All right, so we have eight videos to go through. I think there's one group that's going to bring their laptops up. So if you need any IT assistance, we have that available as well. This is your opportunity to get feedback on your videos and, you know, kind of expand that fund of knowledge that you've already built a base upon. And let's get started. It's a good time. I like the disclaimer. The patient is a 62-year-old female with a past medical history significant for ERD, hyperlipidemia, and type 2 diabetes, who presents for removal of a large colonic polyp of the distal descending colon. The patient had undergone her first screening colonoscopy three weeks prior at an outside facility and the polyp was deemed to be too large to be removed by the local gastroenterologist. Also known as saline solution lift-assisted polypectomy, injection-assisted EMR is a technique first introduced in 1955 for rigid sigmoidoscopy. The procedure involves injecting a solution into submucosal space under the desired lesion for a safety cushion, which helps facilitate capture and removal of the lesion using a hot snare while minimizing mechanical or electrocautery damage to the deeper layers of the GI wall. Upon insertion of the colonoscope, a large polyp was identified in the descending colon. Narrow band imaging was used to help further delineate the margins of the polyp. Upon evaluation of the polyp margins, a needle was used to inject saline solution with dye into the submucosa to help lift the lesion and further delineate its margins. Given the large size of the polyp, additional injections of saline solutions were required to adequately lift the lesion. Once adequate lift was achieved, a braided hot snare was introduced to begin piecemeal resection, using great care to remove as much of the polyp at once as feasible. As resection progressed, additional submucosal saline injections were required to both maintain appropriate mucosal lift as well as lift additionally identified areas of the lesion. Once again, once satisfied with the saline injection and ensuing lift, the Hansner was reintroduced for further piecemeal polypectomy. For areas of continued bleeding post-Hansenia polypectomy, spot electrocoagulation was used to achieve obliteration of bleeding vessels. Once polypectomy was completed and margins were re-evaluated, the colonoscope was withdrawn and the patient was advised to follow up in six months for a re-look of the polypectomy site. In conclusion, lift-assisted EMR is a generally safe and effective procedure for polypectomy. I think we're off to a good start. I have some comments, but I don't know if we want to open it up to the group first. Dr. Raju, do you want to start with your review? I'll go first. Sure, yeah. Great video. It's actually a very good first attempt. Honestly, as I was watching the video, I was thinking to myself, it's kind of funny. We always like to, in video GIE and other journals nowadays, we like to publish things that are just super novel, kind of cowboy-ish, frontier-ish type stuff, but a good solid saline-assisted EMR video is kind of due for a refresh. I agree. Frankly, I think something like this is actually worth considering. Yeah. There's a couple of things that came to my mind as I was watching the video. Three things really. Maybe, I don't know if you caught the same three items. Or do you want to come up here? Yeah, I'll come up here. So to me, there were like three items that came to my mind as I was watching this. Two of them are just really more so like style points, and one is actually like a medically relevant teaching point. One is on your first slide, on the intro, that intro slide is really busy. It's basically like as if you read the entire intro slide verbatim. Don't do that. It's a PowerPoint, so it's kind of like this goes into a separate topic, which is fundamentals of making a PowerPoint. When you make a PowerPoint, you never want to throw full sentences on there. You just want to have like some thoughts, and you fill in those thoughts with full sentences that you narrate into the video. So that was one thing on the first slide. I realized time was limited, but in the audio clip, you can actually hear like the mouse clicks, and so that's something that you want to edit out. So what I do for stuff like that is when I record audio, I'll usually start my recording, and then I'll say my sentence, and then I'll give it like a pause before I make that click, and then that way when I put the audio clip into the video editing software, I'll splice out that last millisecond that has the click. The third one was there's actually a pretty valuable teaching point that was not noted, and I think the faculty will agree that there was a big dominant nodule in the laterally spreading lesion in the colon, and you know, if you guys look at the most recent guidelines for colon polyp resection, right, if you're going to take a big polyp like this in a piecemeal fashion, which is totally appropriate and fine to do, the dominant nodule should be taken out on block, and that's exactly what they did in this video. It just was never pointed out in the video, and I think, you know, it would be very nice to have a learning point slide at the very end where you actually mention that that's like, if you were to take away like the key educational point of this video is you want to save that dominant nodule to be taken out either last on block or first on block, whichever one of the two. I really enjoyed the historical narrative that this person built around, you know, such a straightforward sort of concept, but I think along with that, you know, if you're sticking with the historical perspective, kind of wrapping it up or telling some of the historical story as you go along with the technique would kind of fit with the theme, and then I think the obvious that probably a lot of the reviewers here are thinking about is that there's just a lot of dead space, and we did say, yes, you don't have to talk the entire time, but when you're reviewing 60, you know, videos as a part of your plenary group, you want to continue to be entertained, and so, you know, talking or saying something salient or even further editing down those, you know, those snare resections that you were doing may help to kind of clear up a little bit of that awkward dead space. Any other thoughts, Dr. Eisenberg? So, I was very impressed with the kind of the educational content of the video, and I think, you know, Schaefer brings up a great point about how you can condense some of the snare polypectomy pieces as that's being done. You might want to just show, you know, kind of a few snares being done and then show the video as, you know, it was completed or maybe show some of the bleeding points, but you can talk a little bit about how using different settings on your electrical surgical generator, you could talk about, you know, how you apply soft COAG. So, in the end, I think that, you know, if you add some more details about technique, educational technique, this would be a great submission for the educational endoscopy category for DDW. So, this would be an ideal video to submit for that category. No, I really enjoyed the video. I think it flows really nice to what Schaefer was saying. I agree with Phil. I think economic in words, like, you know, like the intro and even the case presentation, right? Like, patient is a 62, you can just say 62 year old, you know, so try to be economic in words. I also noticed during the video, there was like the frames of the pictures that endoscopy was taking. I think it's okay, but there were a little bit too much, maybe five times. So, you know, you could just cut that frame and the video will flow better. And also to Gerard's point, I think when you have a little bit of silence, it's okay, like maybe five seconds or less, but when he gets over that, you could use more educational comments, like, you know, when there is injection or snare, you can just add to like the technique or like, you know, you could say, making sure the needle is, you know, in the simucosal space or something like that. Not too heavy, but you could like kill a little bit of that space. Or remove the video. Or remove, exactly, remove the video. Yeah. Thanks. But I think what people are saying, this is terrific because obviously going through this long live stream, there's, we know there's lots of dead space. So, finding the key things, telling the story, making it educational, you know, there were a lot of those elements. So, terrific. That's what you want to do with the video is use the video, but also communicate, if you can, what you're thinking, you know, by injecting, what did it do? It brought the polyp out. Why did you start on one side? It also shows Dr. Raju has a terrific technique. Every time I watch him take out a polyp, I think just showing that video of how you go from one place to the other, take the vessel out, that's what you're trying to show, and that's what the video showed. So, Raju, we've got to come to your place and take courses on how to take that polyp out. That's right. So, same group, different video. Endoscopic mucosal resection of laterally spreading tumor. There are no disclosures. A 55-year-old male with a family history of tubulovirus adenoma was referred for EMR after index screening colonoscopy. The patient was found to have a 5-centimeter laterally spreading tumor, mixed subtype. Careful inspection of the lesion with high-definition white light and narrow band imaging is performed. The lesion is then lifted with a submucosal lifting agent with demarcation of the borders. The lesion is then piecemeal resected with hot snare, saving the sessile portion for last. Bleeding is encountered. An endoclip is placed on the bleeding site and closed to cause tamponade effect. The endoclip is not deployed. Thank you. The remainder of the lesion is continuing to be resected with hot snare in piecemeal fashion. Care is taken to overlap the areas of previous resection site as to not miss any residual tissue. The portion of the polyp is saved for last and resected. Bleeding can be seen and the vessels can be clearly identified. Here, coagulation graspers are used effectively to achieve hemostasis. Residual polyp is identified and removed with hot snare. I thought that was an excellent job, too. I think it's fascinating to see how the same video clip can be interpreted in two very different ways based upon your editing. I mean, polyps don't know bounds. I think here on this last slide, so Mac users, which we touched on yesterday in my video, will always default to Ken Burns for some reason. I guess it's just the artsy Apple people. So you have to make sure that you click off of that to just maintain a still frame. Otherwise, it's just distracting and you lose some of the content. But I think this was an excellent job. I really like the narrative style. I mean, I thought that the voice and cadence was kind of just very even kilter and educational. I think just like the last video, there's just a lot of downtime and white space, and you probably could have made some additional edits there. And then if you have a text slide, your reader or viewer expects you to narrate those aspects. So I would just say those parts of your conclusion slide. It's actually really funny to see the full video footage because you guys all kind of worked on the same case, and I didn't realize this was one of Raju's cases. So it's kind of funny to see all the different aspects of it, right? Because you guys clearly chose different areas that you thought were worth mentioning and worth teaching. There were a couple of things that stood out to me. One was there was a lot of dead space that was kind of concentrated, especially towards the front half of the video. And to me, when you guys first examined the polyp, you're looking at it in MBI, you're looking at it in white light. Tell us a little bit about the findings. Tell us a little bit about what you're seeing, right? And that's something a little bit more technical. Show us the areas that are 2A. Show us the areas that are 1S, especially if you're going to say this is like a 2A plus 1S lesion. I want you to point out what's the 2A and what's the 1S for those of us who may not be as familiar with LST terminology. And then maybe even give us some teaching points. Amongst the areas of 2A and 1S, Raju is a master strategist. He knows what parts he wants to take out on block. Every move is very calculated. So none of these are accidents in terms of the portions that he's seared off. Tell us why, what were the portions that were actually really important to remove in an on block fashion. And I felt like the video jumped right into the video, actually. So it was kind of like they gave a one liner on the case and then jumped straight into the video. Give us a little bit of background, especially if you're going to talk about LSTs and stuff. What is an LST? What's significant about it? What's significant about 2A and 1S? Is there a malignant potential? Is there areas that have higher malignant potential and a dominant lesion? There were no subtitles. I felt that this would benefit from some subtitles that might highlight some key maneuvers that were done. The endoclip technique was really fascinating for a tamponade. I've learned, I've seen Dr. Raju do that before and I've implemented it before. I think it does help a lot. Right. And I think it's good to, again, I think I've told a lot of you guys this individually, but it's good to have a couple of teaching points. So at the very end, you can throw up a couple of teaching points. In cases where you're in the middle of a resection and you really need to get good hemostasis, you can either use coagulation forceps like he did at the end, or you can use an endoclip to temporarily apply tamponade. That would be mixed in along with some of the learning points. Yeah. Does the group have any additional comments? No? Covered it all? Dr. Faux. That tech was then fired. So actually, it's actually, I'm glad that you asked that question. So at one time when I first joined Anderson, we had a tech assigned to the room, and that room belonged to the tech. And then we went in and operated there, right? And that actually helped, because tech took pride in providing high quality service. But later on, the administration philosophy changed, and then techs move, and then you don't know whom you're going to work with on a particular day. So when I see a new tech, and I feel that I may not have worked with them, and when it comes to CLIP, when they open the CLIP, I tell them that, hey, there are three steps, and you're going to follow what I'm going to tell you. Open, close, and when I say deploy, then only you deploy. So by doing that, I've actually had the issues when somebody fired, right? It happened. So that's why I said, okay, there is a three-step process I want you to follow. And with that, I would avoid that issue. But I've gone through that, where somebody deployed a CLIP, not knowing. You all may not know this, but sorry, Dr. Raju. I was going to say, Dr. Raju created an entire curriculum for technicians, so that way they can learn how to operate a lot of the devices and clean the scopes. And it's very useful for your technicians if they want to learn independently. So I would like to make two comments. First of all, it's not easy to edit these videos, but at the same time, I put those, those are almost 1.5 gigabytes of video that you guys had to go through and edit. And I felt that, okay, you see the whole video, so that you also learn that even if somebody has been doing these procedures for a long time, they go through some ups and downs during the procedure. And I wanted to make it clear that none of us are perfect, but you try to get better, so that's why I let those videos. I want to make two things that we have not covered. One is picture in picture, right? Most of the setups are set up, most of the either Olympus, Pentax, or Fuji, the way the software is set up is when you click the button, you'll get a picture in the picture, right? You have the picture and then a small picture. So I would work with the vendor or my technician to remove that function, so that there's no picture in picture that comes on the screen. The second one is to make sure that your screen looks beautiful without any names, dates, time, etc., coming as a stamp on the screen when you take a picture, right? So when you have those things, then you're stuck, because you have to block them off. And in 2022, if you have a video like that, if I were to review, I would just reject it. There's no point, you know. What am I supposed to do with that? No, but you have to think about it, right? When you're watching a video, there's no reason why you cannot have a beautiful video, right? So why go through that pain when you can do those simple steps? So I just want to share that, you know, yeah. Can I ask a question? I think Dr. Eisenberg was, yeah, but then you can go ahead, yeah. Sorry, I'll make it quick. So when you're doing some of these videos, you might also wanna point out some of the cost effectiveness parts of some of these things that you're doing. So for example, as opposed to what Raju does, I'll take a soft coed grasper forceps and just apply pressure to a bleeding point and save the $150 to $300 worth of hemoclips that you might just use as a close way of controlling bleeding. I think Dr. Foe might use those hemoclips at the VA all the time cuz taxpayers don't care as much at the VA. But our hospital systems probably would be very upset if we're using hemoclips to just tamponade blood vessels. So think about, think outside the box. Think, what are other things I can talk about in this video? You know, look at each specific instance of what you're showing and ask yourself, what else can I talk about in relation to what I'm seeing, okay? So in my defense, I would probably take that out cold, number one. Number two, Raju knew he was going to use that clip to close the defect anyway. So, yeah. It's good to have friends. Strategy. Just a quick comment. So to Dr. Raju's point, I've made it part of my time out, basically, now, that at the clinic, we have this problem, the picture in picture is there, or the data, right, of the patient. So after I do my time out, I obviously don't broadcast. We're recording, I just say, it's a data button. Can you remove, please, from the screen? Like, I made it part of my checklist, and it helped me, so none of my videos have anything now. So it's kind of like, after your time out, part of your time out, so you could make it a habit, yeah. Yeah, if you do it every time. Why is this for your fellowship? I'm sorry. Yeah, that's the first thing we do before we start taking pictures. Just a quick point, and this is something I struggle with, so I'm just bringing it up, which is that the key to making these videos is getting it as short as you possibly can without losing the educational value. So I have a trouble when I'm looking at my own videos of like, I should definitely include this, or I should include this. Avoiding that, I mean, it's almost like video editing for like a social media generation. Like, how do you get it to be short enough so no one's getting bored of seeing the same snare section again? I don't know the right answer, but on both these videos, you probably could have tightened up the amount of video, or even added in a slide, like you said NBI, like maybe freeze it and show why you're talking about this classification versus just keeping showing the endoscopic procedure. Again, I don't know how to do it perfectly, and I don't think any of us do, but most of these can be condensed down much shorter in general with then added teaching points. And these were both five minute clips, so you could probably even get it down to like a three minute clip. Longer isn't better. So let's move on to the next video, this is group B. Where's group B? Be proud, come on. Case mail removal of a large rectal polyp using endoscopic Nicole's section with hot avulsion technique. These are. We present a case of a 58 year old male presenting with the chief complaint of rectal dysplasia. We present a case of a 58 year old male presenting with the chief complaint of rectal discomfort and hematokizia. He denied any family history of colon cancer or family members with colon polyps. He also has not undergone any screening for colon cancer. He denies the use of any anti-thrombotic medication. I really wouldn't have taken a vial of cold medicine. I said I really wouldn't have taken a vial of cold medicine. The exam was pertinent for a palpable mass. No, I do have a cold sweater. It is my new favorite best friend. The patient subsequently underwent a colonoscopy. As we introduce the colonoscope, we immediately encounter this large rectal polyp. It's important that we first thoroughly irrigate and wash the area of the polyp before proceeding with inspection and defining the margins of the polyp. Underwater action. It is also important that we keep the polyp in the six o'clock position, where we can advance our tools for removal. Upon inspection, it is known that the polyp is a Paris 1S, Kudo 3L pattern. Here we begin with injection of a submucosal agent to adequately lift the lesion for wrist suction. It's important when injecting the submucosal agent to use dynamic injection by first inserting the needle deeply into the submucosal layer or muscle layer, and slowly to pull back until you see the lesion lift. We then proceed with resection using a 15 millimeter snare. We try and obtain as much polyp tissue as possible using the snare. However, we will have to proceed with piecemeal resection of the lesion due to its size. It's important to see the snare in sequence to embed it in the tip into the layer of the previous resection to help guide further resection of the residual polyp tissue. Again, the snare is placed and embedded within the previous resected site to help seat the snare adequately to resect the polyp tissue. It is important to inspect the lesion after piecemeal resection to look for any residual adenomatous tissue. If any residual neoplasia is noted, a vulsion technique can be used, which requires the use of a hot biopsy forcep to grasp and retract the visible neoplasia using the electrocautory setting endocut I with effect 2 to 3. Here we see some oozing from the polypectomy site. We irrigate with water and do some watchful waiting to see if the bleeding will spontaneously stop. However, due to continuous oozing, it was decided that we proceed with hemostasis using hemostatic graspers. The graspers were then used to ablate any other visible vessels that can cause potential bleeding. We then proceeded to continue with the hot avulsion of any residual visible neoplasia. After the resection site margins are free from any visible neoplasia, we then proceed to use ablator strategy using an APC probe for the ablation of normal appearing mucosa at the polypectomy margins. This will help reduce the risk of recurrence. It is important not to ablate any adenomatous tissue as this may burn the lesion and increase the risk for recurrence. This is believed to be because of incomplete treatment of deeper layers. I love watching Dr. Raju APC. In conclusion, colonoscopy with polypectomy is associated with a reduced incidence and mortality from colorectal cancer. Piecemeal resection of large adenomas can have higher reoccurrences compared to end block resection, especially if there is a residual polyp tissue left behind. Avulsion techniques seek to remove visible neoplasia using forceps when snare resection is incomplete. Ablator strategies such as using the snare tip or APC are typically used for ablation of normal appearing mucosa at polypectomy margins to reduce the risk of recurrence. default to that. I don't know why that is. Be creative, but don't get too creative. I think that's always the feedback. It's kind of like your slide yesterday, avoiding the Star Wars. Don't do the Star Wars. Don't do the Ken Burns. It should be entertaining, but this is not Hollywood. Maybe it should be. Maybe it should be. I don't know. I don't know. I mean, it's not L.A. It's Chicago or it's Cleveland. I actually really like the narration on this one. I like the commentary. I like the educational value that was put into it. I feel like watching this video, I was actually learning EMR from Raju, which I still do. Raju always jokes that I don't know how to do proper EMR because I only do ESD. I really liked how you guys talked about the settings. What were the settings that people use for hot forceps avulsion? That's good to know. There was a little bit of downtime in the middle. I think there was a little bit of downtime watching this thing ooze. I think all of us in the room, our blood pressure went up ever so slightly with every passing second of watching the thing ooze. Maybe that was intentional to build some suspense before you went after the deletion. That's my critique. I think another thing to you went from hot avulsion to coagulation back to hot avulsion. I think just stick with that same theme just to keep it consistent. I think you were telling the story in the order, but you may not have to jump back to that. I think you kind of made your point there already. I don't know what everybody's thoughts are on the conclusion slide. I think it's a little bit busy just in terms of the number of conclusions. I do think you taught all of these points, though, in your description. I agree with the keeping things simple. You were the first one to use subtitles, but just make them appear or fade in, fade out. You don't have to do that. Oh, yeah. Okay. Yeah. I actually like the subtitles. I like the poses. It wasn't like there were some very nice poses. There was narration with poses. It gives people time to think about what they're doing. I like the fact they explained what they were doing in details, and the tone was nice. Yeah. The tone. Finally, in the beginning, they were not merely reading the text. They were interpreting the text. I like that. It's not like you're just reading every word. Yeah. They're interpreting that. I think this is good. That's great. One more. As we go on, I'm trying to add new things. I don't know what everyone's thoughts are, but sometimes I've used the picture-in-picture to, let's say, you're APCing, and you want to make a comment. You could do a quick screen with the Irby and some settings. You can split the screen. I don't know if you've done, but I think it's useful. You make your point. You have an Irby mini video that you could do yourself or add images from your own library. I don't know what you guys think, but it's useful. Yeah. I think it's like putting fluoro and the endoscopy video like what Brooke did yesterday. I think it allows you to think in parallel. You have to do it in real time in those cases. Ready to move on? I think it was a little bit loud, too, this one. The video case report for hot avulsion technique. Disclaimer, hot avulsion technique for residual polypectomy. We have no disclosures. This is a case of a 68-year-old male with bright red blood per rectum who was found to have a 5cm laterally spreading tumor granular type lesion in the rectum. Polyp architecture was assessed in keeping with NICE class 2. It was removed with lifting, hot snare piecemeal endoscopic mucosal resection, and hot avulsion. Here we examine the polyp to ensure there are no areas of ulceration or depression to ensure it will be resectable with endoscopic mucosal resection. We inject the polyp base with a mixture of saline and methylene blue with a goal to shape the lift dynamically by moving the catheter while injecting to allow for easier endoscopic mucosal resection. We elect to remove the polyp with hot snare in piecemeal fashion performing endoscopic mucosal resection. Residual adenomatous polyp fragments seen are attempted to be removed with snare polypectomy. However, fragments of adenomatous tissue can be left behind as islands, or may be non-lifting, and are not technically feasible to be captured within the snare for EMR. As such, these non-lifting areas are instead tackled with an avulsion technique. Here we show hot avulsion technique, which is done with a hot biopsy forcep, and is useful in these scenarios. The neoplastic tissue is grasped within the biopsy forcep mouth, then gentle traction is applied with the biopsy forcep still closed, away from the polyp defect base. Current is applied using hot avulsion settings. This would be soft coagulation, 80 watts, effect 4. This is delivered using a tapping technique, with each tap lasting approximately 1 second. If the neoplastic tissue did not avulse with application of the current, further gentle mechanical traction was applied, away from the polyp defect base until the tissue was avulsed. This process is repeated until all visible adenomatous tissue is adequately removed. After revulsing remaining tissue, the base should be irrigated and examined for further left behind adenoma as well as any deep injury to the muscularis propria. Cap assistance is useful during endoscopic mucosal resection as it allows for increased scope stability in difficult locations and closer examination of the defect endoscopically. In conclusion, hot biopsy avulsion technique can be used for residual polyp removal. This is a very different interpretation of the same case. This is like clearly the student in school who had a very different take. It's like the one person who didn't quite go with the rest of the crowd and presented a very, very different aspect, which I think is very educational. It's good. I don't think I've ever been formally taught how to do hot biopsy avulsion like this. So it's actually very cool. I would say, you know, it did like cut very abruptly to that, right? Because I was thinking to myself, maybe I'll see like one snare or two. And it kind of went from like inspection to like 90% completion. So I thought maybe like, you know, you probably don't lose much by adding a couple seconds of like snare removal somewhere in the middle. And then maybe even highlighting that, you know, one of the limitations of piecemeal removal is you might have like a small island of residual neoplastic tissue that's still left in the middle. I think that would further add to the cinematography, if you will, and add to the flow. There was a spellcheck line. I don't know if you caught that on the disclaimer. So I don't know if you guys are aware, but basically when you save a PowerPoint, you can actually, you know how you can save a PowerPoint as like a PPT or PPTX file, right? But you can also export it as images rather than taking screenshots. And you basically just say save as. So you put a save as, and then it comes down as like, you know, emr.ppt or whatever. You can then take that little drag down menu and save it as TIFF or as JPEG or, you know, some sort of image. And what PowerPoint will do is then it will export each slide as an individual TIFF. And that will get rid of all the spellcheck type stuff without, and it'll make your life easier so then you don't have to screenshot every slide. It'll automatically export every slide for you as a separate still image. We're talking with one of the groups about this because they said that their video looked a little bit fuzzy. And I think it's because you have to save those slides from PowerPoint in a very high quality sense. If you take screenshots, you will lose some of the quality in doing so. Does the group have any other comments? Yeah. Go for it. My one comment is sort of lean into the point of the video. In this case, you're talking about hot biopsy evulsion. So some of that dead time should have been utilized to say these are the alternative things we thought about doing. Here's why we chose this. So I like it when there's a theme to the video, which is this hot biopsy evulsion, but talk about cold evulsion. Talk about whether, you know, you could just have done underwater for that. Talk about just ablating it and why you chose that. So I would lean into the reason you did the video and give the alternatives and thinking behind it. Group C was going to present on their laptop. Is that correct? Endoscopic mucosal resection of a colon polyp. No disclosures. A 48-year-old male is found to have a large, sessile polyp on his first screen colonoscopy. He's otherwise asymptomatic and is referred for endoscopic mucosal resection, or EMR. Digital EMR begins with adequate examination of the polyp, aided here by the addition of a distal cap. Polyp margins should be inspected and signs of invasive malignancy, such as central depression, should be noted, as this predicts incomplete resection. The polyp is then injected with a solution containing a dye, such as methylene blue, which highlights the polyp margins, separates the polyp from the underlying muscularis propria, and aids in the detection of deep injury after polypectomy is performed. Failure of the polyp to lift adequately can also indicate invasive malignancy. Larger lesions may require a piecemeal approach, as shown in this case. A hot snare is used in a stepwise fashion to resect the polyp in its entirety. Care should be made to capture polyp margins and avoid leaving islands or bridges of polyp tissue. After primary resection, attention should be turned to the defect. Here we see an actively oozing submucosal vessel. Coagulation graspers can be used to target actively bleeding vessels or destroy non-bleeding vessels seen within the submucosa. Here the vessel has been selectively grasped. The oozing stops after closure of the forceps confirming the vessel has been successfully targeted. The tissue is tented and coagulation is applied. Any remaining visible polyp tissue should be resected from the margins and from the resection bed. Here a hot snare is again used to resect these pieces of polyp tissue. Small islands of residual polyp may be difficult to remove with a snare. Here a hot biopsy forceps is used to resect this small island of tissue. After all visible polyp is removed, the resection margins are then treated with coagulation to reduce the risk of recurrence. In this case, argon plasma coagulation, or APC, is used. The tip of a snare with soft coagulation can also be used. Retrieval of specimens can be accomplished with the use of a net. Finally, the defect can be closed to reduce the risk of post-EMR complications such as bleeding or perforation. The large defect size can make closure difficult. Closure can be made easier by using a so-called zipper technique. The initial clip is placed at the margin of the resection site. With each subsequent clip, the opposite margins of the defect are brought closer together, making clip placement easier. A final inspection of the site shows complete closure of the defect. In conclusion, EMR is a safe and effective way to remove large colon polyps. Polyp recurrence can be minimized by paying special attention to resection margins. And finally, defect closure can reduce post-procedural complications such as bleeding and perforation, and can be accomplished by using the SIBR technique. So every year, somebody comments about the number of clips used and the financial implications. So I think we can skip over that commentary. But I thought this was a great example of, you know, you do use pauses here, but it allows you to give the listener a chance to kind of digest what you're talking about. You highlight so many components to this somewhat complicated piecemeal EMR, and do a great job of enunciating the technical aspects behind doing each of those steps, which can be really hard to do, actually. I think this is a very strong video. I really don't have a whole lot to say aside from, you know, the clip closure is very classic Raju. But otherwise, it's a really good video. I would say if I were to add anything, I would say maybe a couple of like, good subtitles here and there, maybe, at most, but I would say otherwise, the content's good. I really like how you examine the lesion. You know, I think that added a couple seconds of like introduction on how do you examine the lesion is very good. We both perked up during that. It was a very pleased smile on both of us. Yeah, that's right. Do you guys have your other video on the same? Okay. Oh, okay. It's like a gift to be able to explain what you're doing. If you guys ever watch Doug Rex's colonoscopy tips, you know, we all do those things, but we can't often verbalize and explain what we're doing. So, kudos to whoever thought through the steps of what you're doing. A lot of it becomes automatic, but conveying that to another person so that they think about it, you know, why are you lifting, why are you injecting, what are you injecting? I think we need a round of applause for that one, too, right? So, just a disclaimer on this video, I know we were supposed to use the video that Dr. Raju gave to us, but I'd already started making mine with a procedure that I had done. So, no offense, Dr. Raju, but this is not one of your cases. This is one of my cases. So, I just want to make a comment about the number of clips and then how do you figure out how many clips you put in? If the patient is high risk for bleeding, right side lesion, or if the patient has anticoagulants on board, and if the patient is coming more than 200 miles, more clips, and if I'm going out of town, more clips. You know, life is, you know, you have to keep into consideration many, many different parameters, right? Covering weekend service. It's all about us. It's all about the endoscopists. The U.S. guided cis gastrostomy drainage, lessons from my first experience. I have no relevant disclosures to report. This is a case of a 50-year-old man who underwent a cholecystectomy for gallstone pancreatitis and intraoperative cholangiogram-revealed choledocholithiasis. An ERCP was done at an outside facility, which was unsuccessful due to diurnal narrowing. Patient underwent an IR-guided drain placement and was transferred to our facility, upon which he was found to have a low-grade fever, leukocytosis, and elevated liver enzymes. A CAT scan was done, which demonstrated very pancreatic, acute necrotizing collections, which were causing mass effect upon the stomach and the diurnum. The patient was planned for a cis gastrostomy drainage. An upper endoscopy was performed, and upon entering the lumen of the stomach, a noticeable bulge was seen in the area of the body and fundus, located at the greater curvature wall. Here you can see the impression of the cyst on the stomach in a retroflexed view. Next, we evaluated the diurnal stenosis, which precluded an ERCP at the outside facility. You can see the narrowing within the bulb. However, our scope was able to pass beyond the bulb into the second portion, upon entering which we noted the internal-external pilary drain placed by IR at the outside facility. Preparations were now made for an EUS evaluation of the cyst. The cyst was measured and was found to be greater than 6 centimeters in size and more than 70% fluid-filled, which is the recommended criteria for LAM's placement. An E-flow Doppler was then done to exclude the presence of any vessels coursing through the deployment track. Next, we measured the distance between the wall of the stomach and the cyst cavity. The preferred distance for successful deployment is less than 1 centimeter. The electrocautery-enhanced axis catheter was then punctured through the stomach wall into the cyst. Unlike EUS-guided FNA, puncture of the cyst cavity with the LAM's axis catheter should be done by applying a constant moderate pressure on the stomach wall. Next, the distal flange of the stent was now deployed by slowly withdrawing the axis sheath of the catheter. Notice the slight forward adjustment that was needed in order for the flange to fully deploy. Once deployed, the catheter system was now pulled back in order to tent the wall of the cyst cavity against the wall of the stomach with the distal phalange. The proximal phalange of the stent was now deployed within the echo endoscope. In an alternative approach, deployment of the proximal phalange can also be done under direct visualization endoscopically. Once the proximal phalange has been deployed within the scope, the catheter system is now pushed out to release the proximal end of the stent into the stomach. The 20 mm lumen-opposing metal stent is now dilated with a through-the-scope dilating balloon up to 15 mm. This is done in order to rapidly expand the cyst gastrostomy fistula in an effort to assist drainage of the necrotic material and thus provide symptomatic relief to the patient. 2.5 to 3 liters of fluid and necrotic debris was drained at the initial placement of the LAMs. U.S. guided cyst gastrostomy drainage via LAMs is an effective procedure for the management of pancreatic fluid collections. It leads to better short-term health care quality of life and lower costs compared to surgical drainage. It is a technically challenging procedure with a high risk of complications such as bleeding, migration, buried stent, and perforation. As per experts, efficiency of the endoscopist and deployment of LAMs is reached after 15 to 20 procedures. Thank you for watching. Nobody would even know that it was an ERCP needed in this patient and all that. So you can skip the part, just present your point of interest in that video so that make it as concise as possible. It keeps, I mean, again, necessary, a better video. Any other comments from the faculty? Yes. Just two quick comments. Whenever you can, change it up. So I would include radiology. I'm sure someone else was gonna say that too, but bring in the CT scan. It's probably a better size than the measurement of the cyst anyway, because I'm sure it wasn't six centimeters. If you can and your facility allows it, get a room view, especially for something where the device is of interest and how people are utilizing it. And then your conclusion should actually be a conclusion. Like you bring in new information in your conclusion, which isn't in the beginning, like about quality, I don't know, like healthcare costs and learning curves and stuff like that. I don't think that's actually a conclusion. I think that may be a, in the body of the video if you think it's relevant. That's more of an annoying stickler argument. The other two are more like fun. Just throw something else in there to mix it up with radiology. Eisenberg. Yeah. Another simple comment I would like to make is, when you are doing a narration, make sure the terminology that you are using is correct and appropriate. For example, you used EUS guided FNA term when we are inserting the LAMs, quadri-enhanced LAMs. So what happened with that was, this is sort of like, I was just showing this video to show the lessons that I learned from it. I was so used to doing FNA, FNB, that when I did this procedure, I sort of just punctured the cyst instead of going in smoothly like you're supposed to. So my attending pointed that out. They're like, this is LAMs. You don't have to puncture it like you do with an FNA needle, which is why I mentioned, I said, unlike FNA and FNB, with the LAMs, you should smoothly apply constant pressure until your catheter goes into the cyst cavity. So that was the whole point of just putting that in. So again, I think this is a wonderful demonstration of using LAMs to take care of a pancreatic pseudocyst. And I liked how you mentioned some of the different ways of actually deploying the LAMs. You mentioned that two different times. And I think that if you just expanded some of that information, maybe included a couple of slides showing maybe some of the differences in variation or variations in technique, why you chose one thing versus another, this would be a great video to submit for educational endoscopy category. It's fascinating having done this for many years now with Raju, we'll say, is each year when the fellows do it, just the creativity of what you guys are able to do from hopefully from attending this course and taking this and explaining it and the effort and putting it all together is, I'm just astounded at how well you're able to explain those things. And the part where you talked about how the flange wasn't opening and you adjusted and did it, I think that's where the instruction comes in from the video and communicating. And I think what the experts were saying yesterday about creating the video and then showing it to a few people and getting the critiques and adding to it just keeps improving it and makes it more and more educational. So kudos, I mean, every single video is just fabulous. I think another good thing that you did was not everybody might be aware that LAMs for pancreatic fluid collections on necrosis are only FDA approved for 30% or less necrosis, which you pointed out in your video, so that was great addition. And then when you are doing balloon dilation, you went in with a balloon without the wire. So you could have mentioned that you can also go do a wire guided. I prefer wire guided if I'm doing this and I'm pushing against the back wall, because these are long length balloons. And if the drainage is, you are draining a smaller collection, you may hit the back wall. So as Dr. Eisenberg pointed out, just you can point out variations in technique, which would be great education. So just wanted to make a comment. First of all, congratulations, beautifully done. And the one thing is, if you look at it, one of the things that you wanted to comment is you were trying to puncture as if it is an FNB, but there's for puncturing a pseudocyst, it's like a smooth cutting a bottle, right? It's almost like that. And somebody who is an expert like probably and did not catch that, right? She made a comment saying that. So you have to keep that thing in mind because an average guy, I didn't catch it, right? Even expert didn't catch it. So when you're framing your, the way you're going to talk about that, you may want to pause and say, hey, I've done FNA, FNB and I used to use force to get in, but for cyst drainage, we need to do a little bit different. And take a pause and then talk about that. Then what happens is at the end of the day, when you look at a teacher, it's not about what I'm teaching you. It's about what you got out of this, right? It's the same thing. You have to keep that concept whenever you're presenting. What did the learner learn from what you're saying? So you may have to think through that and say, hey, I may need to stop here and how do I frame it in such a way that they get the message? So if you were going to enhance this next version, what would you add? I mean, honestly, I was being sort of diplomatic. So I did the thing and then I said, unlike FNA, you should do this with a smooth pressure, hoping that people would catch on and see that I did it like an FNA. I mean, I didn't really go out there and say, I made a mistake or I jabbed it too hard. I didn't really know how to actually word that. So I just sort of put it in there. You know? I think it's a shift. Yeah. I would, you might add it, if you were gonna take this video and submit it to education. Yeah. The next step maybe would be what Phil was talking about, showing the hands-on. Yeah. So I thought about that. I thought about that. We didn't have it recorded. Then I saw Dr. Ben Moeller's video and I was like, should I take it? But then I was like, there'll be copyright infringement if I cut the thing out and put it in. So I was like, I'll leave it for next time. I'll just answer that real quick. So you cannot hide from us. Everybody in the room saw the aggressive jab. Yeah. We both realized that. And I think you have to realize, especially when you're in training, you may think you can get away with these things, but when you're up and it's like Dr. Channal and Dr. Raju and Eisenberg, there is no way you're getting away with this. So just upfront, hey, I thought this was like an FNA jab. It's not an FNA jab. I'm gonna teach you guys how it's actually supposed to work. That's the educational value of this, right? Also, the same comment about the balloon dilation. It kind of makes you cringe a little bit watching that balloon go in there, knowing that if you pop the cyst, if you pop the back wall of the cyst, there's no rescue. So it's just good to bring that up. So a couple of other things. Just some very minor details, actually, but actually may, when a reviewer is kind of on the fence of whether they want to accept or reject a paper, there are some small things that'll just be like, you know what, that's the tipping point towards rejection. One would be cutting corners in terms of identifying anatomy. So I think you said something like compresses stomach in duo. It's duodenum, it's not duo. One is saying something like three and a half to four liters of stuff came out. It's either three and a half or four. Like you can make a number up, you can take some creative liberty with this, but it should not be three and a half to four because you had some X amount of Is and Os. It was not a range, right? So it's just a couple additional points. And I think this is probably, this is a great example in terms of using mixed media, right? You use the CAT scan pictures, use the endoscopy pictures, use EUS video, all to tell a complete story. So two more. Welcome to this GIE video case report. Today we'll be presenting an endoscopic mucosal resection of an ileocecal valve polyp. I'm Dr. John Campbell, doing this project in coordination with Dr. Raggio. There are no significant disclosures for this case, though I would like to acknowledge the video from Dr. Raggio as well as images from medical illustrator, Angela Deal. In brief, this case involved a 15 millimeter by 10 millimeter polyp that was located at the ileocecal valve. A close inspection of the lesion with high definition white light and narrow band imaging revealed a raised polyp with one central area of depression. A 13 milliliter submucosal injection of methylene blue diluted with normal saline was performed to lift and demarcate the polyp. A hot snare was then used to remove the polyp in a piecemeal fashion. Coagulation forceps were used to fulgurate any residual polyp tissue. Argon plasma coagulation ablation was then performed on the resection margins. Closure of EMR mucosal defect with eight endoclips completed the procedure. Here you can see the polypoid lesion at the ileocecal valve. You can also appreciate that clear cap is being used for this endoscopic mucosal resection. After high resolution white light imaging is performed, narrow band imaging is used to further inspect the lesion. Of note, there is one area of central depression, but no other concerning malignant features. A submucosal injection of diluted methylene blue with normal saline will now be performed to lift the polyp. The needle sheath is advanced out of the scope and the needle advanced from that. The sheath is slowly withdrawn until the submucosal plane is reached and lifting is noted. Two other locations for lifting are performed. The polyp is clearly demarcated and now the needle will be withdrawn and the hot snare advanced through the scope and the needle is advanced out of the scope. The hot snare advanced through the scope in preparation for an endoscopic mucosal resection. Following are potential electrocautery settings for your hot snare polypectomy. The oval snare is advanced and slowly placed over the polypoid tissue. The hub of the catheter is advanced to the base of the polyp and should continue to be slowly advanced as you ask your assistant to close the snare. Endocut settings were then used to slowly cut through the polypoid tissue in the submucosal plane. Here you will see, at a slightly increased speed, the piecemeal polypectomy removing the residual polyp with snare technique. Working from the ileocecal valve over, the final area of residual polypoid tissue is removed. In this instance, scope stability is of importance, and remember to utilize resources such as wheel locks, scope stiffeners, anchoring of your snare, and fine movements. You can also appreciate in this view how the endoscopic cap keeps the mucosa away from the lens and assists with your resection. As this final polypoid tissue is removed, close inspection of the polypectomy site is performed, and decision is made to perform coagulation forcep ablation of residual tissue. Here you can see the forceps fulgurating an area of residual tissue. After forcep ablation, a very close inspection of the margins and polypectomy site is performed. We transition to argon plasma coagulation ablation of the resection margins. This can decrease the incidence of occurrence of this polyp. We start furthest from the ileocecal valve and work our way circumferentially around the margins. Finally, we transition to mucosal defect closure using rotatable endoclips. We start at the far margin and work our way across the lesion, opposing the edges in a zipper fashion. For the sake of time, this has been sped up, and we show the first, second, and final, or eighth clip, closing the defect. With completion of the defect closure, water is instilled through the scope, and a final inspection of the resection is performed. In conclusion, this has been a successful endoscopic mucosal resection of an ileocecal valve polyp less than 2 centimeters. It was cool to see the graphics, right? I really liked, you know, seeing graphic arts, although I do feel like they kind of flashed. Like, they were there, but we didn't hear a lot of discussion about what's going on in the graph. Yeah, I think, so I have a major conflict of interest here in the sense that I trained Dr. Campbell's brother as our advanced endoscopy fellow a couple years back. You know, Dr. Campbell, you're so much like your brother in so many different ways. You're a phenomenal educator, and at the same time, you are brutally honest. You know, I think a lot of us, you know, how often do you speed up your videos? Because I feel like I speed up my videos a decent amount, and I think when I review videos for Video GIE, I feel like a lot of people kind of, you know, subtly speed up their video a bit. But at the same time, I don't know how kosher it is to outright admit that, because I think there are rules in place that you're not supposed to, like, alter or digitally alter footage or digitally alter figures and whatnot. So, it's kind of one of those, like, unspoken truths that everyone seems to do it, or a lot of people seem to do it, but, you know, you kind of don't really want to outright say that you've digitally enhanced your video by speeding it up. So, you know, you are just like your brother. You're honest to a fault there. I think the first slide was really busy. I think that could be broken down into maybe two or even three different slides. And in the beginning, I think you felt that. I think you wanted to kind of, like, get through that slide. So, there were times when you really sped up, and then times where you really slowed down. So, although the enunciation was great, keep the speed of dictation kind of the same throughout the entire video. I'm going to conclude it by saying, making cancer history. That would be too much of an MD Anderson thing. No, I mean, great educational video, I would say. One piece of a sort of more medical part of this that we really didn't touch upon amongst all the teaching points that you provided is, you know, the snare was, like, slipping over the lesions the whole time. It's actually a really good teaching opportunity for, like, I see valve lesions, why I see valve lesions are terrible, why they terrify all of us in the audience, and why all of us still find it hard. Yeah, definitely. Just quickly, also, I think second time I see conclusions in plural, and then there's only one line or one… That's a good point. I think maybe one, two lines at least, I think, in conclusion, you have plenty of educational points, just, you know, as a last comment. Yeah, you kind of concentrated a lot of the educational points in the intro, actually, so, you know, moving some of them to conclusions. I just like the, the graphics is nice. It sort of breaks up a little bit, sort of just watching video of the polypectomy. I agree, it was sort of quick, and, you know, I think it's clever, though, like, if you're talking about Paris classification, you could put up, maybe split the screen and show that, or things like that, where people can really, you know, some of the other videos, people were talking about the pit pattern, or whatever, and sometimes, if it's new to the audience, it might be nice to have a nice little quick graphic. I thought that was a nice placement of a graphic. I thought, actually, you could tell Raju to use a firm, stiff snare. No, I was going to say, I would do a cold. All right, one more to go. Here we have a video of the case report. This is our disclaimer. Here is to go about EMR. No disclosures. These are the keywords for the procedure. So, this is a 50-year-old female with no significant past medical history. Here for screening colonoscopy. Colonoscopy showed a large, laterally spreading lesion close to the IC valve. She has a family history of colorectal cancer. Father diagnosed at age 50. She does not have any weight loss, anemia, or any active complaints. Here, you see a laterally spreading tumor close to the ilicical valve. Next, we are injecting saline to lift the lesion. Here, it looks like we have an adequate lift. Here, we are using stiff snare with heat to perform resection of the polyp in a piecemeal fashion. Then, we removed residual lesion using hot snare forceps biopsy. Now, it looks like we have a clean resection site. We then decided to apply APC treatment to the edge. Then, the defect was closed using resolution hemo clip. In conclusion, this is a demonstration of step-by-step approach for EMRO IC valve lesion. Thank you for watching. Coronial yeah, so I mean in two minutes you managed to tell the whole story Which I think is you know economy of time right you can really make the salient points I think we're all friends here, but there is some formality that is required for formal publication right so not saying Hey, we're doing a snare here, and you know I will throw a biopsy for us I think making a little more formal is probably said this would be like perfect for like it like a tick-tock video type of The first slide to like visually your fonts kind of just scrunched and small and tucked up in the top I think you can expand that so it's just a little more uniform and more pleasing to the eye There's a there's some type of graphical error. I think like you misspelled defect You know please don't do that like run your slides through a spell check It's two minutes, so you know you should be able to like go through two minute with a fine-toothed comb and make sure there's like No, no deep no Also disclosures, I think misspelled I think and yeah, and I don't know for me when somebody says This is my disclosures. This is my keywords It's like little nails on a chalkboard II to me, but that's just maybe a stylistic thing Yeah, like I personally don't do that either. I'll just kind of let it flash by yeah Without really like commenting on you know these are my disclosures or whatnot Yeah, so it's again so interesting that we have had the benefit of seeing the full like, you know Big bigger other parts of the video footage, right? Yeah, you did cleverly kind of gloss over some of the difficulties that Raju had in removing this IC valve lesion You know like the whole issue with like the snare slipping and everything, you know, none of that was present on this one I think you're highlighting a different point Which is you know again all the cases that we do are subject to interpretation depending on how it suits your educational purposes So first of all, congratulations, you guys have done a great job I think you made my day. I should put it that way and I would like to share with you something very special Was in the first batch of this AST video editing scholarship program 2006 rename the program after me So, why don't you talk about that experience because you know, they had they didn't have any idea It will be good and plus a lot has been part of the video selection committee We're a video selection committee for a while and now the CME committee But I think it's I think it's just obviously interesting to see how it's evolved just Stylistically like the things that you're talking about now, we didn't even consider you know font size and we probably had lots of typos, but I think what we still What's what's important about these videos is the teaching part? and so I want to sort of emphasize that because you know right from the beginning when Raju and Peter and Brenna talked about this It's getting a teaching point across and I think that sort of gets to what you're saying in this last video Make sure you have a reason to share a video besides to boast about yourself Like make sure you're teaching something so in an IC valve polyp Whether it was 16 years ago or now Talk about the unique challenges of an IC valve polyp. Yes. It's important to make it engaging That's what we've taught and it's much easier to make it engaging now, but you need to have a teaching point So that hasn't changed the ability to do it more quickly and on computers that don't literally Blow up in your hands because they're overheating It's very nice But the real reason we're here people share videos is to teach It's just so much easier to do now that you know, make sure you have a reason to do it. So Obviously, it's grown a lot Raju Still is masterful in the way. He sort of edits this and and and makes teaching points Not just the way he makes it stylistically nice Hottest remember yesterday we talked about how the potential hasn't really been explored for teaching etc Not just for showing and video Raj And a whole group of people have used the ability to capture video to start looking at training You know, especially for ERCP, can we just capture a video see what someone's skills are sort of try to educate how break down the ERCP in different components and Use it to enhance our training and I don't know Raj if you want to mention what you're doing I mean, I think I don't want to sort of talk too much except that I think that what you're getting at is a real important I think we all do this and if you record video Get rid of the editing part if you record video in general It's such a valuable self learning tool And I have sat there after my cases and watched my videos and seen what I did wrong I've gone with fellows after their cases and said, you know when they couldn't get into a bile duct It's hard and there's this thing that you know The education people talk about a cognitive overload that you can't get too much information when you're trying to scope Sitting back later and watching it helps you as a trainee understand what you could have done differently as us as an attending If you could formalize that into teaching which we're trying to do is, you know Have Raju get 20 people's colon EMR videos and give them a couple of techniques That's the kind of stuff that I think can be really game-changing in how we teach endoscopy And how we get there in our already busy schedules is tough, but at least on a personal level I would encourage you to record your videos Not just for editing so that you know, you can make you know, beautiful videos, but also you can watch them and learn I'm sure others on the on the faculty agree and they do this, too Sometimes to kick yourself and sometimes to pat yourselves in the back. Well, that was that was pretty good It's usually the former like what could I have done differently to make this a little smoother? Yeah, great, so it's Job for everyone, you know another round You

endoscopic procedures

endoscopic mucosal resection

colon polyp

resection margin attention

endoscopic ultrasound

EUS-guided cyst gastrostomy drainage

pancreatic fluid collections

potential complications

experience

ileocecal valve lesion

step-by-step approach

feedback

suggestions for improvement