We'll move on to the next video demonstration, which is placing hemostatic clips. What we'll do now in this segment is learn how to place a clip or a hemostatic clip. And so where this is commonly used is in a few fashions. One, for what's called mechanical hemostasis, meaning if there was an ulcer or a bleeding vessel, we can apply a clip, which is just like what it sounds. It's essentially a clip that just brings two pieces of tissue together or clamps down on a blood vessel. Or sometimes you can use it to close defects, meaning if there's a hole or a perforation. And other times what you can do is use it to approximate or bring the edges of a polypectomy site together. So let's demonstrate what it is. So essentially, this is our clip. Clips can be controlled in many different fashions, and there's many different types. They include the length as well as the length of the actual catheter tip. And so when they open, you can see different ones have different jaws. They open and close. Some can only open, and if you close them, they close down once. Some rotate. Some do not. So it's really, depending on your choice of clip, gives you the functionality. So what I'm going to do is close this. I'm not going to press it down all the way to deploy it. We'll go down into our stomach model, and we'll deploy a clip so that you can see what it looks like and sounds like when it's deployed. I'm going to give the clip to our assistant. I'm going to take our endoscope. I'm going to hold it using standard technique. We're going to lubricate our endoscope, and we'll go down into our stomach model now. So we're entering down into our stomach, and we're here. I'm going to insufflate, and for this purpose, I'm just going to find an edge of tissue that's raised so that you can actually watch deployment of the clip. So what we'll do is we'll take our catheter. We'll place the clip catheter down our channel, and we'll watch it come out the end of the endoscope. Again, we need to remember what is the optimal working distance, and we'll get our clip to deploy. So we'll take this. When we open our clip, you'll see the jaws come out, so let's open, and what we want to do is approximate the tissue margins. So they have some talons on the end, so you can actually grasp tissue and approximate it over to other areas. The other thing that you can do with these is what you want to do is make sure that the tissue doesn't have a lot of tension in it, or it won't actually grab and approximate that tissue together. So sometimes some use of some suction to reduce the insufflation when you're ready to place it is good, and you also want to apply a little bit of pressure, too, when you're pushing out so that your clip actually grabs and approximates that tissue together. So we'll do that right now on this ridge. Let's try to get that piece of mucus off a little bit. Okay, and so what we'll do is we'll go for this piece of tissue here. So I'm going to bring that edge up. I'm going to bring that edge down. We're going to close that clip, but we're not going to deploy, so we're going to come together. And you're talking with your tech the entire time, so now that clip is closed but not deployed. So if I needed to reposition this particular clip, I can reopen those jaws, move it to a better location that's more suitable, and then close it down again. In this case, I'm pleased with how it we got, and so we'll deploy it. So we'll go all the way down. You'll hear a click, and then you'll hear another click as we release from our catheter. Would you please release? And you can see our clip is deployed. We bring our catheter tip back, and our clip is successfully in position and will remain in its location as placed. Thank you. These clips that Dr. Epstein just demonstrated are called through-the-scope clips, and they have been present and available to us since the early 1990s. And there's been many modifications and functionality adjustments, and there's a whole number of various devices now available of different sizes and capacities in terms of what they're designed to do. What we typically will use these clips for is to clamp down on a bleeding blood vessel to use that physical force or that compression to stop the bleeding is item number one. The other reason that we would use these clips is to close or approximate areas or defects in the wall of the digestive tract. So for example, after we do a resection of a lesion inside the colon or inside the upper digestive tract, if we wanted to improve the safety of that procedure and decrease the risk of certain complications, we could use a number of these clips to essentially zipper close that defect, that mucosal defect that is left after we remove the lesion that we're resecting. In addition to these through-the-scope clips, we now have a number of over-the-scope clips, which is a device that is preloaded onto the tip of the endoscope. The endoscopist advances to the site or the target, and by either pulling the tissue into a cap that's also on the tip of the endoscope or suctioning the lesion into the cap and then firing the clip, it results in a much more robust, a much larger clamping and closure of tissues. And so again, we can use that to both treat and compress blood vessels that are bleeding or that have bled recently, or we can use it to close defects in the wall of the digestive tract, including full thickness defects in the wall of the digestive tract. Sometimes when we're doing these closures, especially with the through-the-scope clips, it requires multiple clips to achieve the treatment of any one lesion, whether we're clamping blood vessels to stop bleeding or to close mucosal defects, and it can become quite expensive. One of the other things you noticed in that video with Dr. Opstein is the technician really has an important part in manipulating a lot of the devices that we use in gastrointestinal endoscopy, and it's the orchestration and the coordination between Dr. Opstein and the technician to achieve the end therapeutic event that takes communication, it takes knowledge of each other of what to expect and practice over time. So getting to Jake's question, he asked, to mechanically grasp a lesion or some other tissue within the GI tract, are you fully restricting blood flow to the area, and what situations would you need to use this device? And again, when we're talking about clips, yes, the idea with clips is to compress and stop the flow of blood in a bleeding vessel to lead to hemostasis or cessation of bleeding, but we would also use these devices to approximate tissues or close holes or defects in the digestive tract. Sometimes those are just partial defects where just the carpet is missing, whereas the muscular wall is still intact, but by closing that carpet, we can lower the chance of a bleeding event later after we leave the site, so to speak, and the patient goes home, the chance of them bleeding is lower if we put clips in certain situations to close that defect. Okay. All right, thank you, Jake, for that question. And I think without further questions, we'll move on to polypectomy techniques. So Dr. Tierney, Melissa was wanting to know, on average, how long does a procedure take? And I know it varies by what kind of procedure you're talking, but maybe just in general response to that. Okay, so I'll repeat the question Melissa asked. How long do some of these procedures take? And it's a very good question. A lot of it depends on the goal of the procedure and really what's being accomplished. For us to just do a standard upper gastrointestinal endoscopy or an EGD and maybe take a biopsy, it can take 10 minutes. If we're doing a colonoscopy and we don't find any polyps, even when we're doing a very thorough inspection, it might just take 20 minutes. However, if we're doing a much more involved procedure where we're resecting a very large polyp or a large lesion, which we'll hopefully get a chance to see in just a moment, the procedure can take much longer. And the goal is to make sure that you've set aside enough time to accomplish the therapeutic maneuver without having to rush. So sometimes if I do a colonoscopy and I come across a large polyp that I know is going to take me a good 45 minutes to resect, and I've got another patient that's in the queue waiting to have their procedure, I will often not remove that lesion at that time and bring the patient back for a dedicated procedure where I can spend exactly the amount of time that I need to do it safely under controlled circumstances. Also giving the opportunity to explain to the patient that removing this larger lesion carries a higher risk of complications, and just making sure they have that foresight. Now removing small polyps, we do that all the time during colonoscopy, but when we come across a very large one that is going to take quite an extensive amount of time and quite an extensive number of maneuvers, we really need to make sure that we have enough time to accomplish that in a safe manner.

hemostatic clips

mechanical hemostasis

clip deployment

clip types

endoscopist assistance