So, this is a video I sent to Dr. Rustege, maybe, I don't know, six months ago, five, two months ago, and I completely forgot the history. I know enough to get you through it, but this is—I don't have an introductory slide, but this is a patient that has probably, I think, an ileostomy after colon resection for ulcerative colitis and has concomitant cirrhosis. In probably about 25 patients, we've done exactly what was just shown in patients who have peristomal varices. We're trying to get this—I submitted it for an abstract a couple years ago. We just haven't published it yet, but these patients can get torrential bleeding after either colostomy or ileostomy for a variety of diseases, typically IBD, but it could be certainly other problems as well. And this patient had just torrential bleeding and was transferred to our hospital for management of this. This is a patient who—unfortunately, the thing I like about this video is I had somebody stand with their iPhone actually showing—so I've got the EOS and I've also got the endoscopy video of the nurse who—I'm standing there just doing nothing. She's doing all the work, so I've got to give her the credit, but it really shows how these coils and glue are actually done, which I think is actually very helpful. So I do want to comment before I do this. I do know why people in Colorado take 7,500 steps as opposed to everyone else who gets 6,000, because they're all stoned and they don't know where they're going. So I just wanted to make sure that we could set that aside. Where does 5— All right, so I'll start this—I think I can start it. How do I push play? Oh, there. Okay. So I'm going to try to see if I can—do I know how to pause this? Do I do that? Yep. Okay. So when I do these procedures, the thing about the peristalmal varices, I first spend about five minutes tracking the blood vessel back to the stoma. There are often multiple blood vessels. I want to make sure I track the one that is the problem back to the stoma. So I'll look and try to find one that's large that certainly is, you know, potentially a culprit. I first do an ileoscopy or coloscopy—brief colonoscopy to make sure there's no other colitis or anything else to explain it. And then once I find one of these blood vessels, I'll track it back to the stoma, which I don't show with this video, but I just want to make sure I say what that is. So we're going to play this. Okay, there we go. So this is what I think is the culprit vessel. You can see it sort of going—do I have it pointed? I guess I do. Actually, I'll just use my mouse. The top button, if you just— Oh, top button. Okay. So here's the culprit vessel, and I'm using Doppler here, which will confirm it's obviously a blood vessel. Then I'll put the power flow over this to confirm it's not—you can see the blood's pulsating, but I'm using this just to see that it's actually venous, which this clearly is. But you can see it kind of pulsating, so I'm making sure this is not an artery. I always review the CT scans as well to make sure that there's no other problem, but you can see here this is a nice culprit vessel. I use 19-gauge needles almost exclusively for this. I find it easier to manipulate O35 coils. So I'm measuring this, and I want to pause it here for a second because the measuring is very important because I don't keep these coils in my unit. As I was talking with some other people, I keep these over at IR, which is next door. So I measure this to say, okay, what size needle do I use? And once I measure this, whether it's a varix or one of these feeder vessels, I'll go run over to IR and grab whatever sizes I think I need based on that. So this measured at about five or six—I don't remember what it said, but I want to get usually a coil that's the width, probably a millimeter or two wider than that. So that's kind of my thinking about what I do. So the first thing we did is a needle puncture here. And after the puncture, I always aspirate blood, you know, first to make sure that I'm actually in the thing. And you'll see that this is one of our wonderful nurses. There's blood in here. And after this, you can see the endoscope is down here and the patient's abdomen down here. All right, so there's Sabrina, our super nurse. You can see the scope is in the right lower quadrant. I think the patient had ileostomy. So we aspirate blood first and then flush that through. You really have to have a clean needle tract when you're doing these procedures. So she'll flush that first. We want to clean that needle out. And this is the coil that she's taken out. You know, remove it from the—that little clear opaque thing is taken out. Then that's inserted over where that stylet has been removed. And this is—that little lower lock is then brought down. And you'll see her asphyxiate right there. And then she'll take the stylet, which has been removed, and then place that through the needle. And you only have to insert that. I think this is just obvious. There's not a lot of editing here. But the stylet is then reinserted. Generally, you know, I try to—she'll push it maybe five or six times just to make sure that that coil is actually inside your 19-gauge needle at that point. We're talking the whole time. You know, she's asking me am I happy with how far that's been put in. And after that, that whole thing is removed. And then the stylet is reinserted, you know, to make sure that that coil has been put in. So now we'll cut back to the EUS. I think this is good, sort of unedited, so you just kind of see how it's actually done. And then you'll see here that the needle's been kept in place, and this coil will come out to occlude that blood vessel. So for this one, I decided it was probably better to put two coils in. So this first coil went in. And then after this, after any manipulation of the needle, I always flush it again because it is much harder to put a second coil in or glue if this is not flushed again. So I'll flush this again with saline, and then the second coil is then put in. After the second coil, I was pretty happy that this was, you know, all the coils I wanted to put in. One of the things was Dr. Patel mentioned, I always put the glue in myself because we've had – I'm going to stop this for a second here. Oh, thank you. If you're going to have an embolus, it's going to be because that glue is put in too quickly. We use Dermabond, which takes about 30 to 45 seconds to polymerize once it hits blood. If you use the other one, it might be a little bit faster. But I don't want that to go in too quickly because I don't want that polymerizing in the lung. I want that to polymerize where I'm sticking this. So once that – excuse me, play the video again. Once the sinoacrylate is done, that needle's been flushed. I have a cc of sinoacrylate in that syringe. I have her push in about three-quarters of a cc, which is about all that needle will take. And then once that three-quarters of that cc go in there, I tell her to stop. And then we switch to saline. So that thing will come off, and then I take over at this point. And I push that sinoacrylate into that glue – or sorry, into the varix because I want to see it polymerize. So I go – just like him, I go very, very slowly. And once I start to see that little hyperchoic tuft to form, it's a little less clear with this. But you can see the sinoacrylate actually coming down the needles if you do this enough. But once that sinoacrylate starts coming down, I start – I'll slow down. And it's not as clear with this because the varix is pretty much occluded by the coils. But I want to put in about three-quarters of a cc of that sinoacrylate. And once that goes in there, then I'll pull the needle out. Something I'll mention is when you do these, that needle that I pull out, I don't actually put the tuft in as I'm pulling it out, but actually that needle needs to be pulled out extremely slowly. If you pull it out too fast, that glue can go shooting into another varix. So what I do after this, I'll just go ahead and doppler that. You can see right here where that varix used to be, right about here, there's no more flow just like was already done. So this is something we've done in about 25 patients. And it actually works really well. Now, some rebleed or you got the wrong varix, but I think it's a wonderful technique for – these patients are often desperate because there's very little they can do. You can do tips for these or other things, but this is a technique our hepatologists love where I am. So something to incorporate in your practice if you don't do it. Awesome. Oh, there was a question. What's the length and diameter of coil? This is a – what's the length and diameter of the coil was an online question. Yeah, so most of these coils I think are like 10 to 12 centimeters long, but the width is in this one I think it would have been about 8 or 9 millimeters wide. I think – I don't know exactly. I can't remember, but it's an 035, 14 centimeter by like maybe 8 or 9 millimeters. I think that's roughly what it is, but I can't give you exactly what it is. The most important thing is really not so much the length of it, it's the width. Right. So I want something to be a little wider so it doesn't go up and down in that barracks. Yeah. Absolutely. Thank you. So do you use a 19-gauge needle? Yeah, I find it's easier to manipulate the 035. The 22 and the 018s I think sometimes are a little bit more deep, just what I use. I usually use a 19-gauge also. I mean I know you like the 22s, but we – 018s can be kind of flimsy and tricky to push out, and I've had some issues with that, but yeah. So with the 22, the 025 will not go through that, right? It's a – so you have to be careful when you order the coils. You have to look at the diameter of the coil wire. And that's – because when it's stretched out, it's the coil wire that determines. Yeah. Right. And that comes in 018 or 035. The 018 will go through the 24. 021, yeah. Right. The 035 will go through the 19. We were just discussing if you use the 018 and the 19, sometimes it will coil within the – Within the – yeah, yeah. Right. And so you have to be very careful when you order the coils if you haven't done so before, and to look at those – all three measurements.

ileostomy

bleeding

coils

glue

procedure