Our final video presenter will be Dr. Muhammad Othman, who's a professor of medicine at Baylor College of Medicine. Okay. It will be six minutes. I promise you. Three videos. Six minutes. We'll go quickly through it. I will focus on duodenal and difficult lesions. So, we'll start with this one, EMR and the sweep. You can see the lesion here, trying to see what's happening. Oops. You go to the stomach. This happens a lot. And if you're not able to see behind the lesion, this is the first step. It's okay to inject in the front and remove whatever in front of you, and then move behind it. Because a lot of time in difficult position, you cannot just get behind the lesion. So once you would remove whatever in front of you, you will have to deal with what will show up after that, and it can be injected. You can see here, for piecemeal, you're going to take one piece after another. And we'll see right now how hard it will get when we go to the other piece out there. So now I'm trying to get this other one. And a lot of time, you'll have to depend on your assistant. You ask him, you'll suction, ask him to feel it, and most of the time, unless you have a good assistant doing these cases with you, you may not be good. So unlike ESD and EMR, your assistant is a key, and they have to be very good in opening or closing the snare. And you can see here, going through this area, I'm not able even to remove anything. So I will use a different technique, opening the snare down there, and try to use the tip of the snare as an anchor to get the rest of the polyp. So this is another technique for tough-to-remove lesions. So if you really have a hard time stabilizing the scope, you can open the tip of the snare and flex it. So I hope showing here some of these idea and how to deal with very tough lesions, especially in the duodenal sweep. Another thing you can use is stabilization devices. There's a few stabilization devices in the market. One of them in particular can work in the upper esophagus. And don't forget, when we finish this type of procedure, we can use soft tip coagulation around the margin. And we know that soft tip coagulation, or soft coagulation of the tip of the snare, is really prevent recurrence in this lesion. We'll move on to the next one. That's even more difficult lesion. And in this one, we might need the help. So that's a pylorus. This is a polyp. And what's annoying about this polyp is that it is behind the pylorus exactly. So you can come here, you'll see how it is taken two third. And you cannot see the end of it. The end of it is actually, is involved all the way to the pylorus. So in this situation, the solution would be to use a specialized knife to help. So this would be a more hybrid technique between ESD and EMR. We can also do ESD, but it would be like six hours. You can see, I don't know the video's cut a little bit, but that one, as you can see here, was started at 10 o'clock. You'll find that will finish at 12.30. And yes, it took two hour and a half, and I have to disclose that. So initially, I noticed that even if you're not gonna do ESD, identifying your margin and dissecting it makes a difference. You can see here, I decided to dissect part of the pylorus, mycosa, to go under the pylorus so that we can remove the polyp. Because there's no way to see behind the polyp, so the only way is to do from whatever in front of you and keep going. And you can see here, it's almost like a G-pon approach. That's exposed pyloric muscle. And you can see the duodenal mycosa on the other side. And we can continue injecting and removing the polyp till I'm having a straight view. So sometimes we have to be creative dealing with these types of lesion. And you can see here, it's a very fine product. I notice always duodenal polyp is fibrotic, and it's very hard to dissect through it. So I had to switch the knife to a smaller knife that allow us to dissect gradually. And the more you dissect, the more the lesion would go further away and gives you more stability that you can dissect nicely. That's almost the end result after removing. It's 12 o'clock, 12.19. We started at 10, so it's two hours later. And I think if I had more patients, I could have done that completely with ESD. But sometimes you have other patient waiting, and pleading can happen, as you can see here. And if the lesion is benign, it's okay to do EMR and use, as we call hybrid, or use the ESD knife to allow you to do EMR. And that would be the end result will show up in the next session, as you can see here. So two-third of the pyloric ring, and two-third of the duodenal bulb, this patient should not send them home because you can get what we call post-resection syndrome. So any time you dissect large areas like that, you admit the patient, give them IV fluid and antibiotic for one to two days, and this would be the second one. I will skip the ESD one. Nobody cares about ESD anyway. So I'm gonna show esophageal structure. Some of the esophageal structure, by the way, they are very dense-like material like that. This patient had six-time or seven-time dilation of this ring in the esophagus. I would like to show here, you can use a combination technique of streptoplasty. You do like rings like that. And also, you can go in a circle and try to remove this redundant tissue that is causing the problem. We understand that the process of the structure, part of it is like keloid in some patient. So unlike peptic structure, which is a purified process, some of this process is fibrosis with keloid or dense fibrous tissue formation, and patient might benefit from removing this fibrous tissue and dissecting them. You don't have to, you can even sometime cut with a needle knife, the standard one that you use for ERCP and then use a snare. As you can see here with the use of the ESD knife, you can also dissect all this fibrous tissue, and you can see that gradually, that structure is opening up just from removing this fibrous tissue, as you can see here. So that's it. Hopefully, this video is a little bit helpful and give you a few advice, and thank you so much.

difficult lesions

duodenal sweep

EMR

sweep technique

gastrointestinal lesions