Okay, I think we'll now move on to the next session, which is on banding. What we're going to do now is we're going to look at banding. And so when we use bands, it is typically for esophageal variceal band ligation, meaning big blood vessels in the esophagus in patients who typically have cirrhosis of the liver that can bleed. And we use these to assist in stopping bleeding or preventing bleeding in the future. As bands are placed on these big blood vessels, they will scar down so that the risk of them bleeding in the future tends to be reduced. So in order for this technique, what we'll do is we have a banding kit. And all that a banding kit is is essentially a series of rubber bands that can be deployed or put on the tissue, meaning over that blood vessel, to get it to stop bleeding. They all come with a cap, and I'll do the installation part first. And then we'll go down, we'll place some bands, and we'll go from there. The other aspect on why bands can be important is they can be utilized in certain kits for endoscopic mucosal resection. And so sometimes bands are placed to create an area of tissue that's elevated, so then that can be ligated or resected and block. Sort of a different function, but the same overall technique is used as far as application of the bands. We always will open up these objects here. Objects will have a safety around them so that you don't accidentally trigger or drop the bands off. And these are similar to the bands that you would use almost in braces or dental work. And what we'll do here is in order to get this, this cap actually fits on the end of our endoscope. In order to make that happen, we have a wire, as you can see here. We'll pop our cap off here, and we'll put the wire down the therapeutic channel. And we can see at the end of our endoscope, the wire will come out. We have our wire here. We have our string attached to the cap, and we're going to open this up and basically attach the string to our wire. So let's do that now. So the string goes through. The cap can then be placed through the string, which forms a knot, and they come together as such. What we can then do is pull on the wire from the top of the endoscope, and the cap will come towards the tip of the endoscope here. What I'm going to do is I'm going to take a little bit of the safety off so that I can situate this banding right on to that tip there. And I'm going to keep pulling this so that I can bring it close and situate it so that you can see there's a black line, which can be placed in alignment and should be with your channel that that string is coming out. And that'll place it, as we'll see, so that the bander does not block your field of view with the strings that are in there. And so what I'm going to do is line it up as best I can, and we can adjust it. It rotates and place that cap right over the tip of our endoscope. Now before we've done this, obviously we've gone down without the bander on to gain a survey of what's going on in this patient so that we can have an appropriate plan. But I show you this as an example for the banding. Next what we'll do is up top we have a lot of wire. We'll pull the wire in so that we can have this top object sit properly at the head of our endoscope. Most will have a mechanism to secure this to the endoscope. And what we can do is we'll place this around the handle. This will come out. A lot of times what you can have is your assistant or your tech do this. I do this for you so that you can see how these are placed to gain an appreciation of that. And you can see now it's situated on the handle of the endoscope. And so it forms one unit collectively. The wire is pulled, and then it can be placed into a locking mechanism. Most banding kits have the same functionality in that if you turn the dial, it will release one of the bands. What I'm going to do now so that you can see what the inside looks like is I'm going to turn on the light source for our endoscope. And you can see there's a series of strings that are in there. Simply if I rotate the banding cap, you can place the string in different orientations. What we want is to not block the view. If we twisted it so that it's like this, you can see that there's a string blocking the view. That's why from initially what we said about that black object or the line, you want to put the string so that they're out of the field of view so that they don't block what you're seeing. If we focus here, what I'm going to do is ask my assistant to hold the endoscope as such. And we're going to fire a band outside of the body. So simply we'll hold the endoscope using proper technique. And when you rotate, what you'll do is you'll come down onto the object that you want to release your band on. You'll suction that tissue or that blood vessel into the cap, which is at the end of the endoscope. And you rotate your wheel. When you're done, you'll release suction and the band will remain in place. And so I'm going to rotate the wheel. And you can watch how this first blue band comes off the tip. And you'll hear a click when that first band has been completely deployed and released. And you're ready to launch your next band. Most kits will have a different color band right before your last band. And that's so you know you have one more left before you need to reload. What we'll do now is I'm going to turn on suction. So it might get a little loud. So that I can suck the tissue in and show you how a band is actually deployed in our stomach phantom. Again, we use some lubrication. And we place this down the esophagus. And we're going to actually place this one into the stomach. And the functionality of your endoscope still works in that you can see I just used lens cleaner to get the mucus out of the cap. And we're going to find a nice object here that we want to band. And so let's say it's right here. And we'll suction that mucus up. You'll hear your hum, which is what we want to hear. And you rotate your band to fire that. Now that one looks like it might have misfired into the endoscope, which is fine. Sometimes it's more challenging in a corsene model. We'll try right here. This one hopefully will work better. There we go. And you can see that that band grasped that tissue, at least temporarily in this case. But in a normal object, that should remain in place and hold. Let me see if I can find a nice area. And as you can see, that band is placed successfully around that piece of tissue. I'm going to clean my lens for a good visualization. And we have a nice formation of our band. Let's try to place some more. Sometimes in these models, placement of these can be tricky. As you can see there, we just deployed our white band, which means that I have one more band left. I'll try to get a nice one here. Here's our hum. The band is placed. Oh, and that one fell off as well. Well, that's our demonstration for today. Thank you for your time and attention. All right, so you saw the frustrations of working with an ex vivo pig model. The bands we saw in some of our earlier videos were actually from that recording there as he was creating some pseudopolyps for our polypectomy video. The ex vivo pig model is preserved, and that preservation leads to a loss of elasticity of the tissue. In humans, that tissue comes up into the cap, and once that band is deployed, it virtually always ligates and compresses the tissue. And really the goal is twofold. One is to control bleeding, which we use for esophageal varices, and the banding kits for esophageal varices have been available now for over almost 30 years. And the second most common reason we use banding is to create those pseudopolyps so we can resect abnormal tissue in a process called band ligation-assisted endoscopic mucosal resection. So we'll lift up that tissue, use the band to create a pseudopolyp so the tissue is still elevated, then go in with a snare and excise that elevated tissue with the snare, and obviously retrieve the tissue and send it off to our lab for analysis to understand whether there's cancer present, or if there is cancer, what stage it is. As you can see from this video, there are some assembly required as we're getting ready to use these devices. We will typically go down with a standard endoscope to inspect what is the current status of the bleeding or what's the current status of the lesion that we're going to target. Then we'll assemble the banding device, go back in, and apply the bands and the therapy that we're hoping to achieve. The caps that go on the tip of the endoscope with the bands come in a number of different size caps that will fit different endoscopes, and also a number of bands. So this particular device that Dr. Opstein was using has six bands on them. Some of them have fewer, some of them have more. So depending on what your goal is and what you're anticipating in terms of number of bands needed, you can make adjustments with those specific devices.

bands

medical procedures

esophageal variceal band ligation

bleeding

liver cirrhosis