Okay, we're back. In the last session, we went over band ligation endoscopic mucosal resection. And so now, in that session, we, if we could move it to the endoscopic screen. We did a band ligation EMR of this defect, and you can see here we created, you know, the stomach is well distended, so it's a deep injury. But this is something that we could actually clip. So we're going to demonstrate the use of the vesicle clip here. So I'm going to pull the scope out, okay? Okay. So before we even get started on actually closing this, I wanted to go over just a few things. There was a card here. Oh, here we go, okay. So if we could zoom in on this card. Okay, here. So it's important to know the product well. So for the OTSC vesicle clip, which is an over-the-scope clip, it comes in different sizes, okay? So it comes in 11, 12, 14. There's also a mini that we don't use often. But the first number that you could see here when you're asking for a clip will go over the size. So with the 11 clip, it's important to know that that's used for diagnostic scopes. And for the 11 clip is obviously smaller than the 12 and the 14. For a 12, you would actually end up using a therapeutic scope, okay? So one of the most commonly used clips I use in my unit is the 12, which corresponds with this number 12. Now the second number, when you're asking for a clip, will go over depth. So the six means a standard depth of six millimeters, okay? So that's when you're suctioning, you're able to suction a little bit deeper versus a three, okay? And then there's different types of clips. There's an A, a T, and a GC. The most commonly used is the T, okay? So any questions about this? Sure. Okay, great. Okay. So now we'll talk about loading, okay? So the light is off. So this is a cap. It's very similar to endoscopic mucosal resection banding technique in terms of loading the device on. So this goes like this here. I'll have you hold the scope for me. Okay. There's a little Velcro in the back. Thank you. And it's just snug around the scope, okay? Next is there's, part of the kit is very similar as the clip. There we go. So this is a clip that we'll be using, which is, is there the box that came with this clip? Okay. We don't have the box here that came with the clip, but this is essentially the clip that it is. So we'll slightly remove this a little bit. I'll have you hold this, okay? Okay. So just as we demonstrated for the endoscopic band ligation EMR, it's very similar setup. So this device, this catheter will go down the biopsy channel, and there's no need for to create a hole or perforate the opening. The device is already set up. So it goes down easily. Okay, and this catheter will come out the BiPSTEA channel. Okay. All right, so we'll take the end of this, you don't have to unravel the whole thing. We'll just take the end, it will unravel as we're attaching the clip. Great. Okay. So now you can see here that the string is attached to the end of the catheter. And we're going to pull the string upwards and then as I'm pulling the string upwards, she's unraveling. Okay. And so it's the same thing in that I'll have you hold the scope here and hold it on the hub here. If you could hold it here. One second. We could put this down for a second and then just if you could hold the scope here. And it's the same mechanism where you take the string, attach it in this little groove. So it catches and then turn the knob. And this allows the string to turn. So now we're going to turn it. Keep on turning and the string should backtrack. Is it working? You feel it going in? No? Okay. So it may not be in the groove, which it's not. That's fine. Okay. Okay, great. And it's really important to make sure that the string is lined up with the biopsy channel. So it is right here. Okay. To avoid getting the clip on your finger, sometimes I'll just push it against a hard surface. Okay, great. Okay. So now what I'm going to do is, you know, pass this through the mouth or obviously here we have a pig stomach. So we're not going to do that, but we're going to go down. You could safely pass it through the oropharynx. When you start getting to the larger sizes, it's actually a very good question. Sometimes you could actually use an over tube if you feel like there's going to be some injury, especially with the larger clips. And so when we're deploying the clip, there's actually, there's a few ways of doing it. One, we could use the suction technique, which is the most common. Okay. So when deciding what to use, I actually just will go up against the lesion. And here you could see that the cap is actually going flush against the lesion. So we may not have to use the suction tech, we may not have to use one of the assistive devices. There are some devices that we could use to help aid. So one, I'll have you hold the scope for a second. Okay. So. So this is one device here. Okay. Which when it opens. Let's see here. Yeah. Okay, so. Yeah. So there's a locking mechanism obviously that you can see here but this is a device where you could actually grab the tissue, and then, and then pull it in. So this is a nice little grasper that we could use so that it works very nicely like that. So, I'll have you demonstrate it. Okay. Okay, so it's the yellow device here that actually pushes forward and you hold this down. Okay. So we may need this device we may not we'll, we'll see how it goes. Okay. Okay, so let's go back. So what do you, what do you think, what do you think we should do do you think we should suction this and see how it goes or do you think we should try and use the device. You know, just because the size of the defect. I'm, I'm wondering if trying to dig the device into the surrounding tissue may be helpful. One option is like, let's see if we can get suction comes in, if that works effectively then we may not need it. Yeah, so I'm suctioning right now and I think it's actually the defect is actually moving in it's not a full preparation that we created here, because the stomach is able to descend appropriately so I think I could suction here and actually pull this in. So I'm going to actually take my time and suction really well and really pull this in and really to get a, you know, a good chance of closing this defect. My issue here is that I'm actually not able to suction the top part of the defect really well so I'm actually going to pull the scope back a little bit, and you can see here maybe now I'll have a better, better chance and you can see here that I actually do. Okay. Okay, so I think that's actually looks pretty good. And now I'm going to actually turn this knob here and actually deploy the clip. Okay. Okay. And you can see here that actually it worked really well. You can see here that we're able to close this device really really this defect really nicely. And so that's, that's basically the demonstration of the OTSC Ovesco clip. Okay. Any questions on what we just did or. So the OTSC, I know we're closing a mucosal defect. There are other indications like closing a fistula or a prior PEG tube site. Yeah. When do you consider using like APC prior to that? Yeah, so that's a good question. So what you're, you're talking about is with a lot of these defects is really, you know, creating, denuding the tissue and creating an effort so it could re-epithelialize and actually heal better. And so for PEG tube fistulas, we'll do that quite a bit where we'll actually APC beforehand, and we'll sometimes we'll even take a cytology brush, and we'll actually brush the defect as well, or the hole. And then that allows closure a little bit better so that's a very good question. The other areas we're using this clip is primarily is in upper GI bleeding so especially in the duodenal bulb, where we're seeing a lot of big vessels where sometimes if you put too much bipolar cautery on the, on the vessel or on the defect on an ulcer. It could be high risk for perforation we're finding that use of the Ovesco clip is actually something that could be very helpful. Okay. I'm not sure if you have any familiar familiarity with that or not. So, that's a good demonstration of the, of the OTSC clip I do want to briefly talk about the padlock actually I'll have you take this out. And so the, the padlock clip is actually, it's a, it's a clip by Steris. Okay. So, it has the same indications generally as OTSC clip in that, you know, we could close defects and holes just very similar to how we just used. I'm not going to demonstrate the use of it today but essentially, as opposed to going through the channel. This actually gets, you know, loaded on really just on the outside so really, we can remove this protective clamp here. But you just load it on the back end of the scope. And then once you have a snug fit you secure it with this band, and then you take this off and then you're ready to go. And then you could go down to the defect, and you can find what needs to be clipped. And then your assistant will actually deploy it, which is different from the OTSC which, you know, the endoscopist is actually deploying it, and they'll actually push this out and actually deploy the clip so it's actually a very easy mechanism to use. So a lot of people are using this device as well. Okay. So, so we have two options, the Vesco OTSC and we have the padlock, but that's essentially it. Any questions on the on the chat. Do you have any other questions at all. You know, last question, you mentioned that it's being used in GI bleeds, especially that the ardinal bulb location is sometimes challenging. Have you had any occasions where there's been misdeployment and how do you deal with that? That's a good question. So, it sometimes there could be so misdeployment could happen in two fashions right so the first way misdeployment could happen is if it doesn't actually the clip doesn't actually physically attached to the lesion. If that's the case, you know, we're able to just, you know, grab the clip and pull it out, and then start over again. Sometimes, you know, if in this situation in the first way of lining up the vesicle clip to the defect. If I deployed it, you probably wouldn't have closed the whole defect, you we would have seen that it attached to one side of the defect but it was still open. So you have to remove the clip, and that sometimes can be a little bit of a pain but luckily the manufacturer created a device, a cutting device where we can actually cut the clip. So that's very helpful and then you can start over again. Okay. Okay, perfect. So, I think we had a nice demonstration of closing a defect with the OTSC clip. You know, thank you for your attention and thank you for being part of this wonderful course.

vesicle clip

endoscopic procedure

stomach injury

clip sizes

clip deployment