The other technique, which is the wet suction technique, essentially employs putting some saline in the channel before you puncture, and then essentially putting just a small meniscus of saline inside your needle. And we can definitely, if we have some water here, we can show that, just a basin of water. And then you essentially employ full suction, so you're applying a full suction on top of a whole column of water inside the syringe, the FNA needle. Again, works very well with any 19 gauge. Works well with 19 gauge FNB specific platforms of needles as well. Have you tried like the wet heparin technique or the modified one? Yeah, so the heparinized technique is also something we tried. Not myself, one of my partners is a big fan of that. I have not seen much of any difference in terms of the adequacy or the integrity of the specimen. There we go. Okay. So usually I put just a little bit of saline there, and I turn this valve off, and then I apply full suction, so you have just a drop of, usually, saline up there. And then once you're inside the liver parenchyma, you apply this, and then you turn it off before you pull completely, so it stays under complete negative pressure the whole time you're inside the liver. Okay. So that would be the other technique. How interesting. Have you done the heparinized technique, and what do you ... Because I have not done that myself. No, I haven't done it on an actual human. I just sort of researched the different types of suction techniques, and so I was curious about what different people actually use in reality. But I think what I've seen most people do is slow pull, and that's what we're most familiar with versus using suction. I think the one thing we know, you probably shouldn't be doing a standard full suction FNA at this point, the traditional FNA style of high level of suction in liver, especially liver-specific FNBs or FNAs. But that's also a bigger part of our practice now, is we do many more liver biopsies than we used to do five or 10 years ago. Good. What other structures do we have, since we have a new scope down there? What do you think we can demo? There's another little cyst. Another cyst here. Or should we go to a non-EOS based type of ... ESD and closure? Yeah. We have closure with ESD, and I think we're just a little over half time, so that might be a good time to transition to ... Okay. Yeah. Let's do it. Yeah, we have one of those here, so just any upper ... even diagnostic would be fine, yes. I don't know if we have an ESD device, like a needle knife. Oh, that's a good point. But ... I can get whatever ... Okay. Why don't we go ahead and get that hooked up, and then let's ... do you know if we have any hybrid needles, or any ... Yeah, let me go ask Bob. Just any ESD knife would be fine. Any ESD knife, we'll just have to demo that. Maybe until we get that, Katie and I can demonstrate the use of a deployment of an Invesco clip, which might be your savior in some of these unexpected situations where you have a perforation, and you would like to close this quickly. Either the padlock or the over-the-scope clip are going to be your friends in these situations. Actually, we may stay on this ... On this ... ... X-plant here, if that's just a little bit easier, since it's ... Already. ... in the middle of the gurney. Yep. Okay. So, as we try to get everything ready, I'm going to show you, and you probably ... many of you know this device well, because it mounts on the scope pretty much like a banding device, which is great. Not much of a learning curve here. Yeah. So, I usually remove the ... Do you take the cap? Okay. ... cap off. Okay. I'll give this to you here. All right. I'm going to put that in. Then it kind of snugs in here. Yes. And, yeah, go ahead and use that Velcro to stabilize that. Okay. And then, essentially, much like any other ... Banding kit. ... banding kit, you'll travel down with the cable. okay perfect now we hook the knot in the groove of the cable here the tip of it has a small groove and then you pull backwards pretty much like you do one second let me loosen this up for you perfect okay and then move to the large screen on the scope and pull so what you do essentially you hook this in the groove and then you torque until you get all the slack out and on the dial all right as you do that you're slowly getting all the slack out and finally just watch the tip of your finger do not engage this in the plastic in case accidentally fires I don't want to be there so usually I go to the bottom and pull this or use use either the plastic or there we go and now you know you're as deep as you need to be this is a 12 GC clip yeah let me see if you can expand the endo image yeah it's usually like yes you don't know this platform very well but nope that's definitely not it let's see if we can well we'll try to do that yeah we can maybe you will wait for yeah before help but we can probably get the scope down okay if you want and as you ever have difficulty passing these devices yes that's a problem with esophageal strictures I find also doing this in our older patients who have typical out of neck osteophytes and getting it through the upper esophageal sphincter can be a challenge occasionally you may have to dilate before you pass this depending on how tight if you're dealing with an esophageal stricture that's needed I think we're down the stomach yeah as we wait on our technician to show us how to switch to the large view endo we might be on that the top part the top yeah I tried current view a couple times switches to the large view endo we're done with the US oh no usually yeah did I screw it up oh here we go wait but then we want that you there we go perfect thank you great excellent so now we'll go down so one of the I guess the best applications you would probably come to this device for disclosure of either post EMR ESD defects or perforations because it does provide a very tight closure typically the defect would have to be about 1.5 potentially up to 2 centimeters but no more in size anything larger than that you might want to use a suturing system because that will not be adequate but if you would like to pretend there's a perforation so we can demo this somewhere that's our axis actually it's beautiful and and then so we can maybe maybe here yeah pretend this is this is a perforation okay and if you need sometimes it comes with a special device that allows you to pull the edge of the of the defect into this scope we don't have that device today but it's essentially it's a it's a like a biopsy forceps that opens independently to the right and to the left you can grab the two lips of the of the defect and pull it into the plastic cap but most of the time in my experience you don't need that a very good powerful suction with a long cap like that will get all the tissue in there so let's try that it does require quite a bit of suction and you'll get to what I call the complete pink out so you're not seeing anything but tissue all the way up into that is your suction not yeah no it's okay being wimpy at first so usually you would want to wait until it the tissues all the way up in your face so you're not seeing and then you get to that point where perfect I think you're this is where you need to be okay that so just it's a good powerful 90 degree torque and then it gives away which tells you it got deployed and so I don't see you don't see much of anything but now you can trust it's been deployed okay release you can see that the metallic clip now being deployed now this is a basic concept of the FTRD device essentially there's a that device comes with it with a snare on top of the cap so you basically you cut over this the the the clip and by cutting over the clip even if you cut through the muscle layer you know you're not perforating because you have that clip completely interdigitating underneath the lesion so you're not really having any issues with perforation occasionally I do it if I see for example this I do this do this for smaller neuroendocrine tumors I would pull the neuroendocrine tumor above and deploy the clip underneath of it then use just a regular snare to cut over the clip as a as an EMR safety mechanism if you will okay excellent that's fantastic all right let's talk tissue resection maybe okay what knife do we have okay let's why don't we do this hybrid knife the only issue I have with the hybrid knife is that it set up of the cartridge is somewhat difficult because it does require a cartridge which I don't see here so why don't we use just traditional micro knife setup is a bit complicated and for the sake of time why don't we go ahead and and use there's so many ESD knives out there so we probably will not get into that but all of them have very similar structure the one thing that makes some of them stand out is the ability to inject and dissect at the same time that's what they call them hybrid okay now we will go down and create a injection catheter so we can create a bleb we have one of these injection needles this one yep Picking an easy spot. Now we might need a different cable for the grounding doesn't seem to be going all the way in. Oh, you have another grounding cable, yeah. So while we're trying to get this knife to go, why don't we go ahead and create a... Let me get you... Move this to you and we'll use some of the lifting solution. We have a... Do you want the Orize? Yes, we'll use some of the Orize. There are now several products out there on the market for lifting. This is what we have available today. okay now let's pick a spot that's relatively neutral so we can conduct our tissue resection a little bit lower if you can that wall perfect right there is good so i'm gonna put that needle out for you okay and i'll jab and we are going to inject to lift let's pretend this is okay i'm gonna pull back oh hold on loosen some there we go there you go pull back just a notch again the tissue compliance is not the same with you when you're working with a cat cadaver and explants of this type but How does that look to you Jill is it okay good okay so now I think we created a mound let's pretend this is an area that has either adenoma or maybe a T1 adenocarcinoma that we're trying to resect. Okay we'll take this back. Thank you. And one of the things I still do with the ESD is lesion demarcation and I like to use a heat to demarcate the margins because once you start the dissection it's relatively easy to lose track of what areas you're interested in resecting. So I'm going to go ahead and pick that needle out for you, do you see it's coming out? Oh there it is there's always a delay. So why don't we test by creating a the perimeter of or marking the perimeter of the lesion with just short taps of energy of coag or cut you can use either either coag usually because it does leave a larger kind of okay see if it works bummer let's try this there we go okay there we go good perfect beautiful. Didn't mean to do that oh boy again we're not using a very specialized ESD knife here but we're hopefully mimicking what we usually do so yeah you're right on sort of making my own little circle yes good okay let me know if at any point you like any and I think usually if you get 360 around which is which you've done here is sufficient and sometimes that injection by now may have fizzled some so you can go back and re-inject and elevate the lesion okay other times you can just start and I'm going to pull this back just a little you have a little bit too much there you go perfect now you can start I like to dissect the perimeter first unless I'm using a tunnel technique which is has its own applications but for the simplicity we're going to do a 360 circumferential dissection first okay maybe and that can be done with a pure cut mode okay and so you just sort of yeah exactly. Again this is where the hybrid needles may stand out because they allow you to inject once you get access to the submucosal plane they allow you to inject and raise simultaneously so you're not exchanging devices back and forth. When you're doing ESD do you do a lot of like left right dial work or like how are you? Yeah so a lot of it is exactly just you know riding the riding the curve as they they call it where you're allowing your scope to naturally follow the plane of the submucosa. Okay. Let me help you get to the submucosa and then maybe we can maybe we can come back and inject a little bit more so it becomes a little easier. Get the spice out. obviously we would be using a cap as well which we don't have here a clear plastic cap usually helps but I think like right here would be a good example of how this actually may work out I think this is this is a submucosal plane right there as you can see and see some of the blue there again the needle is not exactly what I usually would use for an ASD but yeah no that's pretty Okay, so we will, now we, on the other end, usually drag this back to the start point before we start the dissection, doing a little more tangential here and my needle is not helping me as much, but you probably get, you get the point. So here we have access to the submucosa because that's a deep dissection, getting through the entire layer, entire mucosa, right? And we can drag this cut from here. towards the and now we're losing a little bit of that again this knife is not designed so now we've done a circumferential cut around it as you can see here yeah the audience can maybe appreciate the next step is usually trying to get in a little bit further and this is where a cap helps I don't know if you have a clear plastic cap Jill yeah we I like it because the cap will essentially allow you to dissect by insinuating that underneath the mucosa and lifting and then slowly cutting through without the cap it gets a little bit tough to do that but while we use this time while Jill is getting a path to inject some more yeah lift that lesion make sure I'm not knotted here you go kind of hard to inject thank goodness oh it's very hard yes yeah again this is not the malleable soft that you see that alive hang on a second let me get to that side Yeah, let's, let's go to the side if we can have induced a muscle injury here as you can see. Yeah. This is a myotomy. Myotomy not a full thickness yet, but let's see if you can inject right here. Oh Pop it out Beautiful and let me put some on this side Okay, again usually it's much easier done Okay, I don't like that I think you can probably And if we have a clear plastic cap Got this, thank you That will help some. All right, where was this was our clip and this is our ESD site? Yep. Okay, let's go back to that knife. Okay. So you're going to inject with this knife. That's cool. I find it hard to believe this will produce much of an injection. It seems like it's a, especially at this stage, it's pretty beaten up, I would say. But we'll see how it does with the dissection. Okay. So the cap does this job for you. Immediately exposes some mucosal fibers. That's nice. Very nice blue cushion, needle out and let's get the knife to do the work for us. Now in dissection, if you're not, if you're not encountering any vascular structures, you can dissect using the more efficient cut mode, whatever it be, it's the yellow pedal. If you see vascular structures, obviously you want to switch to force coag or potentially even use a coag grasper with soft coag to get rid of the larger vessels. So if you're doing ESD, do you have two ports for a coag grasper or are you exchanging? So usually I would pull this, put down the coag grasper, switch to soft coag and coagulate the vessel that I'm working on. But you can see, as you can appreciate, the most important part of ESD or any submucosal dissection or third space endoscopy is making sure in the right plane. And how do you know that? You get the muscle layer as your floor and the mucosa is the roof and you're essentially staying there. And how do you know this is submucosa? It's those fluffy submucosa fibers that you see after injection and they usually dissect fairly easily and quickly. Now, if you have, if this location was a previous EMR attempt location or a previous recurrence location, obviously it won't be as easy to dissect, right? But again, it's not. And usually I come back and check the orientation every time. We have a muscle injury here. That's a myotomy. Again, we're not using a great device here, but I'm going to try to dissect some of these fibers here to enhance the exposure. As you can see, we freed up probably a third of a lesion already from this side. It's still attached from the top, so we can go in and dissect some more. What lifting solution do you usually use? At this stage, usually I'm only working with saline and methylene blue, believe it or not. I only use polymers in the very first stage of lifting for the initial lift. Now, some people or even experts think that using some of these like heta starch and sustainable lifting solutions is advisable during the dissection. I think this is an area that's not completely settled yet, but I find working with just saline and just a few drops of methylene blue to be quite effective in this context. But yeah, you can use pretty much any of the products that you see in the market. So right here, this is kind of a quick demo of what we call the pocket technique. Essentially, drilling into one specific part under one trajectory, like a blind pouch or a pocket, then essentially this might be a technique that might lend itself better in places like the rectum, for example, for larger lesions. So you keep the roof or the lesion intact until the very end of the procedure. Obviously, if you want to commit to the pocket technique, you wouldn't have done a circumferential incision first, but I'm trying to use that as a demonstration. There's a mucosa still attached. The submucosa is still in a good place. Again, this is just sort of trying to demonstrate we're not using the usual tools, but I hope you get the point. Wait for the question, wait for the question. That's submucosal plane, submucosal plane. Nice. It looks like we do have a question. Yeah. Do you use traction devices during your ESDs and if so, when do you decide to implement them? Yeah, that's a good question. It depends. For example, in larger lesions in the rectum or in the stomach because those are larger diameter organs, a traction device might be needed. There are newer clips now that you can attach to the mucosal surface and then you attach to the contralateral wall and provide a triangulation sort of model. In the esophagus and the G-junction, I would say that's not of any use because it's a very tubular and straight organ. You really don't need much of any traction in the esophagus. Tunneling works great in the esophagus and tunneling works great also for the antrum and the pre-pyloric area. Traction works really well in the body of the stomach. Again, you have a large surface area and you really would like something to help with the traction at that point and exposing that submucosa. If we had one device here today, what I would do, I would attach it right here and pull that and clip it right here. So, I'm creating essentially a constant lift force on that side of the lesion that will allow me to quickly dissect through it. Okay. So, I guess it depends on location of the lesion. Again, rectum, gastric body probably, the size. You probably don't need it for a small one to two centimeter lesion, but if you're doing a four or five centimeter lesion, you probably will get to the point where traction might be helpful. There's some data about the ease and how quickly you can get through a lesion of that size using traction versus no traction. So, I think it does make your procedure slightly faster, a little bit less frustrating at times, and more effective. Speaking of procedure speed, depending on the size of the lesion, I'm sure is the length of the procedure, but I guess on average, how long do you spend on your ESD cases? That's a great question, and we struggle with that at the day and age when we don't have endless access to endoscopy hours and anesthesia time because we do these under general anesthesia. Right. The shortest I book these for is 90 minutes, but sometimes I know I'm getting in for a smaller lesion and I would only book it for 60. If it's a known local recurrence, only one centimeter or so, but if it's a three centimeter, four centimeter lesion, usually I book about 120 minutes, so two hours. Those are still time intensive. That's why this technique has not taken a strong hold in the U.S. yet as it has in places like Japan where the models of reimbursement and the way we schedule our procedures has a lot to do with adoption of this procedure. I'm very hopeful next year we'll see a CPT code for ESD and that we will start to essentially get more traction on the referrals for ESD. Basically, this is how the technique works. Again, I'm trying to cut this bridge of sudden necrosis. Katie, what do you think we should demonstrate next? I think we've done some tissue resection, closure, device, EOS guided interventions. Yep. What else is on the, or maybe any of the audience? Yeah, I think we hit everything on the agenda, but what does Mark want to see? He's asking all the questions. Yeah. I guess you could, I mean we didn't show the coag graspers, I don't know if we have them in the room though. Yeah, I don't see a coag grasper here, but essentially a coag grasper is, once you dissect, maybe we'll pretend there is a vessel somewhere here. You would get your coag grasper, essentially you dissect some of the submucosa around it so you skeletonize that vessel so it's completely free of submucosa. Then you gently apply the forceps and use soft coag and you would see that turn white as you apply energy. Typically about three seconds is all you need. And then you remove it and you go back and you cut that now what looks like a dry cord essentially with your needle knife. But it's a very basic technique for that. The esophagus dissection is easy, you probably don't use it as much in the esophagus, but rectum and stomach you probably need to use the coag grasper. Those are larger vessels that you need to preemptively clear them as you get through. Otherwise your risk of post ESD bleed is higher. But that's a great question. What else? I think we've demonstrated FNA, FMB, LAMS deployment. Not a lot of success today. I think the model here is not as cooperative. So we apologize for that technical part. Was there another question? Do we have a snare? I want to demonstrate something that actually a lot of people use, which is what we call the hybrid EMR ESD technique. This would be a great time to show it. You may not be proficient in ESD, but any of you can do a hybrid EMR ESD. And I think there's one at the bottom of the pile right there. It's a hexagonal snare. So pretend you have a lesion here, but you're comfortable that you've dissected the perimeter of the lesion quite sufficiently. And at this point, you'd like just to take it out. So this is where the hybrid technique kicks in. If you think that the probability of deep submucosal invasion is not very high, and that you can get away with just a snare cut of the base of the lesion, I think this might lend itself to a good resection. And I think I will be able to demo that for you. Now that I have a circumferential incision around the lesion, you can actually comfortably put the snare in and remove the lesion. I just need to have grounding, that's all. Oh, we need to be hooked up. All right. Does that fit? Do they go together? They may not go together. Try the other one. Yeah. Let's see here. Try that one. This one? So basically what you do is encircle the lesion pretty much like you do with a polyp. I can tell you circumferential dissection makes this an incredibly easy process once you have isolated the entire perimeter. So let's show that. Let's go ahead here and let me show you. I wish we had a larger snare, but a larger snare would sort of get, and I think we can still get that. I think a larger snare would have been helpful. But basically what you do is you get the snare in the groove that you just created and you resect the lesion in one piece. Obviously our snare is not large enough here, but I think you get what I'm talking about. Typically a 2-centimeter snare, 20, at least 15 or 20 would be the one you want to go to, and I don't think we have a larger one, do we? Negative. Okay. But when you do that, essentially you get most of the lesion. But let's pretend this is probably as large as the lesion is, and go ahead and close. Okay. So now you have a pretty good grip on the mucosa. You have traction of the submucosa as you can see, and now you just essentially. I'm not sure where. Oh, there we are. Yep. So we're connected. And then you actually get a nice. Obviously if it was large enough, it would have gotten the whole thing in one piece, but we can come back and do another. But the goal of this is actually not to do piecemeal, but to do an en bloc resection, so an entire resection in one piece. But since we don't have a large enough snare, let's do this. Close. Yeah. Close for me. and open. So that's the hybrid technique. Again, it doesn't work for every lesion. Again, if you have suspicion for deep submucosal invasion, you don't want to use this. This is just for mucosal-based lesions when you, again, don't suspect submucosal invasion. And it does make your procedure go a lot faster. There's quite a bit of literature on it at this point. Okay, so I think you probably get the concept here of this. Again, not designed to be a piecemeal, but we don't have a large enough snare, and this might be able to get the last piece here. Let's go ahead and... Good, so we have trapped the entire lesion above and have a clean submucosa here as you can see. Take this out. Ah, it's following you. That's our ESD specimen right there, that's our LAMS. And let's see where's our resection site. There we go. That's our ESD site, again hybrid technique. And we can get this last piece out. Beautiful. Beautiful. Short tap and it's out. So if I'm doing ESD and I have gone through a muscle injury, this is not a full thickness muscle injury, it's almost there. I would want to close this site with either clips or sutures. We don't have obvious sutures here, but we have plenty of clips so we can start to clip the site if you want. I'm not suggesting every ESD site needs to be clipped, however, if you're suspecting a full thickness injury, you do not want to leave this unclosed. Okay. So we probably won't have time for a full closure, but I hope we can demonstrate the technique briefly. And then we'll be good to go. Okay. So how do you close, and I have a video tomorrow for closure of esophageal perforation with clips. If you're with us tomorrow morning, I hope you see that. Essentially, we start from one of the margins and we start to create a zipper line basically by zipping one edge to the other. So I'll get rid of that first. And here's the edge of that resection. Start distally and come proximally is the easiest way. Open. Thank you. And then orient this. And we're good to go. engage that side if I can I say what you're doing yeah bring it over to this side I mean that's a resolution 360 sometimes you might find a wider angle or jaw clip easier for a process or a lesion of this type but you can try again okay okay did it's a boy Lloyd now everything's going haywire that's all right deployment from one clip type to the next varies but I can I'm hoping just to demonstrate to you that you can start at one edge and zip your way through the through defect to the other edge decide first it's ideal that you start distal and come proximal and if your technician is able to rotate for you okay that's not bad Go ahead and close. Okay. Slowly. Okay, good, good, good. Okay, go ahead and deploy that. Okay, that definitely deployed that time. Yeah, and then freeing it up requires that you go back and forth on the handle a couple of times. There you go. Perfect. So that's the concept. Basically, you create that angle at the tip of the lesion or the defect. That makes deploying the next clip a lot easier. So in this case, the next clip will ride right on top of the or below the first one, and you go down on the defect one clip at a time. I suspect this will take probably another five to six clips. We obviously won't go through that. But other option, OTSC device or over-the-scope clip or flexible endoscopic suturing. You can just with one interrupted or two interrupted sutures or one continuous suture, you can get the whole thing done in about two to three minutes. That's awesome. If you want a clip, this is how you start, one clip after the other. Any questions from the audience so far? I don't know if we scroll down. I feel like maybe we're missing one at 4.03 p.m. You can close this out, and then, sure. And then scrolling down on this, yeah. Yep. I hope you guys found this helpful today. Thank you, sorry. He said, sorry, I'm dominating this chat. Oh, Mark, you're absolutely fine. We like as much interaction as possible. I hope you guys enjoyed this. I know we have limited time for how many things we could demonstrate, and the model did not serve us very well on the ERCP side, but I hope you found the other stuff helpful, and I appreciate, again, you guys joining us this afternoon. Thank you so much again, and we look forward to seeing you in the future ASGE course. Thank you.

endoscopic procedures

wet suction technique

hybrid EMR ESD technique

saline

19 gauge FNA and FNB needles

mucosal-based lesions

submucosal invasion

ESD procedure