All right, good morning, ladies and gentlemen. It's on behalf of myself, Dr. Barham Abudaya, and my colleague, Dr. Shiva Omar, welcome you to the suturing station in the ASGE esophageal course. We're going to demonstrate exciting technology, which is endoscopic suturing using the Apollo overstitch device. Truly, I mean, we take this loosely, but what got surgery to be surgery is the surgeons were able to suture, and suturing is a high fidelity platform that allows us to tackle many interventions in GI. So if you want to do bariatrics, if you want to do complex resection to close the defects, if you're doing third space endoscopy to allow us with the safety that we could close defects, even if they're large defects using this suturing device, and then what we're going to use it today is we're going to use it to demonstrate how we could anchor an esophageal stent using endoscopic suturing. Now the device have multiple components, so it might be intimidating at first glance, but actually it's just like driving a car with a manual shift. Once you get the sequence, it becomes second nature, so you don't think about this sequence, but we're going to have to start somewhere, and the first step is to orient to the components of the device. So we're going to move to both the endoscopic view and the room view here, because there's the two components of the device. We're going to put them hand in hand. You could see that you see it endoscopically and you see it outside of the scope. That is called the suturing arm, and the suturing arm has two motions, either open or close. There's nothing in between, so you kind of, it's not like that, so it's either open or close. That is the first step of the first component is the suturing arm. The second is the needle driver, and the needle driver is what drives the suture and the needle back and forth to the suturing arm, and these are strong 2-O-proline sutures. They come loaded in the cartridge, and this allows you to do either continuous suturing or interrupted suturing. The first step is to take the suture from the cartridge and load it on the needle driver that we're showing here, and that's an easy step. You take the needle driver, you click it into the needle, which is going to serve as a t-tag at the end of the suturing sequence, and you pull, and now you have, as shown here, you have the needle loaded on the needle driver and ready to load into the system so we could transfer it to the suturing arm. So now we're going to unwind the we're going to unwind that suture. I'm going to take the scope here, and then we're going to introduce that needle and transfer it to the suturing arm. Those who do ERCP, we love to use our pinky finger, and the pinky finger in this is used to hold the suture and make sure it's not getting coiled, and now simply we're introducing the suture, the needle driver, into the therapeutic channel of this double channel scope. By the way, this is the overstitch original device, which is a double channel scope device. Now there is the overstitch SX, which is a single channel device and does not require a double channel scope, but the motions are similar between both of these devices. Now we start loading the device with the suturing arm open. We introduce the needle and the needle driver into the channel of the scope, and you're going to see it coming out momentarily. So here we're seeing that needle, and that's the suture as shown endoscopically here. The first step is you want to make sure that the transfer is safe without bending the suturing arm of the scope of the device. So the maneuver here is you pull the suture or the needle driver until you do not see metal anymore. Then you close the device. I'm going to just pull it back up so we could have more room. You close the device, and then you push the needle driver onto the suturing arm, push the plunger, and keep it pushed and pull the needle driver by about one centimeter. And now we have the tissue loaded and ready to fire into the stent that we're going to anchor it to the esophagus. Okay, so the third component, which is not necessarily used in stent fixation, but it's good to demonstrate because that's used in bariatric indication and full thickness scroture, is the helical device. And Shiva, if you could push the helical device from there, it has two motions. Pushed, you get the helix out, and pull, you get the helix shooted back into the sheet. So push it out again please, and then rotation in order to engage that tissue helix into the tissue, you rotate clockwise to have the helical retractor go into tissue. That will allow you to retract whatever wall, whether colonic, gastric, esophageal, into the suturing arm for full thickness acquisition of that tissue. Please shoot the helix, and that goes into the auxiliary channel parallel to the suturing arm as we're going to show right here. So we'll demonstrate that here. This is going down, and now you have the suturing arm for suturing, and you have the helical retractor to retract tissue right there. Okay, now helix out. Of course, when you engage tissue, you're going to engage the helix, and pull, and then pull it toward you, and then do the suturing. But we're going to start by suturing the stent, so I don't need to use the helix to engage that stent. So helix in. So I'm going to just shoot it in the channel, and now we're going to go and suture the stent. So with movement of the device, I'm going to start with a closed device, and I'm going to simply send it to where the stent is, which is right here. We're going to open the suturing arm, and we're going to use a simple figure of eight suture on the stent, and we're going to dip into that stent, and simply take a bite from the stent. Here we're going to go deeper, and try to take a nice deep bite. You can see we're engaging the interstices of the stent, and you don't need to get esophageal wall here, you just need to get the stent. And then we're going to take that needle back by pushing on the needle driver to grab it back from the suturing arm, and then pulling until it's grabbed back, and then open the device, and now we have the first suture easily placed into the stent. Okay, now we took the suture, the 2-O-proline from the stent, now we're going to transfer it back to the device. Again, this device allows for continuous suturing. We're going to close the needle driver, we're going to send back the needle through the needle driver back to the suturing arm, and we're going to transfer it back, and now we have the second, the suture back into the suturing arm. Now I'm going to demonstrate the helix just for to show you that how we could use the helix for tissue acquisition. Now we took the bite from the stent, now we're going to have the helix open, pushed out please. Helix open. And now we're going to take that helix and dig it into that esophageal wall close to the stent. We don't need to make this a huge placation, we're just going to get close to that stent right here, and I'm going to just twist my body, and I'm going to ask you to start rotating. Go ahead. Rotating. One, two, three, four, five, six. Okay, that's good. So you could give us a couple of more rotation clockwise. Okay, good. So now you could see we got the full thickness of that wall. You don't need full thickness, but I'm just demonstrating this in the esophagus so you could see the idea. And now we're going to pull that suture using the helix. We're going to pull that wall, sorry, using the helical retractor, and then I'm holding this to keep tension on that wall that I'm going to try to suture. And now we're pulling it to become into the suturing arm of the device. Once I'm pulling that suture or that wall into the suturing arm, I'm going to close, and now I'm going to take back that suture. Shiva is going to unhelix, now going counterclockwise the other way. Yeah, keep coming. And now we took it out, and now we're going to open that device, and now we have another bite from that tissue. So we had a bite from the esophagus and a bite from the, sorry, a bite from the stent and a bite on the esophagus. And now we would like to cinch that configuration. Now we have robust anchoring of the stent with stent and then esophagus, and now we're going to cinch it together. The first step in the cinching is to release the T-tag, and the T-tag will act as an anchor to anchor that one end of the suture line, and the release of the T-tag is quite simple. You take this blue plunger and you just depress it, and the T-tag releases, and now this will anchor the suture at one end of the plication. Now we're going to remove the suturing arm, it's free, and we're going to introduce the cinching device which allows us to now cut and tie that suture for secure anchoring of that stent. The anchoring device is a little bit, require your assistance to help you out with it, but we'll demonstrate that concept here. So basically you're threading that suture into that small loop and then pulling that to follow the suture downward to where you started the sequence, and then Shiva will remove that safety mechanism by pushing forward on the blue to remove that safety plug right there. We're going to put it back for the purposes, and then using both index finger and two thumbs, okay, both the index finger and two thumbs to gently apply constant pressure, and that constant pressure what will allow is it will allow the razor in that device to cut the suture, and then you'll see two pieces of plastic here. One piece, two piece, this is the barrel that once the suture is cut it will lock it in place and tie that suture. So that's the suture tie that we're going to demonstrate here, okay. So I'm going to give Shiva this, I'm going to take that suture, and I'm going to introduce it through that loop. Now I've seen this done many different ways, the easiest way to do this is to take that suture, introduce it to that loop, give it some slack, and then leave it alone, let it dangle. Don't mess with it because you don't want to start fighting yourself. Then what you need to do is, is actually maybe if we exactly, thank you for switching that view, what you need to do is to take that yellow piece and start applying downward pressure gently on that suture to allow us to be pulled through the hole in the side of the device, and now what we have is we have the suture tracking over to where we started over that suture, okay. You could see that suture now, that cinch is tracking over that suture, I put some tension on it and now I'm introducing it to the channel. Now let's switch back to the endoscopic view. Now the t-tag is anchoring that suture line at one end, the cinch is going to cut and anchor it on the other end, so we cinch where we started the suturing sequence. So now I'm going to introduce that cinch, slowly, keeping tension outside because I don't want things to start looping inside of the channel of the scope. We're going to introduce it and here is that cinch coming. Now I'm going to use my, align it to where we start the suturing, which we started the suturing here at the stent level right there. Remember we took our first bite from the stent. I'm going to introduce the cinch to expose it out until I see a few rings of the sheath of the stent or the sheath of the cinch, then I know that I have enough cinch out and now you're becoming more of a hybrid between an endoscopist or an endoscopist and a surgeon. I know we hate to give up the scope but at this point you need to feel the tension on your suture. So you have to give up that scope and the maneuver is pretty simple. You use your, you use your torso and your chest to anchor the bellow of the scope on it. You give up your hand from the dowels of the scope and then you use your right hand to hold the cinch in place so it's not moving forward or backward, it's stable in place and you use your left hand in order to apply tension on that suture as shown here. So bellow of the scope sitting on your torso, right hand managing the cinch by stabilizing it so it's not going forward or backward, it stays where it is and your left hand is putting tension on that suture in order to allow it to cinch and clip and and cut. So now I'm in that position, my hand, my right hand is stabilizing the cinch, my left hand is pulling on the suture. All right, I'm going to ask Shiva to feel the tension here. Feel it Shiva, what do you, what, what, comment on that? Why, what do you feel? I feel like that it's, it's pretty, pretty straight and taut. Yes, exactly. So that's the feeling, huh? So now we're ready for cinching. You're going to push the, the blue forward a little and release. Exactly. And now one constant motion, cut and cinch. That's it. All right. Could you describe your experience with, with that process? Yeah, so like Dr. Abu Dhaia described, I use both my thumbs on the white end and my fingers in the, in the blue end and you have to just pull it, approximate these both ends and you hear a clicking noise. Awesome. So now. It did take a little bit of force. Exactly. So not excessive force because you do not want to cut, there's an inner guiding metal piece, you do not want to cut this and leave in tissue, so just constant force until you feel it give. And once it gives, you don't need to, to go any further. And now let's inspect that anchoring of that stent. We're going to remove the tissue, the excess suture here, and we're going to inspect, close the scope and you could see, go back to endoscopic view, please. And what you're going to see here is you could see there's the plication anchoring the stent very securely to the esophageal wall. So the proline is going through suture, then going back to esophageal wall and synch. So that is the sequence. Now, if you want to secure it in a different place, all we need to do is load another suture and we could, we could demonstrate that. Usually what I try to do is I do at least two plications, one on one side, the other on the opposite side, so the stent is suspended at two locations. It's very important if you're using this esophageal stent to manage leaks, that you want to create a seal. This is a really good use for this. If you want to create a proximal seal, so things are not leaking in between you and the esophageal wall, it's important that you could see on the endoscopic view that the the esophageal wall almost roll into the stent. So it's a good way to create a seal. So if I'm trying to create a seal, I will use three plications and then I will invaginate the esophageal wall into the stent. So now there's a seal and things are not leaking into the leak cavity and that will provide a good seal. But again, if we want to do a second suture, all we need to do is we open another, another suture, load it on the, load it on the needle driver and then, and then introduce it as such. Again, to load it, you take the cartridge, click, the needle driver, pull. So it's pretty simple. The setup of the device is pretty quick and now we unroll it and then within 10 to 20 seconds, we are ready to introduce and fire another suture. Now again, for anchoring stent, you could use suction. You don't need to use the helix because the, the esophagus is, is more sensitive or, or, or more susceptible to injury than the stomach. So the, the way you do it without the helix is again, you go to the opposite end of that stent. Let's say here's the opposite end. And then the simple sequence is you go forward, take a, take a sample from the stent, from a couple of entrances, you transfer, pull it back, pull back, transfer back here. I'm going to open here, get, avoid the stent, transfer back, and then use suction, suction, suction to acquire that wall. Take it back. Okay. And now you release the T-tag and bingo, that sequence is done in, in less than 10 seconds. Okay. And now you just cinch it again. And now you have two plication on opposite ends of that stent. And you could see if you do a third one, it will create a very nice seal over that stent and it will prevent migration in a significant portion of patients. Now, migration is not going to go down to zero, but without anchoring like this, almost all these uncovered stents will migrate. With anchoring the stents like this, the migration rate is cut down to about 20% or so. So I think it significantly helped with preventing the migration, especially if you do a good suturing sequence. Now, if just for practice, we could open another cinch, I think we have a minute or two left, and cinch that second sequence. Again, once we deliver, we could remove the needle driver. All right, thank you Shiva. They package it pretty tightly and now again the transfer is you take that loop, you introduce it into the, you take the suture, you introduce into that loop, you pull it and let it dangle, don't fight it, just let it dangle, you take that yellow piece and pull downward with nice constant motion, okay, until it is down and now you take this and you follow it to your, to your channel, so it's following the suture and then we're going to go to the, where we started the suturing which is at the side of the esophageal stent and again at that point you're going to give up the scope, use your torso, we start to go in line with where we started and again I'm going to expose a couple of rings of that cinch, my right hand is holding the cinch stable in position, my left hand is putting traction on that suture, you could see things are coming together nicely, I'm happy with the traction and Shiva is going to, Shiva is going to open, remove the safety mechanism and apply the cinch, perfect, see it's cut and now everything is retrieved and now we have a nice anchoring and sealing effect on top of the stent as you will see momentarily here, we're going to push, you could see one is up there and one is here and both are providing both sealing, you could see now the stent wall is tightly opposed against the esophageal wall and this is secure anchoring on both ends of that stent, so even if I drive through it, it's very unlikely, here I'm driving through the stent, very unlikely I'm going to be able to dislodge that stent, even with a big device in it like this, because this anchoring system is quite secure to do that. So let's see if there's any questions, I don't see any questions and I think we're running out of time, appreciate everybody's attention and joining us in this excellent esophageal course, thank you Shiva for your assistance with this and again my name is Barham, I'm from the Mayo Clinic in Rochester, feel free to email me if you have any questions about the device or the technique, but it's pretty straightforward to use this device to anchor stents to the esophagus, thank you.

Apollo overstitch device

endoscopic suturing

suturing arm

needle driver

double-channel scope

esophageal stent