So, we have to switch to Dr. Kashab at Johns Hopkins, who is accompanied by Dr. Repicci and Dr. Ortman. We will start with case presentation by Antonio. Our next case will be an endoscopic repository scan with Dr. Nouri Kashab at Alphalete. This is an EMR for a 30-millimeter tubular adenoma. The patient is an 85-year-old female who presented with painless rectal bleeding. A rectal exam showed no palpable rectal lesions or other abnormalities, and an index colonoscopy was performed. What was discovered was a 30-millimeter, Paris-class 02A, laterally spreading lesion in the ascending colon. Biopsies were consistent with tubular adenoma. The plan is now for EMR resection of this adenomatous lesion. Thank you, Antonio. Dr. Kashab, you're live. Hi, everyone. Thank you for joining us. First, I want to introduce the entire team here, the nurses and the anesthesia team, and my two good friends, Professor Alessandro Repicci and Professor Mohamed Ortman, both experts in resection. I have an Olympus adult colonoscope here with a clear cap at the tip. We have GI Genius from Medtronic activated, and you can see here that it detected right away a small polyp. We're going to come back to it and resect it offline since you've seen a bunch of cold snare polypectomies. The goal of this exam today is to demonstrate a little bit of AI and then to show you endoscopic mucosal resection of a medium-sized polyp. It's actually two centimeters, not three centimeters. What I want to show you is just a lift and snare, a simple technique, and then how to treat the edges with soft coagulation. Then, we're going to show you a couple of techniques to prevent bleeding. The lesion is not too big. I think this was a good demonstration here. I didn't see this polyp. I think the AI saw the polyp before I did. For the prevention of bleeding, we're going to apply Puristat to the base and then hopefully close it with, through the scope, X-stack closure from Apollo. Again, multiple goals of this exam. We see here a 1S polyp with a nice 2 pattern, no high-risk features. This is in the ascending colon. We should be about 20 millimeters. We should be able, I think, to get that on block. I'm going to inject simply with heterostarch and then use a 20-millimeter captivator snare from Boston Scientific endococcus eukaryotes for resection. While I'm injecting, Alessandro, do you want to give a comment? Yeah. The first comment is I just was looking to the lesion and macroscopically and also on the P pattern, it looks benign. So the question is, in the medical history of the patients, there is a biopsy. I think making a biopsy of a lesion that you think is respectable based on macroscopic appearance of P pattern, vascular pathway evaluation, is a mistake. We should remark that once the lesion is being evaluated as potentially respectable, we should avoid to make biopsies because that is creating fibrosis. There are papers showing this fibrosis can increase the risk of incomplete resection of first product. Moana, a comment on your visualization with AI. I'm not sure it's projecting together with the image. I'm wondering if it has a different feed. Oh, possibly. Okay. So you didn't see the boxes? No. Okay. Back. Okay. Good to know. Thank you. I think it's not activated right now. And now it's off, but it was on at the beginning. Out. We can see that they're using dynamic injection. So he's using his wheels, a small wheel, and he's going in both directions. So this saves you the amount of time you spend injecting and also decrease the number of puncture spaces so that you have less lesions. So is there, back, is there a, do you try to avoid injecting through the polyp, Mohamed? Do you try, do you avoid injecting through the polyp? Or if the polyp looks benign without high-risk features, is it okay to go through the polyp? You can go through the polyp, but I feel like if it's safer to go around and use dynamic injection, and dynamic injection will ensure that the injection will be everywhere. So I would start behind the pulse exactly like that and highlight all the borders and make sure that the injection is even. Muin, I don't want to make you angry, but based on the elevation, the polyp is becoming difficult to be removed. It's not getting polyploid, but it's flat on flat. This is a major challenge also when you look at EMR. So do you have any suggestions on how we can afford a better resection? So we go underwater, is there any, we cut all around the mucosa to create some space to allocate the snake. So what can be the strategy now? Because you keep injecting, but the lesion is now flat. And I don't think there is any way to change this morphology. This will remain. So what we need to do is to discuss is how we prevent the failure of EMR, because they may reach here, they will leave some more pieces of adenoma, not just at the edges, but just in the central part. And it will be visible to us, and for sure they will give recurrence to the patient. Yeah. Dr. Keshav, can you repeat the question, please? Because we can only hear you. We cannot hear Dr. Othman or Dr. Repicci well. Okay. So I think if you guys want to speak, just speak louder. Okay. And I don't think you're shy, you can come closer to me, Alessandro. We've known each other for a while. But so the question is, we are lifting the lesion and it's becoming flatter. So is that going to make it harder to grab the entire lesion? And is that a risk open of us leaving some, all the way, some pieces behind and which can be associated with recurrence? So he mentioned underwater EMR. I think that's one thing. One of the things that we don't talk a lot about is what scope we're using. I definitely like to use an adult colonoscope because that allows me to suction well, even when we have the sneer in. And when we suction the lumen, and then push down a little bit and suction slowly, we're going to try to grab the whole thing. And again, this is EMR. So if I ended up piecemealing it, it's not the end of the world. But I think we should be able to get this. Go ahead and start closing slowly. Slowly, slowly until it's snug. So you see here, the lumen is deflated. And we always talk about when we cut now, it's good to have the lumen a little bit deflated because the tension on the wall is proportional to the diameter of the lumen. So it's good to deflate a little bit. And then I've taken the snare. I closed all the way. And that way, we are sure that we don't have muscle. And then we're using endocut cue. We're going to cut. So if this takes more than a couple of seconds, it means you have muscle. And then you have to stop. We're going to examine now the base. And if there's anything, we have a little edenoma here. Do you ever use AI to examine the margins? Can you hear me, guys? Can you hear me? Yes, we hear you well. OK, OK. So very nice demonstration. Because I think we summarized a couple of technical points that can improve your resection, especially when you make and block this kind of lesion. So using the wheel, using this action, so combination and using the right side also of the snare can allow you to transform a complex resection in pretty easy and also quite fast resection. So for this smaller specimen, I would suggest to go with a smaller cold snare. So I'm using a 10 millimeter. We're still using hot. Yes, we can use cold. Not a problem. Can you see the AI here? Or you're not able to see it? We can't see it, huh? No, we can't. Yeah. So my question to Alessandro, is there a value of using AI to look at the margin? I mean, this is clearly visible, but what if it is smaller? Is there any studies on that? Are there any studies? That's a very good point. There is no evidence yet. I do believe that anyway it's very useful because especially those systems that allows you to predict histology are also helpful for discriminating residual adenomatous tissue versus non-adenomatous tissue. Because sometimes when you do this hot resection, there is a burning effect on the tissue. It may be difficult to recognize adenomatous from non-adenomatous. So in the future, artificial intelligence will also guide us on the final steps of resection. Okay. So the other question I have, Mohamed, since you do a lot of ESD, if you see a vessel like this, is there any value of treating the vessel? Yeah. So we see here in the bed of the EMR that we have a bulging blood vessel, this one to the right side. And I tend to treat all of these with soft coagulation if I'm doing ESD. If I'm doing EMR, you can still use the tip of the snare with soft coagulation. Yeah. So we're going to switch to soft coagulation now. And in the colon, you want to have low current like 7U, machine from Irving, set up here at 4.5. And you can even go less than that if it's too much. And you make sure that the tip of the snare is just a small area out, the same as Dr. Kashab is doing now. Because the larger the surface area, the more that the current will spread. So you only need a small amount of the tip of the snare. Mohan, there are a couple of questions in the Q&A box for you. One is that during the injection, why did you not start injecting towards the most proximal side and then come up this way? Why did you do it the other way around? Yeah, I don't think that's needed. I hear that a lot. But I like to actually, especially when I'm resecting a large lesion, I just attack the part of the lesion that's more accessible to me. And then once I finish, the part that's hidden or further away is going to be more visible to me and more accessible. So there is no rule of you have to start in the back. So I don't think that makes any difference. Of course, there is individualized cases where you have to start in certain places. For example, if part of the polyp is hidden behind the fold, you go there to make it more visible. But I don't think there is a rule. So do you like this? Should I coagulate more at the edges? Or this is good? You still have to coagulate a little bit. OK, let's do that. And then I'm going to apply PureStat. So Alessandro, this has been in Europe for a while. It just got FDA approved here in the US. Can you tell us about your experience with EMR, ESD, upper GI and lower GI? OK, great point. So PureStat is a transparent peptide gel that is released on the bed of a section and just creates a protecting layer. There are several advantages in using PureStat. The first one, it's very easy to use. Absolutely easy to use. And since it's transparent, you can use also during ESD when you get in trouble and you want to slow down the big bleeding and try to identify the bleeding point. That's very nice because it's not interfering with your further resection. So the other big point is that we have several studies that have been published, mainly by the Portsmouth group, led by Pradeep Bhandari. So they brought in an observational study in prospective randomized trials. They were able to demonstrate that using PureStat in different clinical situations, including EMR, ESD and especially colonic ESD, is preventing significantly the risk of delayed bleeding. So the third point you're demonstrating, it's very easy to be used. So it's like fainting, little movement, use anti-gravity concept and you deliver all across the bed of the lesion. Takes a few minutes. You have different syringes. I don't know in the US, but in Europe, we have 1ml, 3ml, 5ml. We normally use the 5ml only for large neoplastic lesions, self-bleeding that we want to control. Rather for EMR and ESD, we normally use 1ml and 3ml. I have a question. Can you come closer and raise your voice? Yeah. If there's any data about using PureStat to prevent post-electrocautery coagulation syndrome. That's a good point. So there are no data. I just confess when I get scared about very deep resection in the right colon, I can anticipate some problems with this kind of deburring. I always use this hoping that, but we do not have data. I think it is a smart solution. Very easy. And somehow I think it's working. So I've also noticed if you have some oozing bleeding, it kind of tamponades it right away actually, and it stops it. And then it helps you see better and continue the resection. You buy some time to understand and to make a very proper emulsation. So it's a smart way to get out of trouble when you do not understand where the bleeding point is, or where the bleeding is too big to get control of it right now. And just you can use PureStat to slow down the bleeding. So the last part of the procedure is extract closure. Do you guys want to go to another room and come back, or do you want us to continue? You can go to another room and come back. Okay. Why don't you do that? Dr. Keshav, you're back on. Okay. Hi. So this is to demonstrate XTAC through the scope suture closure. So the lesion is relatively small, two centimeter. So not very high risk of bleeding, but this is really more for demonstration. Still, right-sided lesions. If we do prophylactic closure, it's beneficial, but this is just in case somebody has a question why we're closing. This is the Apollo through the scope suture system. It's basically suturing made easier. See here, this is a helical tag that extends 3.5 millimeters into the tissue. So our goal is to get into muscle and hook this helix to the muscle. And we can do whatever suture pattern we want and then tie the suture. The key here, so this is the lesion. In terms of suture pattern, the way I think about it, if I have a linear lesion, I like a Z pattern. If I have kind of round oval lesion or asymmetric lesion like this one, I like to do a figure of eight. I think you guys have to mute the other rooms or other people on Zoom. So this is the lesion. We're going to go further away from it. And important is when you apply it to be perpendicular to the tissue so that we can get deeper into the muscle. So we like to get away from the lesion. Go ahead. So the way we're going to do this, I'm going to push on the tissue. And here, Sophie is slowly, slowly, slowly, slowly. Okay, go ahead and rotate, please. Stop, stop. Rotate a little bit. Rotate, yeah. And go ahead and deploy. Okay. Let's see how this first one looks. Okay, not bad. So now we're going to exchange here. So maybe we can turn the lights in the room up and we can zoom in on the device so that we can show it to the audience. With the camera, can you zoom in here, please. So this system has four tacks, one already loaded, which we placed. And then we have three more tacks. We're going to just push. It loads right away. Just push a couple of times to make sure it's hooked. Sophie, give me some tension here. And we'll get some slack. So I like to hold the suture so that we're not dragging suture with us. And this is one of the issues that can happen if the suture coils within the channel, then problems can happen. But here there is no risk of overlapping or crossing of the suture. We don't have to remove the scope to apply the suture. We don't have to change scopes. So we're just right there. So now this is the other tag, and it's already on the suture, you can see here. So we want to get some slack. So just in and out a little bit. And if you pull the scope, it will be okay. So here is one suture, one tag. So I'm going to come on this side, do the next. So the way I'm thinking about it is that's 11 o'clock, 10 o'clock. We're going to do five. Then we're going to do two. And then we're going to do seven. The one you cinch, it cinches at your last stack. So that's why I like the last stack to be close to me. So that's why the last stack I wanted here at seven o'clock. And there's many patterns. There's a Z pattern or a figure A pattern. And Dr. Kashab chose the figure A, which is also strong closure. And for a lesion like that would be perfect. Go ahead. Yeah, just slowly. So we're going to push on the wall to drag it in. So she's pulling on the, Sophie is pulling on the handle. And then at the end, after she pulls it all the way, we're going to rotate. Rotate a couple of times, please. And then deploy. Yep, go ahead. It's Haiko. Great demonstration. I'm seeing that you're placing the tacks pretty far away from the margin. Do you want to comment on that? Yeah, so sometimes if you don't get deep into the muscle, there's some movement of the tacks. So you think you are far but then miraculously it gets closer. So to avoid that issue. We place them a little far and. And you know this is at the end this is. This is too much tension on it. At the end this is kind of, we're getting tissue to cover the polyp rather than anything else so I think if you get normal tissue around it's it's a good thing but but yes it's on purpose to get further, further away. And you see here it's not too far. Really, this is just a little bit far, but not too far. So now I'm going to go up to two o'clock and then we'll come to seven o'clock. So, Alessandro is this available in Italy? No, we're sorry. Not yet in Europe. We expect the first quarter of next year. We're hoping. And you know the, this fills a gap with suturing, because with the overstitch it's very hard to get to the right colon, complex, and you have to use a double channel scope, and it's just very complex so here we need some slack. So I'm gonna leave the suture so that we can get some slack in and out a little bit, and pulling the scope gently to get some slack on the suture. Hey Maun, I also saw that you removed, or you didn't use the catheter, when you first deployed it. Do you want to say something about that one? So again, this is not something I'm, I think Apollo is changing that sleeve or that scope liner. I think the liner creates a lot of tension on the suture, but there's a lot of basically rubbing between the suture and the liner, and it's hard sometimes to push the suture through it. So I think it is material related. So that creates a lot of issue, and the tip of the pack is blunt, it's not sharp, so I don't worry about passing it through the scope. So I changed my practice of using it without the liner. It's kind of, when we started using the overstitch in the past, everybody is using an overtube, and then now almost nobody uses the overtube. I think about it similarly, but much, yeah, maybe further in. So, go ahead. So, yep, so here's a good demonstration. You see how perpendicular we are. We're pulling on the handle, and we want that eyelet to be flushed with the tissue. And once the eyelet is flushed with the tissue, it means the entire pack is in. Now we're going to rotate a couple of times. Rotation also digs it further in. Yep, and deploy. And this is a third, and now we're at the fourth pack. So sometimes with bigger lesions, you need more packs, and I think now Apollo is considering kits with six packs instead of four. So this is the last stack that's already within the system, and we're going to place. So I'm going to start deflating here, and you're going to start pulling the tissue together, you'll see in a minute, before we cinch. So we did present some data at DDW, this last DDW, on using the system for colonic EMRs and duodenal EMRs. It performed very well, and the rate of bleeding after duodenal EMR is just spectacular. Very low, although I can tell you with the large lesion and duodenum, obviously it's hard, narrow lumen, and you don't want to switch the lumen closed, but with lesions that are less than 50% circumferential, the performance is spectacular. So this is, again, this is the horizontal margin of the lesion, and so the horizontal and vertical. So we go further out from both, like here. And go ahead. So you see the eyelid there, I need to flush this into the tissue so that the eyelid is at the surface. Go all the way, please. And rotate it three times. And that gives you 3.5 millimeter that you know you are in the muscle. Okay, deploy, and then after that we're going to cinch. So one important thing with the cinching is that this is a 3.0 suture, not a 2.0 like the overstitch. So the suture is thinner, slimmer, and breaks easy. So now when we start pulling on the tissue, bringing the tissue together, part of bringing the tissue together is suctioning the lumen. So it's just suctioning, brings things together. And then when the tissue is together already, then we have to pull less. That looks good already, Alessandra. A little bit of a learning curve, but really not much, because one thing is like there is no difficult suture patterns, there is no risk of overlapping the suture. So we're going to cinch this, which means we're cutting, we're going to cut the suture and have the cinch in place and that closes it. And here we want to also demonstrate how we're going to do that. So I'm going to suction a little bit to bring the tissue together. We never use a leak for perforations? Yeah, perforations and leaks. So I tell you about a wonderful case I did the other day, a leak at the UES, and impossible to do anything else. So we close it with this. So now, so you see I'm using, so if you can just zoom in a little bit here. We're going to continue to suction. And I'm not looking at the lumen anymore, I'm just because I know I approximated the lesion, I'm going to use just two fingers like that. There's not a lot of pulling, just a little bit. It's tactile, and it is, when you get used to the overstiff, this is probably 25% of the pull. Okay. And then, and that's it, you know, if you over pull you're going to cut it. So go ahead and deploy please. Okay, so let's pull this out. I'm going to show it and then we will be done afterwards. Zoom lights off please. I will say this looks great. I mean, you see no base. That's absolutely, absolutely nice. And especially all patients that needs to resume anticoagulants, they can do the day after. Yeah, yeah. That's a very good point. Yeah, so I think you're not going to do this for every lesion. Patients who are at high risk, this makes a lot of sense. And I don't think it's hard to learn it. And Heiko and I actually are planning prospective studies. Hopefully, Heiko, after you've seen that, you're still on board. No, it looks great. I can just echo what you were saying. I think the X-TAC is a bridge for, or provides an opportunity for very large defects that you can approximate those far margins. And then if needed, you can even add clips to it for a second system or so. Yeah, so that's a good point. I think Sawani is going to have an opportunity where she's going to use it after an ESD, where it's very hard to clip the entire lesion. She's going to do X-TAC to basically make it smaller, followed by clips for complete closure of the lesion. So I think we're done here. So unless you guys have a question, feel free to switch to another room. Thank you, Dr. Keshavanti. Great presentation.

endoscopic mucosal resection

EMR

polyp

Paris-class 02A

colonoscope

XTAC

post-procedural bleeding