Good morning, I wanted to say hi to everybody joining us virtually. We are going to discuss esophageal stenting here and we'll do a virtual demonstration. Let me introduce first myself, I'm Peter Dragunov, I practice at the University of Florida. Hi, I'm an advanced endoscopy fellow at the University of Chicago. My name is Shifa Omer, excited to see everyone virtually, of course. Okay, so for esophageal stenting, I want to first start with the two major type of stents that we have. One is that is advanced through the scope, and that requires therapeutic endoscope. That is the variety that is less commonly available in most endoscopic units because it is not routinely available and it's a newer addition. The benefit of using a through the scope stent is that you don't have to exchange the scope out and you can immediately deploy the stent under endoscopic view. You don't have to have fluoroscopy. What we're going to demonstrate here is over a wire stent deployment where we first go with the endoscope and then drop a wire, exchange the scope out and over the same wire advance the stent. And here we have two types of wires. One is a 0.035 inch ERCP wire, and that can be used, but it has two distinct disadvantages. The first one is, as you can see here, the wire is 450 centimeters long, which is a very long wire that makes your exchanges much harder compared with a shorter wire. The second thing is this wire is relatively soft. And because of that, when you're trying to advance the stent to a tighter stricture, it may not provide enough backbone for the stent advancement through the stricture. That said, this can be used in the vast majority of cases. And if you don't have a dedicated savory wire, which is what I have here, that ERCP wire will do the job. I personally prefer a savory wire because it's stiffer and also it is shorter, which allows for faster exchanges. Furthermore, the savory wire has these markings, and we need a really close up view to demonstrate this. I'm going to use the back of the package. And here are the two marks. You probably can see them, one, two. And interestingly enough, each mark, you would think that it's 10 centimeters, but actually it's 20 centimeters. So from here to the tip of the wire, because I have two marks, I have 40 centimeters. When I move to the next set of marks, which is three marks, let's zoom on those, one, two, three. So that will be 60 centimeters to the tip. That can create a cause of confusion because people see three marks and they may think that this is 30 centimeters. It is actually 20 centimeters per mark. Let's go ahead and drop the scope as a first step. Thank you. Beautiful. We can insufflate some air to get the stomach a little bit distended. Thank you. Yes. So we probably retroflex. So if we can get somewhere towards the antrum, which will be to our right. So pull back a little bit and uh-huh, uh-huh, uh-huh. Nice. Yeah, that's the right direction. Probably in a clockwise rotation. Okay. Okay, so at this point, and we can cheat here and we can see on the stomach where our tip of the scope is, if we can get it a little bit more towards the antrum, that will be good. Okay, so now when working with savory wire or any other type of wire, I always wear my goggles or I wear a mask with face shield. And the reason is that the back of this wire, it's basically stainless steel wire, which is quite sharp. If this catches you in the eye, you will have an eye injury and we rather not have that. Next thing we're going to insert the wire through the therapeutic channel of the scope until we see the wire endoscopically. If we can have an endoscopic view as well, we can switch from. That's it. Perfect. Push a little bit more. That's fine. Okay. Stop. Can we go now back to the room view of the big picture? Because at this point, I want to discuss how to exchange the endoscope out with the wire staying in place. And there are a couple of options. The first option is for me to be pulling the scope out as the endoscopist is pushing the wire. So you're pushing, I'm pulling. Okay. And we're not going to do it. I'm just explaining for now one option. The other option is to have the assistant, in this case, me pushing the wire and you are pulling the scope, basically opposite of what we described. In both of these cases, we have to be relying on the coordination in between me and you. If I'm pushing, I have to be pushing at the same speed with which you're pulling or the other way around. And that predisposes for losing wire access. What I like to do is to do both the pushing and the pulling myself as an endoscopist. But how do you accomplish that when you have only two hands? And the way to handle it, I'll show to our audience. This is how you normally hold the scope. But I will move my left hand from the scope controls to the wire. And I will lay the scope on my wrist. Okay. So my left hand now, the scope is laying on my wrist and with my fingers, I can hold the wire. If we can zoom a little bit more on my left hand. So you can probably see the wire. I'm holding it and I can push it and pull it with the scope laying on my hand. If we can unzoom now and show my right hand, that is perfect. So now with my right hand, I'm holding the scope and I'll be pulling with my right hand the scope and pushing with my left hand, the scope, the wire. So in this way, I'm in control of the whole system. I control the scope with my right hand, pulling out and I, with my left hand, I'm pushing the wire. So go ahead and do that and exchange out the wire. Perfect. Let me move it exactly. So move a little bit closer to the hub. Exactly. It takes some practice. So the idea is that this hand stays here all the time and this hand stays here all the time. So you need to balance this. Let me show you again. So when you put your scope here, I'm anchoring it against your body, my body and the umbilical is in front of my hand. So I had it like that. So in that case, I can do the both things together. So umbilical stays in front. There we go. Perfect. Nice. And we continue to exchange and let's imagine that this is the mouth. At this point, I will grab the wire and you move the scope again, be cognizant that end of the wire is sharp. So you don't want this to flop. So keep pulling out. There we go. I'm just rapidly pulling out the scope. Exactly. So you see how much wire we have outside. Imagine if we had twice as much length of the wire, it would have been a very long exchange and I can help here. Okay. So thank you. Absolutely. You're very welcome. So next we're ready for the stent. And I will pause at this point, I will let the, in real life, the assistant will be holding here firmly. Some people may even use a hemostat to clip at the mouth, but we're going to use a, over the wire stent, and I'm going to open the package. So, if you ever have issues and you don't have used this device. This is the little booklet which is called if you or instructions for use that comes with any device. Of course, in most cases we take this and just put it in the trash. But if you have any questions or concerns for example, what is the outer diameter of this stent delivery system. I don't know off the top of my head, but it is usually in the IFU. In many cases, the crucial information about the stent is also available on the label. And if we can zoom on the label, even a little bit more. So this basically shows me the length of the stent it's 125 millimeters long. It gives me the diameter of the body of the stent which is 23 millimeters wide, and also gives me the diameter of the flanges which is 28 millimeters in diameter. It also tells me that the outer diameter of the delivery system is 18.5 French. As you're well aware if you want to convert that in millimeters you divide by three. So, we'll take the stand out. And if we can come a little bit up close here in the room view. Would you please support this for me? Yeah. Okay. Right here. This stand, a little bit bigger view, yes. As you can see on the delivery system, there is a mark here and a mark here. And basically the way you deliver this tent is by holding this steady. Some people even anchor it on their hip and hold their hand there, and then pulling with your left hand towards the right hand. So rather than pushing with the right hand in, I will be pulling with the left hand towards the right. So the movement will be this. And as I am starting to deploy, let's focus on the tip of the stand. Okay. You will see that the stand will start to pop open. And I will continue in steady fashion. So can we unzoom for a second? And I want to show here, oh no, too much. I want to show here this yellow part of the delivery system. You see that there is a mark on the delivery system. So this is what we call the point of no return. Up to here, I can continue pulling, pulling, pulling, pulling. And you see, I'm approaching now the mark. I'm almost there. And if we can unzoom and now show the whole thing in one view, right there. You see, I have deployed roughly a half of the stand. And if I'm not happy with my positioning, at this point, I can actually rather than continue to pull with my left hand, I can start pushing in order to recapture the stand. And that's exactly what I'm going to do. So now I can recapture the stand if I'm not happy with where the stand is positioned. And readjust and then deploy again, as we did before. Again, and I can start deploying again. Keep in mind that not all Azoffo GeoStand have the capability to recapture the stand. This is only possible with woven stand. If you have a laser cut stand, you are committed to deploy it in your original location. So now I will recapture the stand so we can advance it over the wire. I will be holding the wire here. Please place the stand over the wire. okay so the wire is a little bit of a kink exactly this wire has been used one too many times let me help on this side that would be helpful yeah some people put some ky jelly or okay there we go it's coming through yes yes yes yes yes so here finally so we had uh here we had four marks which is 80 centimeters which is plenty so we'll insert okay did oh this this wire will broke up uh this is not supposed to be there but we are reusing the wire let's so now at this point we'll advance the stand over the wire stand over the wire and at this point you need fluoroscopy and the stand uh has marks of the distal end proximal end and also you have a third mark in the middle which is the point of no return as seen under fluoroscopy so you have a point of no return mark on the handle and you have a point of no return mark on the fluoroscopy image uh i will favor of using the one on the fluoroscopy image over this one because uh the fluoroscopy image mark is more accurate compare with the one here on the handle so now under fluoroscopic guidance we'll do exact same thing as we did outside of the pig stomach can you deploy this tent without fluoroscopy yes you can uh you insert the scope alongside it we need a good bit of ky jelly because plastic will plastic will rub against each other let's distend okay we have too much stencil i will withdraw it there is a transition zone oh no we're not can you come back a little bit more until we see a yellow transition zone there is the yellow transition zone right there you see it uh it's in the upper uh left corner of the endoscopy image so now i can start deploying the stent without fluoroscopy and monitor i want to keep that transition zone not moving which will mean that i have to withdraw the stent as we are deploying so i will start deploying and you see how the stent is going away from me so i will pull back up i pulled much too much there is the transitions on i'll keep it steady there so i'm gently pulling back gently pulling back i have some movement but not much so i'm deploying the stent as we are talking and basically trying to keep that transition in between the yellow and clear plastic in one place and minimize movement i strongly will encourage you to use fluoro if you have that capability it's more user-friendly as compared to what we're doing here but this will be a good way to deploy a stent at bedside let's say in icu without the need to bring the patient downstairs to your endoscopy unit and have to use the fluoroscopy of course through the scope stent will be even a better choice and there is the stent deployed let's go in a little bit there is the stent deploy and at this point i will remove the delivery system and alongside with the wire and this wire has seen a better day so we may need to get rid of it and that's that if we can go back to the end of you at this point we will document the distance from the incisors to the top of the stent in this case is 20 centimeters obviously we don't have the mouth here so and we'll put that in the report the stent was deployed with the proximal end at 20 centimeters in our case and we are done this stent can be repositioned but it will be difficult to do so so you have to use some type of a grasper to get the purse spring a purse string but i will suggest that try your best effort to deploy the stent in the right position to start with because repositioning can be challenging thank you

esophageal stenting

through-the-scope stent

over-the-wire stent

endoscopic view

wire exchange

fluoroscopy