Good morning, everybody. My name is Arvind Trindad. I'm an associate professor at Hofstra Zucker School of Medicine in Long Island. I have the pleasure of being at this virtual hands-on session here at the Sophagology course, which is a wonderful course being put on by the ASGE, and the course directors, Pratik Sharma and Bonnie Condor, are doing an amazing job. I have here with me an Advanced Industry Fellow at the University of Chicago, Shifa Umar, and together we're going to demonstrate the use of two techniques today. The first one will be endoscopic mucosal resection, and then the second one will be endoscopic closure. So first, we're going to start off with endoscopic mucosal resection, and there's many devices that we could use. Today, we're going to demonstrate the use of the Cooke Duet kit here, and you can see here this could be used for a gastroscope here, and today we're going to be using the H180 Olympus gastroscope, and we're going to demonstrate this technique. There is another device, the Boston Scientific device, and these are all band ligation devices. There's two ways of doing an endoscopic mucosal resection. One is band ligation, where it's essentially where you're putting a band over the lesion and creating a pseudopolyp, and then you resect it, and there's a second way of doing it, which is basically called Kappa-assisted EMR, where you're not putting in the band. The most commonly used technique in the United States is a band ligation device, but this is a second device by Boston Scientific, and then there's recently a third device called the SmartBand, and this is distributed by Steris Endoscopy, and it's a newer device where they all have a hood. It's a little bit shorter, and this is a little bit wider, so the clarity may be a little bit better, but this is something that's a little bit newer, okay? But in my practice, I tend to use more of the Cooke Duet device, but all devices work equally well, okay? Do you have any questions before we start? I think we can get started. Okay, all right, perfect, okay. So they all come in this nice handy packaging like this. This is the snare that we'll use. It's a hexagonal sniff snare, and the snare is usually a 15 millimeter snare, and it's stiff, so it could go and grab the tissue very nicely, but we'll demonstrate that, okay? So this is the kit that it comes in, as you can see here. I'm just removing the fancy packaging. So generally, what you'll do is you'll go down with the upper scope. You'll visualize a lesion that you want to resect, and then you'll come back out, and then you'll load the device. I already know what the lesion that I'm going to be resecting. It's just basically a tattoo that was placed in the stomach, so there's no need to go down and take a look at it right away, okay? So I take all the components out. So this is the cap that you can see here with the string attached. You'll see deployed, okay? I'll put it down for a second. So the first thing we're going to do here is, this is a device that will just go in the Biopsy channel. I'll first create a little puncture here, okay? Just like that, and then a common question that I often get is, you know, does this go on on top of the cap or without? We're debating about this outside. My partner likes to take it off. I actually like to keep it on so it's a little bit more snug, okay? Sometimes it pops out, but hopefully it doesn't today, okay? And then there's this little white introducer that I'll unravel, okay? And this will go down this port that we just punctured, and that's the reason why we created that puncture, was really just to allow this to go down easier, okay? And it's always helpful, actually, to have the light off. Shifta, I'm going to ask you to turn the light off. Thanks, Shifta. And then I'm going to have you help me, actually, with this. So this white catheter is going to come out of the endoscopic channel, okay? So in a second here, okay? And then the string will actually go around the tip of this catheter. I'll ask you to zoom in, and I'm not sure if you can see that or not. I'll move my finger away, and we'll zoom in. There we go, okay? And then, Shifta, I'll ask you to just put it a little bit lower. There you go. Okay, perfect. And then I'm going to pull this catheter from this end, okay? Slowly. And then you'll slowly guide it. Okay. And then, here, sometimes you can have your assistant do it, or you could do it, but this goes firmly on the scope. And then, Shifta, I'll ask you to hold this apparatus for me here, just if you could hold the scope. So generally, what your assistant will do this, or the endoscopist could do it, but I'm not sure if we could zoom in here, but there's a, maybe we'll move it like this so you could see it better. There's this little alcove here in this device. So the top part of the string will go in here, and there's a little groove where it catches. And sometimes, believe it or not, this is actually the hardest part of the whole procedure. And there. So the string is gone in the groove, and I'm turning this whole device now. If you don't do that, and you just start turning the string, the string is actually not going to catch, and you'll have issues when you're deploying the band, okay? So there's also, on the Cook Duet, there's two-way positions. There's a firing position, and then a two-way position. You want to make sure that it's on the two-way position, and then you pass the scope down the esophagus, and to the lesion that you want resected. And then when you're ready to fire, that's when you move this valve over to the firing section, okay? So now we could turn the light on, okay? I generally like to have all, on the endoscope, all the locks unlocked when I'm going down. This creates a little bit of a stiff situation when you're passing through the oropharynx. Here we're in a pig stomach, so we don't have that issue. Sometimes with the cap on, it could be a little tight going down, which we're seeing right now. We may have to hold this pig in place. Okay, thank you. All right, and then there's these lesions that have been created for me, which I'll show you in a second. And sometimes, actually, this is actually a good point that's brought up here, created, is that the hood of the cap could sometimes actually create a little bit of a shadowing. So you may have to actually increase the light a little bit, which the light is right there. You can make it a little bit brighter. Perfect, okay. So you can see here we have this nice little red lesion that was created for me, and so it's important to really center yourself and know what you want to resect here. So you can see here, I'm going to go in the center of the lesion. This lesion is actually on the bigger side that's created, so we can actually do a multi-band technique where I will actually place a band over it, resect, and then go next to the border of where I've resected, and I'll actually resect the second part of the lesion. Okay, so maybe I'll start right here, and then when I'm ready or about to fire, I'm going to go into the firing section, and then what I'm going to do now is suction to create a pseudopolyp. So here we go, and it's important to hold the suction for a little while. You know, you don't want to prematurely let go. If you do that, then you may not get the band firmly around the lesion, and that could be an issue. Okay, so it's looking pretty good. And you can see the lesion still coming in a little bit, and I think I'll deploy it right now. And I turned the knob, and you can see here we have a nice little pseudopolyp that's created. So now we're ready to actually resect this, and the nice thing about this device is that the snare could actually be passed through this little channel here without removing the whole device, and so you can remove multiple pieces. Okay, so let's, do you mind opening up the snare for me? Great. So a little tip is, so we'll close the snare. Thanks, Shifu. Okay, and then a little tip sometimes is that you may want to put the snare tip right at the edge of the sheath, just so you don't get a little bend when it's going down. Okay. So the snare is going down now. And a common question I often get, which is debated, is should the snare, which I've I'm sure you're wondering, you're asking, should the snare go over under the bend? What do you think? I think it should be going over the bend. Like below it or right on top? Right on top. So that's a common response, and why do you think that? I think that the bend like prevents, you know, over-snaring or causing a perforation. That's what I would think. Yeah, so that's commonly what people say. So generally I find when that happens, I may not get a full resection that's desired. So generally what I'll do is actually I'll end up going underneath the bend. That's most of the time. So I'm going to ask you to pass the cautery pedals towards me, if you don't mind. Thank you. Okay, so the other common question we get is, okay, blue pedal or yellow pedal? And so the blue pedal is coagulation current, and the yellow pedal is actually going to be cutting current. And generally what I'll do is I actually use more coagulation. And the reason why I do that is, do you know why I use more coagulation than cutting? I presume that's again to do with like, you know, avoiding any deep mucosal injury. Exactly, that's perfect. That's an excellent answer. So that that's exactly the reason why. So with the cutting current, sometimes you could get muscle, and when you injure muscle, obviously that's not a good thing. So now we're going to put the snare over the lesion, and you want to make sure at the appropriate time that we're set up for cautery. So here we go. Thank you. What pre-settings do you prefer for this? Yeah, so I use an Irby generator, and I use force coag is generally what I use here. I think we're set up more for a cutting current here, and we have a ConMed generator. Okay, so I'm going to ask you to open the snare. Great, that's perfect. And again, I'm going to go underneath, I'm going to push on my scope a little bit, and I'm going to go underneath the bend. So I'm going to have you close, close, close, close. Actually, it looks like I'm going to have you open a little bit, open. I'm more open, open. I just want to get a little bit more underneath the bend. That's not the end of the world, if it's not. Okay, close here. Yeah, close. Close, close. Okay, good. You can see here I'm firmly snug, and mostly underneath the bend here. So I'm going to start the cautery, and what Shifta is going to do is she's going to close slowly. And a lot of people will use a tugging motion. If we're using mainly more cutting current than COAG, there's no need to shake aggressively, because you're letting the cutting current do the job. Okay, so I'm going to push the pedal, and you're going to close, close, close, close, and it shoots through. Okay, and you can see here, overall it looks good. Maybe a little bit deep, but we're in a pig stomach, remember. So that's to be expected. Okay, and then if we wanted then, you know, to actually remove a piece right next to it, we could actually go next to it and repeat the same maneuver. So that's basically the technique that's done. This actually looks a little bit deep here, but that's again to be expected in a pig stomach. And if that happens, which is not unexpected, sometimes we could actually close it with a clip. Okay, and this actually, we could leave this defect because we're going to move into closure, which is closure with a vesicle clip, so we could actually close this defect. So it actually may not be a bad thing that this happened. Okay, any questions about what we just did? Yeah, Dr. Trinidad, how do you make sure that you're not suctioning a lot of tissue? Yeah, so a lot of it is feel, and so in this situation in a pig stomach or a pig esophagus, it's actually, it can be very difficult sometimes to gauge that. But in a human, for the most part, you know, you could actually feel how much you're really grabbing in. So sometimes if you feel like you're grabbing in too much, you could let go and really grab in. And that's again why, one of the reasons why we use coagulation sometimes over cutting current because you're not really grabbing a lot of that muscle and you're not worried about those perforations that could happen. And this device, like I know we're using a GIF scope right now, is it compatible with other scopes? So you could, so I, you mainly use the Olympus scope, are you asking if it could be compatible with the, you know, are there like sizes that are compatible with like beats colonoscopes? Yeah, so this device is mainly for an upper scope, for a gastroscope, but they're, you know, for usually if you're going to do a lesion in the colon, we could use a therapeutic scope and go a little bit further, like a single channel therapeutic scope, but you're limited by, by number of scopes. The therapeutic scope you can, but you just need, sometimes you'll need a bigger cap, but a lot of people do use the therapeutic scope for this. Okay, thank you. All right, no problem. So why don't we, do we have any questions from the chat? No? Okay. So if I were to do, we could actually demonstrate another one if we have time. You have time, oh five minutes, okay. So hopefully we won't cause a mucosal defect here. Let's see here. So I like sometimes to go even a little bit, just so we don't cause too much of issue. That's our resection specimen that you can see here. We could go here, and then again, when you suction, maybe suction a little bit. So in this part of the stomach, actually, it's going to be hard to resect. So sometimes look for a fold when you're in with the pig stomach. So there we go. And you can see here, this is not suctioning well. So maybe we'll find something else here. So this would be a good area maybe too. This is already another area that was marked out for us. So this might be good right here. Oh, that's suctioning very well. And I'm going to turn again and deploy the band. OK. I'm sorry. The snare is in there. OK. All right. So the snare was in there when I was suctioning, which was causing a bit of an issue. But actually, the band actually did go on it pretty nicely. Let's do it here. I think, let's see here, here we go. It's all clear, right? Okay, good. Thank you. Why don't we turn the light up a little bit? Because this cap is actually causing a little bit of difficulty to see. And the lesion should be down to the left here. We may be running out of time anyway, so we may actually skip, yeah, we have very limited time left. We only have about two minutes left, so we're actually going to skip resecting that. I did want to briefly just talk about just this device here, which is the SmartBand by the stairs. And I'm not going to open the whole device up, but I'm not sure if you've seen this before, but this device actually has the hood is a little bit more shallow. So this little shadowing effect that you could see, you won't see so much with the SmartBand device. The Boston Scientific device, the hood is a little bit longer. So sometimes you can see a little bit more shadowing, but the thing about the Boston Scientific device is that when you suction, you sometimes you can hear a click when you're deploying it. So sometimes people like those tactile feel a little bit better. So I do encourage everyone to actually try all these devices out and take a look. Okay. Are there any other questions in the chat? No. Okay. Do you have any other questions for me at all? Yeah. I was going to ask you, what's your experience when you're deciding to do a band EMR based on the location of lesion, like whether at the GE Junction or the fundus, which are locations that you prefer and where you're like, maybe I should try a different technique or maneuver. Yeah. So when do we use band ligation EMRs is essentially what you're asking. So I generally use it in the esophagus. I do a lot of barotasophagus work. And then I'll use it at the GE Junction, which is a good, good place to use it. The stomach is a very good place to use it actually. And areas I don't use it are essentially in the colon. I try to avoid to unless it's in the rectum. Okay. And then what are the limitations to this? You're limited by size. So if you have a lesion greater than 15 millimeters, generally that's something that you, you want to do ESD for, or sometimes we briefly touched upon it. There's a cap assisted EMR and that can actually resect bigger lesions than the band ligation EMR. Any other questions at all? No. Thank you so much. Okay. Perfect. Okay. So I think we'll wrap up the endoscopic mucosal resection. I think we demonstrated resection of a lesion. We saw a little bit of a, of a deep injury that we're going to close in the next section. Okay. All right.

Dr. Arvind Trindad

Hofstra Zucker School of Medicine

Sophagology course

ASGE

endoscopic mucosal resection

endoscopic closure