate. Yeah, it's thin walled. Don't try this at home. Not advocating this, I'm just saying that there's, this is a pain point of diverticular bleeding, okay? It would be very reasonable to leave those clips on there and call your colleagues. I would have to say, I would be very concerned about doing that. You're an expert, so that's why you can get away with this, and you know what you're doing, but for the average person to just put heat into a diverticulum is probably not recommended. Right, and so definitely do close it. Inject it, put a little tattoo there if you can as well, just to make sure everyone knows exactly where it is. Okay, and then you can move on. Assuming that they rebleed from that, which may or may not be true. Right. But it's a very good idea to touch. This direct method of clipping inside a diverticulum seems nice, but you can imagine how morphologically challenging that is, especially as the clips are all 16 millimeters or greater these days. There are some smaller clips. Here's another bleeding diverticulum. Again, you can see through underwater technique that you can localize the bleed. Here again, I went with heat, which is maybe not the best idea, but it does work. You just need to be very careful. If you use heat, you definitely need to close that diverticulum. But perhaps like Alan said, I would say the people with the most experience are our friends from East Asia who have a lot of right-sided diverticular bleeds, and they banned them. So in this situation, I adopted that method. I injected dye first, just beyond, so that I could refine it when I installed the cap. And then I targeted it and basically everted it, like Alan said, and this works very nicely. I know what you guys are also thinking. Is this gonna have a perforation? Will this cause diverticulitis? In the last series that was shown, 700 East Asian patients, the majority of them had no problems whatsoever. There was, I think, two or three, less than five cases of diverticulitis. There was one perforation, but that perforation was in a patient who was on chemo and on prednisone and so on and so forth. Yeah. If I can just make a comment. Yeah, just to highlight that the point is to do what you're comfortable with, and first, and then obviously employ the other techniques. And the question is when to then call your IR colleagues and that kind of thing. I mean, fortunately you had all the techniques and tools to do this, but until you get comfortable, just do what you're comfortable with and then bring in the multidisciplinary team. All right, the final point, Jack. Final point. Lower GI bleeding, forget endoscopy, right? We understand each other. The guidelines are there's no role. When you look at the outcomes, you get an increased evidence of bleeding lesions, but no impact in re-bleeding and so on. The reason the Japanese recommend it is that they can go from ER to a CT angio within two to five hours, and then have a scope prepped and down within six to eight hours. We cannot do this. And if you don't do that, and you look at the data, in fact, the American guidelines have now changed to hands-off. So the great majority of patients is you schedule an elective session. Subsequently, if the patient continues to bleed in the acute setting, they go to angio just so that we're clear on that. But if the occasional patient where you see they're particularly bleeding, this discussion is appropriate. All right. Thank you for an excellent discussion. Everyone, give them a round of applause. Hope it's a good way to kick off the post-grad course. We're gonna move on to our next session here.

bleeding management

gastrointestinal cases

ASGE

hemostatic powders

over the scope clips