We'd like to welcome our last speaker up to the stage, Dr. Andy Tao from Austin Gastroenterology in Austin, Texas. He'll be speaking on hot cases with videos using old devices in new ways. Thank you so much. It's quite an honor to be here. Thank you all from ASG for inviting me to talk to you guys. If you perform endoscopy, this one's for you. I don't know how I fit into the education platform, but this one should be fun. The tools that I'm going to show you, I'm going to show you 10 tools, none of which cost more than $50, and I hope that just one of them, just one, you'll bring home on Monday and you'll be able to utilize it for the benefit of your patients. Here are my disclosures. By the way, these companies are not going to be happy about what I'm going to tell you because these are really cheap. Number one, how to augment suction. Even in moderate endoscopy, one of the main limitations is being able to suction large clots. This is Poucille's Law. It says that the flow rate or suction rate is directly proportional to the pressure exponentially to the fourth power related to the radius of the actual channel, indirectly related to the viscosity coefficient, and indirectly related to the length of tubing. You can actually alter these almost free of charge. The radius, obviously, is the most powerful. You want to try to buy this scope. We call her the clot buster. I said long live the queen because Olympus, I told you they're not going to be happy about this, for some terrible reason has decided not to continue servicing this scope, not to sell this scope. It's the only time, I think, in modern endoscopy where technology has been stopped and then not replaced with something better. What I'm talking about is this scope has a six millimeter channel. It's absolutely enormous. If you combine it with other methods I'm about to teach you, it can really suction some serious stuff. Another way you can increase the suction is to reduce the length. You can reduce the length by bypassing the umbilicus, which is half the length of your scope. You can borrow the suction from the back of your scope, just like that, and directly plug it into the biopsy port. That reduces the length or L by 50% and effectively doubles the flow. That increases the suction by even more than that because it increases the R because the umbilicus is actually the narrowest part of the scope. You're effectively increasing the radius as well. The actual amount is closer to about three to four X. See that? Take it back off the back of your scope. It's not going to be the first time I borrow something from my own backside, pun intended. The Steris also makes this, essentially the same thing, it's called the BioVac Direct Suction Device. It basically is another suction system that directly ports into the biopsy port, except the interesting thing is it has an irrigation line. You can tell this dates the scope because you'd have an irrigation line because this was invented before the GIF 180 when you didn't have a separate irrigation channel. It has this interesting suction line here that has a button that you can control. You can hold it with your right hand. If you combine this with the Clot Buster and then you do this next thing, which I'm about to tell you, I mean, you can suction the heavens. You can also increase the pressure. How do you do that? Well, you put two vacutainer pumps in series. Remember, that's a vacutainer pump. It connects there. There's another alternate port called Ortho. I don't know what that stands for, but connected to another vacutainer pump, which has its own canister. This is not one sucker and two canisters. This is two suckers and one canister. It's like me and Dr. May are drinking from this. She's got her own straw. I got my straw and we're drinking from the same pot. It effectively doubles the flow. My brother went to MIT. He worked out the physics. It's true. All right, number two, moving on, the Clear Cap. This is for tamponading bleeders and you can use it to suction food bolus. The Clear Cap is a transparent distal attachment. I know everyone's seen or at least used this before. It can tamponade the bleeding and isolate the visual field because you can make a little terranium with the cap. Let's see, this is the bleeding source right here. You can put the scope right over it and you can block out all the other clots. If you move it to the side like this, you can actually use the edge of the Clear Cap to tamponade the bleeding. You already know how to do this because you use band ligators and that's already built in, right? Except they don't have a suction hole. It can also be useful for food boluses as well. Now, you may ask, well, Dr. Tao, that little hole there, what's that all about? What's that little hole about? Okay. They put it, I asked Olympus, practically I called Japan and they told me, the reason why we have the little hole is because when you do gastroscopy and you line up the hole at five o'clock, gravity naturally drains out of that hole and that can be useful. If you're doing a food bolus though, flip the cap around. See how I did that right there? Flip the cap around. That way you don't lose suction, right? Because you want to suck that food bolus back into your cap mouth, right? So you can reverse impact it. So remember to install it. Hemostasis clear cap. Here you go. Do a dental ulcer. Forest 1A, you see the arterial bleeding right there. And I turn it so that it opposes where your instrument comes out at the 5 o'clock position. And you can see, look, I'm tamponading the vessel. You can even see it pulsing. You see that? But good visualization. First, I take out a little bit of epi. And then we do some coaptive cauterization using the bipolar probe. But that vessel was actively bleeding. But during this whole time, do you see any blood? Bloodless endoscopy. Thank you, ClearCap. There's the vessel there. And if you guys ever wanted to know what coaptive cauterization means, it means that you compress mechanically the vessel, and then you seal it with heat. They said there's going to be hot videos. Here's your hot video. And it's like pimple popper here. Get ready. Pops. All that's left behind is the shell of the vessel. That's kind of how it's done. OK, we'll move on. You can combine the ClearCap with water immersion. They're an excellent combination, because the ClearCap will stabilize the scope. It'll open up the folds. And you can use it to tampon out the blood vessel. Meanwhile, the water immersion, as you guys know, softens the walls, underwater EMR, remember? It stabilizes the scope. And it allows the jet of blood to just be a jet rather than pooling on top of its source. So you can clearly see where it's coming from. And now you can pass your bipolar probe and give it a burn. OK, what about for food boluses? OK, remember, you want to use a cap where the hole is not exposed so you don't lose the suctioning, right? So here I'm using, well, that's super disappointing. I thought my videos were going to work, but alas, they will not. So OK, well, I don't know. Just imagine I went in there, and here's the food bolus, and it looks something like this. And it spits out into the water. Trust me, it works, OK? And if you don't believe me, if you don't believe me, here's a meta-analysis, OK? This is six studies, 677 patients treated with CAP-assisted versus 694 conventional endoscopy. I was given some feedback that I don't provide enough evidence for my videos, so here they are. So this is the CAP-assisted method, and it was superior in every way. Technical success, odd ratio 7.1, on-block removal, odds ratio 26.6. Have you ever seen an odd ratio that high? Shorter procedural time, delta 4.6 minutes, OK. They sell different types. This is my favorite one from Avesco because it has a really long cap, very, very soft, no hole. Steris and Olympus show the short ones. You can also repurpose it. Don't tell Jayco, I guess, from Boston or Cook. The Cook ones are kind of smooth. The Boston ones have these little ridges, OK? Hemostatic forceps. So here is a post-polypectomy arterial bleed. This is bad. This is pretty deadly. It has an arterial bleed. And look, it's pouring on top of itself. You cannot see. In this circumstance, you want to turn the patient to any direction. Even the most ergonomically unfriendly right lateral decubitus position is acceptable because you just change the vector of gravity, and you can grab it. Now, what tool are you going to use? Use the cheapest, fastest one you have, the hot biopsy forceps. Coming back from circa 1995, the gray-haired guys in here will be like, hot biopsy forceps? I haven't seen that in a long time. That thing costs $20. And on soft COAG setting, it is super effective. It's super effective. Soft COAG setting, 60 watts. Let's take a pause. I don't think that the advancement of thermal energies in various settings have gotten its fair day in public. Back in the day, 20 years ago, there was just blue petal. Hot, hot blue petal, forced COAG. Now we have much better different energy settings, but no one really talks about it. I mean, the fastest way to put a group of you all to sleep is to talk about an energy setting lecture, right? But trust me, they've made tremendous advancements, and you need to hear about them, OK? So here's another example. This is like a dulafoil. That's a hot biopsy forceps there. You can always tell because it has a little hole in the cup. It's very, very cheap, 60-watt setting. And the reason why I like to use them is not to just show off old tools in new ways, but because it's so cheap that now you can feel liberated to use any other type of combination therapy you want. You want to put peristat on there? Be my guest. $600, no big deal. You didn't use a biopsy. You didn't use a bipolar probe, which costs $275. You can put a clip on there. You want to put an expensive clip? Be my guest. You just saved, what, epi, bipolar? You saved a lot of money already, right? Here's another biopsy forceps. This is on the apex of a fold. This is where it really shines, because if you took a bipolar to that, you might slip off and instigate bleeding, right? So you just grab it, and you burn it, and you just move on. I've got a million of these. Come on. COAGrasper for sphincterotomy bleeding. The COAGrasper is like a hot biopsy forceps, but with a marketing team, OK? You can just grab the little vessel there. This is a post-sphincterotomy area. Now, I have to admit, the COAGrasper is unique, because it has different shapes of its beak. It has some smaller ones that are very, very nice for ESD and EMR work, OK? But it works all the same. You close, you gently tent and pull back, and then you just tap the blue button until you see the burn. And then you don't pull it off, because you're not interested in the biopsy. Remember, those biopsies sucked, right? So you're just interested in burning, opening, and letting it go, just like here. You burned it, all right? You're making sure there's no more bleeding open, and then you let it go. And you can do even precision work near the papilla. That's not blood, hello. That's water, OK? It worked. OK, there you go. There are four types of monopolar hemostatic forceps. There's the one everyone knows from Olympus called the COAGrasper. It costs $200. It comes in a variety of sizes, decent-sized jaws. There's a new one from Microtech called the Ensure. It's a bit cheaper, as many of the Microtech devices are. It has about the same jaw length. Biopsy forceps, hot biopsy forceps, my favorite. They don't rotate, but boy, they're cheap, right? Many, many vendors make them. The Ovesco also has a COAGrasper. It looks like a Maryland forceps. It's very expensive. If you don't believe me, here's some evidence. Randomized control trial, 112 Japanese patients with peptic ulcer disease, all with high-risk stigmata. They were randomized to hemostatic forceps or CLPs. And hemostatic forceps were superior in all regards, just like the clear cap in the food bolus. Initial hemostasis, 98% versus 80.4. Recurrent bleeding, 3.6 versus 17.7. Duration of procedure, 200 seconds less. Length of stay, short by a day. No adverse events. So consider it. The hemostatic forceps or the hot biopsy forceps went out of favor, as many of you guys know, because the biopsy specimens were terrible. They were just like charred tissue, but consider using them for hemostasis. Number four, endoscopic vacuum therapy. I'm gonna go over time, but it's the last one. You'll make it. Number four, endoscopic vacuum therapy, fistula closure. Okay, this is where you have like a esophageal perforation or a fistula, and you place a sponge that's crafted out of a wound vac sponge, and you connect it to a nasogastric tube, and you basically put it into the cavity. You set it to 125 negative pressure, and it promotes healing through multiple modalities. Increases perfusion, controls exudate, clears bacteria, and macro and micro deforms. This is exactly the same methodology that external wounds are healed, and all the evidence that went into developing that, it actually works inside your body too, right? It's much more effective in the intracavitary or intraluminal position than the intracavitary, better than intraluminal. So this is how it looks. You have a perforation. You go in there, you wash it out. You put the NG tube in the wrong way, which means you make it come out of the mouth. You can use a grasper for that. You tie the sponge on there. You put a suture loop on the sponge. You grab it with the forceps, and you drive it all the way down, and you stuff it in there, and you put the pressure on. In case you're wondering, we don't have to go through this, but I made it go at 3X speed. Those are the devices you need. That's the KCI WoundVac system. There's the sponge material. I like 14 French or 16 French NG tubes. Cut the tip off, make it however long you need it to be. This is after it's already coming out of the patient's nose. You do a little arts and crafts. Cut that to size, stick it on there. Tie off the sump because you don't want an air leak, and then you connect it to the KCI system by using the extension cord. You can cut that pad off, which normally goes to the skin, but we're putting it inside the patient. There it is. Right, so you cut it from the granulofoam sponge. This is kind of what it looks like. This is intraluminal. Remember, you wanna make a little loop at the end in order to be able to grab it. This is very laborious because every three to five days, you have to exchange the sponge, and every time you exchange the sponge, you wanna make it a little smaller. That way, it has some tissue to grow. Ah, no evidence? Yes, evidence. A systemic review and meta-analysis showed that esophageal defect closure rates is significantly higher in AVT versus self-expanding metal stents, which is currently probably the standard of care. Four studies, 163 patients. Better in every way. Leak closure rate was significantly improved. Shorter treatment duration, and endoscopic vacuum therapy had lower complications. Better inpatient mortality compared to self-expanding metal stents. However, it is laborious. Requires multiple EGDs and longer inpatient stays. Okay, let's see if this one works. Yes, okay. This is an anastomotic leak from an Ivor Lewis esophagectomy. That hole that I just came out of was actually the fistula. The other hole is actually the lumen. You can't tell, that shows you how bad it is, right? So you make the NG tube, and you plug it down into that defect, which I'll show you in a second. This is the defect. It's very, very deep, that cavity, and that's the sponge at the bottom here. This is after I remove it, after the second. It makes this tunnel. It's not quite perfect yet, but it's starting to have some granulation tissue. That's actually the lumen. There's some necrotic debris here at the dehiscence site. You gotta get rid of this. You want the necrotic debris out of there. You want pink on pink at all times, because that stuff will just clog up the suction system. I did it four sessions over three weeks. Very laborious, I know. It ends up looking like this. It's kind of like a divot or like a pseudo-diverticulum. Many people say you can just leave it like that, but I get worried about it opening up again, so I ended up just closing it with an over-the-correction, the Apollo overstitch system. The defect is here at the bottom, and you can see in a second I'm gonna cinch it, and this will go away. Cinching, cinching, cinching, cinching, and kind of just basically remodeling it. So there it is back in its original position. You can use combination therapies to finish this off in order to shorten the hospitalization. That's what we've learned in our institution, and by institution, it's just me. So here's another one. This is a Central Texas special this is a boar hops that ruptured through there's a food bowl that's that's straight up three day old sausage right there jalapeno sausage you debrided it you put the endovac sponge in there you come back it has a granulation tunnel which is success but then unfortunately I noticed there's another tunnel going off to the side that's more jalapeno meat you got to get all that out of there okay keep the breeding a little bit little by little I know this seems frightful and no one else isn't gonna even consider doing this but remember what the alternative is it's even worse right the spit fish or the whole thing right make sure that they're always very well drained this is a continuation of the process here I enter into the to the right pleural cavity there's the chest tube and it's clogged so I kind of debride it with the scope brush this is kind of like a trans oral vats I'm just showing off now honestly but it works okay eventually the tunnel gets becomes like this beefy and red and that's now you're getting very very close to success that granulation tissue is the glue of the human body when you get to this point you can just put the the sponge intraluminal you don't need to put it in the cavity anymore just lay it inside the esophagus and the next time you come out it'll look more like this the analogy I often give is if I took sandpaper to your elbow crease right here and I just rubbed it until all your skin was gone and then I closed your arm like this wrap tape around it three weeks later told you to open it up you couldn't you'd be glued together you'd be stuck together it's the same thing on the inside okay no let's move on nightmares okay number five percutaneous suture closer officialist those spy bite forceps are very useful for this if you have for example an interior gastric or I'm sorry an interior cutaneous or gastric cutaneous fistula that won't close despite over the scope clip despite trying to suture it then suture it closed I know you're not a surgeon but you can do this grab one old silk suture and then you pass it intraluminally by first passing 225 gauge needles all the way intraluminal almost like you're gonna do a peg tube and then you pass the spy bite forceps through that area and you grab the suture that's coming out of this end and you grab it over therefore making it like this then you tie a knot and you can cinch it down you're essentially suturing true full thickness abdominal wall transcutaneous and transluminal and you do that in multiple sites or in a circumferential pattern this is a video of it see you're passing the 25 gauge needle through look this is the fistula here that's the that's the hole that won't close all right so then you pass another one through you put your spy bite thing you grab the suture loop and now you've you've made a full thickness transfer right you do that multiple times maybe in a cross pattern or just in a linear pattern and you can eventually close that that defect up this is very very effective now you may oh and then on top of that go ahead and Apollo over stitch the the bottom for some extra security okay this is very very effective it's not published a lot it's not done very often the surgeons don't do it because they never have time for you to do a combined endoscopy surgery with them logistically speaking but if you can pull it off yourself it's it's really effective and it can really change people's lives okay oh crap rotating the clip the clip the clip is very useful for removing x-tacks have you ever wondered oh I can never remove or remove an x-tack the clips can rotate so you can unscrew them out instead of just leaving them there forever and the one I like to use is the resolution 360 clip you can rotate rotate because you can do the rotation remember so you can be very very controlled so that's one benefit of using a rotating clip another benefit of using a rotating clip is when you're pulling a peg j-tube down into the jejunum right so I don't know if you guys do peg j-tubes they're quite annoying but one of the points of the procedure is you grab it see look and you can rotate it so you wrap it or you like alligator death roll the thing and then you drag it down because it's so painful to drag it all the way down to the jejunum to realize that you lost it like a meter up in the duodenum right now you close the clip onto the jejunal surface and in a one-to-one fashion you withdraw the scope while you advance the clip don't deploy it all the way okay don't deploy it all the way because you still might rip the clip off keep it down there and in a one-to-one fashion just like you're passing a savory guide wire withdraw and then finally when you get to the stomach deploy the clip you don't need to see yourself deploying the clip you know what it looks like it will release it and hopefully there'll be no alpha loop that's called the UAB Raptor technique by Klaus Monk Mueller I think he published that and it's just like the Heisman you're leaving it down there as long as possible until you get to the stomach fully covered self-expanding esophageal metal stents are now through the scope okay so this is useful for the general GI guys out here they're useful for refractory esophageal bleeding and esophageal perforations okay this is a post banding ulcer one of the most frightful bleeding situations you can get yourself in there was banding that was done eight days ago the bleeding actually is coming from down here and and I'm suctioning and it will not read out it will not come up into the cap because it's become fibrotic this is very bad right and I and I and I can sense this is not gonna go very well but in desperation I went ahead and you know just turn the wheel and deployed the the band anyways hoping that it would hold you never want to see this that means you have a ligation failure not only that that little thing is gonna get sucked up in your suction channel so immediately we tried sclerosin that didn't work by the way and then we just got a fully covered self-expanding metal stent and we deployed it at the bedside no fluoro why why don't you need fluoro anymore because it's not a stricture you can get down into the stomach and you can directly visualize its deployment now for the non advanced endoscopist you may be wondering okay like what's new about this the thing that's new about this is that we didn't have this technology six years ago we hadn't cracked the technological know-how to get a fully covered stent through the scope okay it could only be achieved outside the scope but now they've got it skinny enough that they can get it through the scope so you don't need a guidewire evidence randomized control trial 29 patients randomized between a fully covered self-expanding metal stent or Blakemore tube and the success was better in every way the overall success control of immediate bleeding lower transfusion requirement lower adverse events one of my mentors once told me that the Blakemore saved just as many as it kills there's many types of through the scope stents Boston Tyun sells them Olympus as well remember they all require 1t gastroscopes and none of them require fluoroscopy or a guidewire because you're not doing a stricture right band ligation band ligation is excellent for diverticular bleeding they're experts in in Japan and as well as forgave I know people are like well we never see this yeah it's rare but in case you ever do run into a diverticular bleed and you're having a hard time blindly putting a clip over it or if your clip failed you can you can tattoo the the proximal end of it remove the scope load the banding kit on suction the diverticular like here you can invert it and and you can stop the bleeding in a very very durable fashion over the scope clip can also work you can use a banding kit now if it's in the right colon I fully admit that that's much more difficult to do okay it's further away and more time-consuming here you get excellent inversion it causes a little bit of mucosal trauma there but there it is the pseudo polyp of an inverted diverticula with a high risk stigmata of bleeding right here on the left side where you see the adherent clot you may say okay well that's really weird dr. town no evidence right multi-center retrospective cohort code blue j-study this is gonna open your eyes 1,679 Japanese patients with confirmed diverticular bleeding who were treated with either band ligation or clipping this took nine years across 49 hospitals that's 500 hospital years to find 1,679 diverticular bleedings my friends this will never be repeated ever in the history of mankind okay and a logistical regression was used to compare the outcomes EBL or band ligation was independently associated with reduced risk of early rebuilding and late rebleeding okay and they had good odds ratios to about 2 to 1 diverticulitis and perforation following band ligation were very rare look at how low that is what about gave right let's say you tried already a PC on this these are this is nodular gave you can ban these as well not only is it very effective it's very satisfying I mean look at that mmm right just just band as close as you can to the pylorus if you run out of bands of course you can use a PC if you like or another technique that I'm about to show you but go ahead and use all the bands and it's very effective if you don't evidence meta-analysis for randomized controlled trials 204 patients EBL is associated with higher eradication rates less bleeding recurrence than APC remember these are randomized controlled trials guys is level one evidence EBL is associated with fewer blood transfusions fewer hospitalizations and few number of sessions and there was no difference in adverse events he must pray modifications here's two of them you know he must pray is awesome but it has some significant technical limitations one if you're bleeding if it's refractory bleeding then blood is pooling actively and everything you tried just failed number two according to the manufacturers instructions you're not allowed to suction number three according to the manufacturers instructions you got to dry the scope number four once you finally get the catheter tip down there and if you successfully got it down there dry you can't dip it in the blood or else it would immediately clog by capillary action but there's a way to overcome this it costs about $10 you take a piece of bone wax from the ortho department and the three-way stopcock right and you add the bone wax onto the tip of the catheter this bone wax is hydrophobic and it will prevent the catheter from getting obstructed or I'm sorry without preventing it from getting wet okay then you put that onto the three-way stopcock and then you take an air flush a syringe that's preloaded with air to blow off the bone wax when you're finally ready to fire the powder okay so this is what it looks like ex vivo demonstration this is my only claim to fame I've published one thing in the last few years and this is the only thing okay so here it is ex vivo you have it ready to go and just like a booger you're blowing out of your nose you're gonna miss you can dip it in water so you blow it huh pow turn the stopcock and fire you can suction it doesn't get clogged you don't need a flush now now when you blow off this bone wax though and you start firing then it can get clogged but remember this the first firing that really makes a lot of difference okay if you don't believe me here's one in vivo the bone wax you turn the stopcock oh you can suction see but I have a 1t scope here so I have a little room to suction okay you can blow the bone wax off pow there it is turn the stopcock and fire there was no preparation this it takes seconds guys all right if you don't like that and you think bone wax is weird you can add a stopcock and you can borrow from your own backside your own co2 and attach it onto the third way of the stopcock I like to use the seven French catheter in a 1t scope and you can even suction as you pass the catheter so here's the regulator the co2s there where do you disconnect from your backside you just connect it right before it gets to the indicator right you see take it off here put that where you were going to put the the air flush right and now you have a continuous flow of co2 right guys this is exactly how the endoclot system and the next powder system work right they blow continuous room air but this is your own co2 now you pass it through the scope now you may say I mean dr. Tao that's a bit gassy because it's just gonna continuous blow co2 are you allowed to suction absolutely see as I'm passing the catheter through I'm suctioning while the catheters blowing inside the catheter the channel it's like a two-way street right it still will not clog the catheter because you surprisingly need only a very little flow of protective co2 from preventing the catheter from clogging and then now your technician can choose between two ammunitions powder or protective co2 powder or protective co2 okay this one costs 50 cents which is the cost of a stopcock if you don't believe me here's in vivo application this is a big gist that totally failed from that through the scope clip I tried and you can see here the the catheter is blowing a continuous flow of co2 it does not clog I can still suction right then you could just turn the stopcock and fire away your scope you can use room air at the push of a button why do you need room air because remember to clean the lens you need some type of you need some gas to be propelled so you'll still want to use that last thing number 10 spray coagulation spray coagulation is APC without argon okay spray coagulation was invented I think about 10 years ago and completely in my opinion buried by the energy industry because they didn't want you to stop buying APC probes it's a form of non-contact coagulation with large tissue area of effect and superficial depth of injury I'm basically describing to you APC it's used in Japan it's used by our surgeons as well in the United States but it's not advertised to you and me except for right here right now it has the same principles of physics as the APC it uses a very high voltage electrode which is actually just the tip of the snare relative to the mucosa and it leads to a plasma arc of the intervening air so in other words the energy industry figured out how to create a non-contact plasma arc out of room air instead of plasma but decided not to tell you well I'm telling you right now use this instead of APC because it's a lot cheaper APC probe cost $150 snare as you guys know cost $25 right it creates a burst of high voltage electricity which dampens immediately in the current stops as soon as the tissue is full graded or charred this is exactly the same way that APC works okay if you don't believe me here we go there's chicken guys that's not APC that's spray coagulation okay and here it is in vivo the sad part about this is these are not actually the slides I wanted to show you there's another video of this that I just used on Friday that I tried to upload it was me using spray coagulation except the catheter tip is not out the catheter tip is in did you hear me the catheter tip is in the inside the catheter so you cannot cause contact thermal injury you can put it against the mucus that you don't have to hover and you can fire and you won't cause full thickness thermal injury okay follow me on Twitter you're gonna laugh my handle is dr. blood and guts but just follow me and you'll see my video that I posted okay the cross-sectional area for a spray effect is a little bit better than APC and it's it's a very safe it doesn't cause any MP injury the submucosa can be affected but it's very very low and so it's exquisitely safe as well this is a study done by dr. Fitz this is ex vivo pig stomach so the top 10 list here we go augment suction by bypassing the umbilicus and adding to vacutene or suctions in series use the clear cap to tampon on bleeding and suck out food boluses use hemostatic forceps because they're useful and they're very cost-effective consider learning or trying endoscopic vacuum therapy it's very low tech just requires an ng tube in a sponge it's very effective but laborious you can suture and tarot cutaneous fistulas with a needle and a spy bite forceps rotating clips can unscrew X tax and securely drag interluminal tubes by using the alligator death roll suture loop technique I made that up fully covered self-expanding esophageal metal stents are now through the scope and they're superior to Blakemore tubes in every way and I genuinely believe that the general GI endoscopist can per can perform that stent placement if they can perform through the scope esophageal balloon dilation band ligation is effective and safe and diverticular bleeding and gave bone wax and borrowing co2 can optimize hemo spray delivery and spray coagulation is a PC without a PC try it with the stair tip next time you'll find it deep buried in your energy device is it was really a pleasure to give you this talk thank you so much

endoscopy tools

suction techniques

Clear Cap

hemostatic forceps

esophageal stents

band ligation

spray coagulation