Well, morning, everybody. Thanks for sticking it out. Happy Saturday. Great way to spend it. Thank you all for editing videos for those of you that have done that. And so the legacy of this course really started with Dr. Chuck creating the idea in an airport terminal I believe, and it's evolved to include video editing when that started to come into existence. And actually, the original video editing course was founded by industry, and they actually gave the participants laptops to be able to do it at that time. It wasn't like the giant computer. I know that's what you all are thinking. And as we've gone along, we actually now have it as a medium for publication, as you all know. So I think it's a valuable skill. It's obviously a very interesting area of endoscopy. It's a tremendous resource for those of you, if you're doing a new case, to look on there and be able to learn something from your peers. I know that being an attending, I still am learning new skill sets. I didn't know FTRD when I was an advanced fellow. So just note that, too, that it's important this year to gain a good foundation, but there is still the prospect to learn new skills moving forward, both through video and through industry and coming to these sorts of courses. So without further ado, Phil, I don't know if you want to come down, too. Yeah. So Phil was the PC counterpart to my Mac, and we'll show the first video from Group A. Is yours available? Okay. In the early years, you used to get a super big clip of some sort the night of the course, and we would all sit up all night editing. And I remember being next to my co-fellow at the time, trying to record video, and you could hear his audio and my audio, but it was really fun. So I decided to be nicer to you guys this year and give it to you in advance. So in years past, this was Amitabh Chak and Raju who ran the course together, I think with Pentax sponsoring. So I tried to give pretty vague videos of more common things, less common things, and let you guys kind of interpret it and use your creativity. So it'll be kind of fun to see what everybody comes up with. The bleeding vascular malformations of the upper gastrointestinal tract. We turn up the volume. Big management of bleeding vascular malformations of the upper gastrointestinal tract. To Max. A 75-year-old female with ESRD on dialysis, compensated cirrhosis, and other comorbid conditions presents with recurrent intermittent melanoma for four years. Currently, she's stable. However, her hemoglobin shows 8.5 gram per deciliter with a MCV of 71. Platelet is 210,000 per microliters and ferritin is 12 nanogram per ml. She's had prior EGDs and push enteroscopies where AVMs were noted in the proximal small bowel along with GAVE in the stomach. VCA, video capsule endoscopy has also been done in the past showing similar findings. We directly proceed with balloon enteroscopy. Gastrointestinal bleeding is the most common gastrointestinal diagnosis leading to hospitalizations in the United States. It accounts for up to half a million cases annually. On the right, the table shows the most common causes of gastrointestinal bleeding. Peptic ulcer disease is still the most common cause followed by viruses of the esophagus or gastrointestinal tract. However, what we've seen in the past few decades is that there has been a decrease in the peptic ulcer disease related bleeding and there has been an increase in bleeding from other etiologies such as vascular malformations and malignancy. In our patient, we begin our examination with the use of a single balloon enteroscope. On entering the stomach, we can see this vascular lesion which on cleaning is still oozing. What we see is an angio-dysplastic lesion which is the most common vascular abnormality of the upper GI tract. It accounts for 4 to 6% of all upper GI bleeds. These are small tortuous dilated thin-walled vessels which are more likely to occur in elderly patients and its prevalence increases with age. It can be associated with chronic kidney disease which was seen in our patient. Also, other associations are aortic stenosis, von Willebrand disease, and left ventricular assist devices. The treatment can be either thermal or mechanical. In terms of thermal therapy, we can use APC or radiofrequency ablation. Bipolar probes may also be used. In terms of mechanical therapy, we can offer clips and band ligation for the treatment of such lesions. Here, we use a clip for the management of this bleeding angio-dysplastic lesion seen in the stomach. We encounter a few more such lesions which is then treated with a non-contact thermal therapy using APC or organ plasma coagulation. A good thermal charring effect can be seen over these lesions. As we move down to the antrum of the stomach, we see more of such vessels which, however, now have a more characteristic distribution. This is referred to as gastric androvascular actasia. These are ectactic and sacculated mucosal vessels which give a characteristic appearance of a watermelon stomach. This accounts for around 4% of all GI bleeds. This can either be idiopathic or can be associated with systemic disorders such as chronic kidney disease, systemic sclerosis, bone marrow transplantation, and cirrhosis. The treatments are again band ligation, organ plasma coagulation, and RFA. Here, we use APC for the management of such lesions. We then progress to small bowel. We encounter more of these lesions which is treated with APC. The examination continues with the insertion of a single balloon entroscope deeper into the small bowel. We encounter an angio-dysplastic lesion likely in proximal jejunum which is then treated with APC. The point of maximal insertion is tattooed. The scope is then slowly and gently withdrawn with examination of the mucosa to look for more bleeding angio-dysplastic lesions. As they are found, APC is used to treat them to prevent bleeding. After treatment of all these lesions, our patient did well with no recurrence of bleeding during the admission. Patient was discharged on iron replacement therapy with close follow-up. Of note, such patients have high risk of re-bleeding. A meta-analysis of 14 studies, which included 623 patients, showed a pool re-bleeding rate of 34% after endoscopic therapy. Another study documented a rate of 46% after APC treatment of such lesions. These patients should also be on medical management with iron therapy. Other alternative therapies include somatostatin analogs and angiogenic therapies, which should be considered in patients who have recurrent bleeds. Thank you. All right. Very good. So I think, really great job. I don't know if this was your first attempt, but excellent first attempt for sure. Who did that, right? How long did that take you? Four or five hours? Just four or five. That's pretty good. Did you learn a lot from doing that? Yeah. In terms of, you know. I had the video on one side, and then I was doing this on the other side. Yeah. I think the great thing is all the, how you marked the video with going into explaining educational things and doing the both, because that's the great part. Yeah. The educational content was phenomenal. I think you did a good job kind of researching the background and creating a narrative around the case discussion. I think that a person viewing this would really learn a lot, medically speaking. My thoughts are with the editing portion, I think that in terms of vocals, you could maybe increase the cadence of the voice, so the speed at which you speak. There are definitely some points in time where it was obvious where you leaned into the microphone and leaned backwards, so keeping that same distance, you can hear the difference now that it's on the big speaker, right? And I think that there are definitely points, when I gave you guys that video, there's that death by bubbles, right? So there are all these points during all the cases where we're kind of drowning in liquid, suctioning fluid, you know, going through parts. Those can be edited, and this is where you put your director editing cap on, and not all parts are really necessary. So if there's a big point where there's dead space and you're not speaking, you probably can remove that point in the video. Great video overall. I actually learned a lot from this. A couple points that I would bring up. One is to Amitabh's point, actually, it takes a long time to make a good video, and I remember being taught by my attendee who taught me how to edit videos, that it takes roughly an hour per minute, so like, you know, a six to eight minute video for publication will take you about six to eight hours of good solid editing time just to get it to a point where you really like what you produce. You know, this is a really good first attempt. I would say, you know, in terms of the educational material, I know for the purposes of this course, you put a lot of the educational material in, which I thought was really nice. I learned a lot from it. In terms of publication-wise, you can actually move some of that stuff over to the manuscript, because when you submit to Video GIE, it's not just a video, but it's also a manuscript as well. And a lot of people never picked up on the subtleties, which is that the video in Video GIE is a supplemental, so, you know, it's actually the manuscript that is published, and then the video is a supplemental that comes with it. Dr. Eisenberg. This has nothing to do with how the video was done, but Ashley's going to roll her eyes at this, being a former English major. So angiodysplasia is actually a misnomer in this situation. It actually should be an angioictasia. There's actually no dysplasia in these particular lesions, so the correct term is actually angioictasia. Some people use arterial venous malformations, or AVMs, and that's also incorrect because that's a subset of angioictasias. The other thing that when you're tattooing a distal site for your maximum depth of insertion during enteroscopy, when you're injecting something like carbon black, the first thing that you want to do is actually create a saline submucosal pillow, so you don't inject carbon black all the way into the peritoneum. It makes it very difficult for surgeons who actually subsequently operate on these patients sometimes to find whatever particular lesion that you're identifying that's true, whether it's in the small bowel or colon. So always use a submucosal saline injection to make that pillow first and carbon black. Those are my two nonsensical comments for video production. I always learn a lot. Tough reviewer. And for those of you that don't know, it's an upcoming lecture. Dr. Eisenberg was in charge of the World Cup Committee for DDW for years, so he's looked at hundreds of these videos. I think the thing that's always interesting every year the fellows present is the voice thing, because I don't think you realize, so was it interesting for you to hear? We've had a number of times where you could tell it was recorded in a different session, and if you're not in the exact same spot with the exact same acoustics, it's like you can tell the difference and it's a little disconcerting. You can also tell the cadence of your voice, you're trying to be very methodical and slow and whatever, but you need to sound a little enthusiastic. At the beginning it sort of sounded like you were super bored with the whole thing. I think it's funny when you hear yourself, and you can hear over, I don't know if you can notice the difference, but it is funny, like Schaefer's saying, you're leaning in or further away. You don't appreciate it until you- Yeah, and you don't realize that you just have to be in the same room, same distance. I also hate the sound of my own voice. No, but a quick point in terms of recording is when I was taught how to make videos, there's a couple of key lessons that it really took to heart. One was to record using, nowadays everyone has AirPods, but before AirPods, there was the actual headset that went into your ear, and I think Apple still has those, where it has the little speaker here. That's nice because then it's always at a fixed distance from you, so it's not like you're recording in or recording, so the distance thing does not quite matter. The second thing was the best room in your house to record in usually is a master closet. A closet, yep. Because in a master closet, you have four walls, and it's lined with clothes, so the acoustics are really good. You know you're talking to fellows, they probably don't have master closets. They might have a small closet that they can't fit in. The endo closet where they keep all the... Right. In between cases. And then the third is taught to record. You record in one session, but you record them in individual sentences, so it's like you'll have one clip with one sentence, and then another clip with another sentence, because that way you avoid the frustration of having narrated a whole paragraph only to stumble on the last word and then be super pissed off going, oh my God. Yeah, I completely agree with the last comment is to record at the clips because then having done the whole recording and then fumble and you're like, are you kidding me? So the next one is also group A, so it's the same case, but it'll be interesting to see how somebody else interprets the same video. Ah, Ken Burns. Little zoomy, zoomy. Yeah, Ken Burns. I talked about that in my video. He had a typo. He had a typo for overview. Yeah. Corrupted. What happened to a renal failure? They're making it. It got better. Seizure consultation was obtained, deep sedation with MAC was preferred. Upon entering the stomach, an actively oozing lesion with a visible vessel was seen in the proximal stomach. The lesion was washed with water that confirmed active oozing. A hemoclip was successfully deployed with good control of bleeding. The stomach was then carefully examined. We noted evidence of moderate vessel gastropathy with active surface oozing at several areas. These were successfully treated with APC using a circumferential lip-firing catheter. A few treated areas with re-bleeding were seen and were treated again. There were no evidence of VDCs in the distal esophagus or the stomach. Then the interim was examined. It was remarkable for extensive surface changes with vascular ectasia, suggestive of GAVE. Again we chose to treat with APC. As you can see, we carefully evaluated the interim for any residual or missed areas. Also there you can see the interim appeared quite distorted. The scope was then advanced towards the duodenal bulb. But before that we noted several lesions at the pylorus that were treated. Upon entering the bulb, we noted a superficial mucosal erosion with active oozing. And that was treated with APC successfully. Care was taken not to let coagulum at the tip of the catheter interfere with vision. So the catheter was frequently removed and cleaned outside the scope. The scope was then advanced into the second portion and beyond, into third and jejunum. As you can see there, most of the examined small bowel appeared healthy with only an occasional red spot here and there, which could be small erosions versus small AVMs. We anyway went ahead and treated them with APC. As we advanced the scope distally, significant difficulty was noted with scope stability. Given that the majority of small bowel was fine, we decided to withdraw the scope then. Prior to that, we placed a spot marker at the distal most extent for future reference. Yeah, let me know. Yeah, I know. I've got a lot of irons in the iron. Let me know if you need a bandage. No, there's no need. I've got a major wound. HSS. Oh, nice. Oh, that's nice. You have red pads, right? I'm on the NCCN. Red pads. Once the spot marker was placed, the scope was then withdrawn with careful attention. Withdrawn with careful examination for any missed or bleeding lesions. We used the APC catheter tip handy to apply treatment where necessary. Upon entering the stomach, an area of erythema was seen that was ablated as well. That's really cold. That's really cold. No. First aid. Finally, GE junction biopsies were obtained prior to removing the scope. Presence of microcytic anemia suggests chronic GE losses. End-out therapy is feasible. Bleeding can recur. All right, another good effort. You're welcome. Cool. Interesting to see how people interpret the same endoscopic information. Again, I really like the vignette that was created as a part of this. I think you did kind of a comprehensive view. Just like the other one, I think audio-wise, you could hear your papers rustling. There's a lot of background noise, so just making sure you're in a place that's padded well, that there's not a lot of that. If you are shuffling through paper, just turn your mic off temporarily or record it as a new clip. Then, again, I think just hitting the editing room floor, cutting out those suctioning bubbles, the times when you're just kind of awkwardly sitting there not hearing anything, helps to make it more concise. I really like the subtitles, by the way. It's very well done. Yeah, that was cool. Endoscopic. What I would say, having watched these videos over the years and learning from others who do it, trying to get the audio and video together is great. I think you both did a great job, but one thing both miss and opportunity is trying to teach someone how APC works. What is the mechanism? Why is that porcelain probe at the end of it? Which direction is the gas coming out? What the difference in the probes are? There were times where it's a non-contact method. You did touch on having to clean it, but when it makes contact, which is unavoidable, and you get a little bit of coagulum on it, and then there were parts where the arc is not quite going in the right place, and then you clean the probe. So there are opportunities, even with video like this that's showing what you do every day, you can teach someone a lot from looking at the video if you can sort of convey your thought process. Why did you do that biopsy at the end? And people who do this well, and I'm not one of them, I'm a critic, are verbally able to explain what they're thinking and why they're doing it and what the different steps are. Why leave that APC probe in the endoscope even as you're withdrawing? Because you don't want to go in and out and you want to be ready to treat something. So trying to explain what you're thinking during the endoscopy and convey it to someone else watching so they can learn from it is a difficult skill, but these guys do it well. And what other advice do you guys have? So you saw he was doing the zoom in, zoom out, and the little captions I thought were great that showed up, but sometimes maybe they were quick, you don't want things to be distracting, like people go whoa, but it's kind of cool when it works, but how do you figure out sort of... I mean in the video I sent you guys, the Mac software will default to Ken Burns for some reason, I don't know why. All you have to do is click on your pictures and turn that feature off to a still, it's as simple as that. So first of all, it bothers me to see typos in a video, so just make sure you spell check things. I don't like seeing the little red line under the words, when it's like my spell check does not understand APC or whatever, so just make sure that when you have the actual slide, that you have the actual slide without the pooping marks on there. From a video standpoint, I actually really like what Amitav just said in terms of teaching the technique. So this reminds me of when I was an advanced fellow, we put out a video on coiling and gel foam, and the advice that I got at the time was to record how coils work and record how gel foam works outside of the patient. So like an equivalent to this, obviously you guys didn't necessarily have enough time to do this, would be to run to the endo lab, grab an APC probe, and with your iPhone, shoot what the APC probe looks like, different configurations, that would be solid educational material. You can also use the endoscope as a camera, so if you want to film a technique like heparinizing a needle for something, you can actually have somebody film your hands doing that with the endoscope itself. Although it's easier to just use your, nowadays modern phones are so good, just use an iPhone to do it, because with the endoscope, you don't have to worry about it. We did the virtual thing yesterday, Jen and Ajay did it. They had the camera on when they were mixing things, had the camera on the hands. It's very instructional, hands on the scope. So it's sort of, if you've ever seen it in practice. We often forget the value of actually showing the hands doing something. Especially for certain techniques that we do in endoscopy that are more like educational value is more in what the person is doing. The case in point that I have would be Pathfinder, for example. How to use a Pathfinder, or how to use a single balloon. There's tremendous value to recording what you're doing and what your hands are doing, rather than what you're seeing endoscopically. Great. See how the volume is. I don't like my voice. Incisional therapy. When I have subtitles, by the way, I usually have them extend for a good solid five seconds or so. That way it's not abruptly there and abruptly gone. Just a stylistic thing. Mitomycin C for a benign esophageal structure. This person mailed the herb ball I was trying to throw. We describe a case of a 78-year-old man with a history of distal esophageal adenocarcinoma who underwent an Iver-Lewis esophagectomy. Three months after surgery, the patient began experiencing dysphagia to solid boots. He underwent endoscopic evaluation at an outside hospital, where he was noted to have an anastomotic stricture and a small tracheoesophageal fistula. He subsequently underwent multiple balloon dilations without improvement in his symptoms. Given the lack of improvement, the decision was made to treat the stricture with endoscopic incisional therapy and topical mitomycin C. During endoscopy, the anastomotic stricture was identified and examined. The inner diameter of the stricture was estimated to be 8 millimeters, and the scope was unable to pass the stricture. The patient was also noted to have a small tracheoesophageal fistula proximal to the anastomotic fistula. Once the stricture was examined, an insulated-tipped needle knife was passed through the scope. The stricture was cut using a radial incision and cutting technique. As seen in this diagram, in this technique, the stricture is first cut with a needle knife in a radial fashion, parallel to the longitudinal axis of the esophagus, as shown by the red arrows in Figure A. Once enough cuts have been made around the stenosis, the parts of the stricture in between the radial incision line are sliced off using the needle knife, as shown by the arrows in Figure B. The end result of incisional therapy is a wider lumen as seen in Figure B. You can see the radial cuts being made here in the initial steps of this technique. The cuts are continued along the esophagus until they are made around the entire stricture. The rim of stenosis is then sliced off in between the radial cuts using the needle knife. During this case, a staple from the esophagectomy was found along the rim of stenosis. This staple was subsequently removed using a needle knife. Following removal of the staple, continued cuts were made in order to completely remove the rim of stenosis. After incisional therapy, the scope was able to pass across the strictured segment, revealing gastric mucosa on the other side of the stricture. The needle knife was then removed, and a balloon dilation catheter was cut through the scope, and the stricture was dilated to 12 millimeters. Following dilation, the site was again examined with no evidence of perforation. An over tube was then passed down to the area of the stricture to help maintain stability during administration of mitomycin C. For the mitomycin C therapy, four by four gauzes were soaked with mitomycin C and attached to the end of a snare in order to form a pledget that could be directly applied to the mucosa. The pledget was directly applied to the area of incisional therapy for approximately three minutes. The over tube was subsequently removed, and the scope was passed down once again to examine the site of therapy, which showed no evidence of perforation or severe bleeding. In this case, endoscopic incisional therapy was used for treatment of a refractory benign structure. A majority of benign esophageal structures are secondary to chronic acid exposure, but others may be associated with Schottky rings, webs, post-radiation strictures, caustic ingestion, or anastomotic strictures as seen with our case. Incisional therapy may be considered, especially in benign strictures that are short segment and fail to be adequately treated with balloon dilation therapy. In this video, we demonstrate the radial incision and cutting technique, which allows for precise displacement of the fibrotic tissue of the structure and complete removal of the rim of stenosis. This therapy can be performed in either the pure cut or blended cut mode. The procedure stops once the scope can be easily passed across the structure. Balloon dilation is generally performed after incisional therapy as an adjunctive measure. Topical mitomycin C was used as an additional adjunctive measure after endoscopic incisional therapy. This is an anti-neoplastic agent isolated from the bacteria Streptomyces casepitosa. It is thought to reduce scar formation by the suppression of fibroblast proliferation. Mitomycin C may be administered through various methods. In our case, mitomycin C-soaked gauze was formed into a pledget that could allow for direct application of the mitomycin to the area of incisional therapy. Other studies have also applied mitomycin C using injection. Initial studies have demonstrated good safety profile and efficacy of mitomycin C in reducing structure formation. However, these studies have been small and largely retrospective. In conclusion, endoscopic incisional therapy and topical mitomycin C are alternative techniques for refractory benign esophageal stricture, as seen with our case. Further studies are needed to evaluate these methods and compare them to more common methods of stricture management, such as balloon dilation. In our case, the patient responded well to therapy, and his dysphagia symptoms resolved in a few months. All right, nice. Thank you. Thank you. Where's Field Willingham? We should tell him that this video is ready for peer review. I know. Great. Yeah, no, that was really great. I mean, I think I have to make the cases more bizarre next year or something to make it harder, but great job figuring out what we were doing. And I love the narrative around things. I mean, I did the case, and I still learned things as a part of your discussion. I would say the only thing, if I were to, I think the vocals were great and the cadence. And you did a pretty good job editing the actual footage to keep it concise and moving forward. Towards the end, with a little bit of the educational content, this is a stylistic thing, so people may disagree. But I think the things that you're saying, if they're on your slide, may help the reader to follow along with you. Do you feel differently about that? I agree. Yeah. And I think that maybe some of the educational content at the very end could have been taken out. I mean, I personally, I guess stylistically, I personally don't have a problem with that. I think it's just sometimes it's quite nice to talk about these things. I think it could have probably been moved to the beginning rather than at the end. Because at the end, if you're showing key learning points, it should just be bulleted as a couple of key learning points, a couple of key takeaways from the video. I really like the diagram that you made. Yeah, I was going to say the diagram. I'm seeing thoughts from Dennis Yang and other people around the room. I really like the, it's cool. Yeah. Glad someone did that. Yeah, I mean, your cadence, your clarity, all that was really, really good. I mean, really, really nice. I actually thought that that diagram was supplied. So I'm very impressed that you made that and incorporated it. It was so easy to follow and so appropriate for the video. So kudos. OK. So same footage, different person. So everybody nailed your thing, huh? Yeah. It is scopic stricturotomy with mitomycin. Not that interesting. My wife would agree. Not as creative as you thought. We have a 65-year-old male with a history of esophageal cancer status post-esophagectomy, which was complicated by an anastomic stricture. He was referred to us for recurrent dysphagia after failing multiple esophageal dilatation. Upper endoscopy was performed under general anesthesia, which revealed severe anastomotic stricture. As you see here in the video, we were unable to pass the scope through the stricture. The decision was made to proceed with endoscopic stricturotomy. As you see here, we used an insulated tip electrosurgical knife to perform the stricturotomy. We incised the stricture in a circumferential or radial manner until there is an adequate passage of the scope. Some cases reported that the incision should be along the aspect opposite to the aorta. Here, we moved to the opposite wall to continue the stricturotomy to achieve sufficient stricturotomy to allow for the passage of the scope. After completing a full circumferential stricturotomy, we were unable to pass the scope as seen here in the video. So we proceed to expand our incision using the same knife, cutting deeper and in a circumferential manner until we are able to pass the scope. We are extending the cut approximately here to achieve a better stricturotomy to be able to pass the scope. Here, this is the final cut. And now we're going to try to pass the scope through the stricture. As you see, we were able to pass the scope into the stomach without any complication thus far, no bleeding, and no signs of perforation. After finalizing the stricturotomy, we proceed with balloon dilation using a through-the-scope balloon dilator. Since the scope is around 10 millimeter, we started with a 10 millimeter balloon up to 12 millimeter. Once we reach the balloon maximum size, we leave the balloon inflated for 30 seconds. Then we start deflating and remove the balloon to assess for any changes. After deflating the balloon, it is important to observe for any signs of bleeding or perforation. As we see here, there is some minimal bleeding, but no signs of active significant bleeding or any perforation. In preparation for the application of the mitomycin C on the stricture, the upper endoscope was removed, and an overtube was advanced at the level of the stricture to minimize mucosal contact with mitomycin C. A gauze soaked with 1 millimeter mitomycin solution was delivered at the level of the stricture using a cold snare, holding the gauze in the middle to achieve the maximum contact with the mucosa. The gauze should be applied at the level of the stricture for at least three minutes, but there is some studies that suggest a second application can be done for two more minutes. When applying the mitomycin C, the endoscopist should be systematic to make sure that mitomycin was applied to all walls of the stricture. After finalizing the application of mitomycin C, we remove the gauze with the snare and the overtube as well, all together, to minimize any contact with the mucosa. In conclusion, endoscopic stricturotomy provides another effective option for refractory and ostomatic strictures. Further prospective studies needed to evaluate the efficacy and safety of the procedure. All right. Nice. Very good. Yes, sure. Strong start. I wonder if you like, did you kind of run out of time in terms of editing the video towards the end? Because I know as the video went on, it's almost like you kind of lost steam. And then towards the end of the video, you kind of pick back up again. But I think a lot of people are still trying to figure out how to do it. And I think it's a good thing that we're able to do it in a way that's not kind of pick back up again. But I think overall, it was well cut. It was well edited. It was a very different approach than your colleague who did the other version of this. So it was actually very fun to see different interpretations of the same case, or even the same interpretation, but presented different ways. I thought that the cadence was good. It was not too slow. It was not too fast. There was like an area, I think, it was more towards the beginning of the case, where like your sentences kind of almost like accidentally stacked on top of each other. That's just a little bit of an editing thing that you would catch when you go through the video again. Amitabh? You know, it's hard not to contract. The thing that was nice about this one is it sort of catches, it grabs you a little bit more. Because in some ways, we've all become used to seeing things quickly. And this is one where you can watch it while you've got a minute here, a minute there. And it's something about the cadence and the way it's presented. Yeah, I don't know. You get the same stream, and they're presented differently. Each one has a different flavor to it. Yeah, that's the fun part, is the interpretation. It's almost like this one is very well-suited for social media. Yeah, exactly. Where the other one has a little bit of a longer intro into it, and it really builds into the educational content. Yeah, I think it is just stylistic. But I think that I probably could have learned a little bit more about mitomycin C, or incisional therapy, or those sorts of techniques from this one. And I agree with Phil that I think kind of towards the middle, there was a little bit of a lull. Maybe not enough coffee in the middle there. Maybe you did it last night, and it was getting to the witching hour. But I think overall, really great, great effort. And last but not least. Thank you very much for the opportunity to present a case where balloon dilation was used to facilitate a full-thickness resection of a duodenal neuroendocrine tumor. Yeah, it's like super long videos, though, isn't it? My name is Idrees Suleiman, and I'm currently a fellow at Midwestern University in Mesa, Arizona. Thanks for the credit. I don't know why I needed to do a D for it. That's the best I've ever heard. That's the best I've ever heard. He accidentally left out the disclosures for author 2, though. Yeah, for me, yeah. To be rejected upon submission. Those are small bowel or rare. Out of the United States, accounts weren't mentioned. There are approximately 12,000 new cases per year in the United States. Neuroendocrine tumors represent a subtype of small bowel tumors. Endoscopic resection can be considered for non-invasive in situ and T1 lesions. In order to resect these lesions, the full-thickness resection device, or FTRD, can be employed. Its components include a cap, a grasper, and an over-the-scope clip. In figure B, we see grasping the lesion with the FTRD grasper. In figure C, we see retrieval of the target tissue into the cap. In figure D, we see release of the over-the-scope clip. And in E, we see closure. The gastrodudinal FTRD set has an external cap diameter of 19.5 millimeters. The internal cap diameter is 12.11 millimeters. To put this into perspective, the diameter of a standard gastroscope is 10 millimeters. As such, it may be technically difficult to utilize this instrument in the dudinal bulb. A technique which may assist in this is utilizing balloon dilation to assist in the passage of the gastrodudinal FTRD device. A balloon is inflated in the stomach to dilate the pylorus and the dudinal bulb. The balloon is left inflated for a period of one minute. After one minute, the balloon is then deflated. The target area is then re-examined. Prior to resection, the target lesion needs to be marked with electrocartery to make a halo around the target tissue to be resected. Once this is complete, the FTRD device can be affixed to the end of the endoscope. And the target area can be approached utilizing the pre-targeted electrocartery marks. Once in place, the grasper can pull the target tissue into the cap and shred it 50% of the time. The over-the-scope clip with assistance with electrocartery can then be deployed in order to obtain a full thickness resection. Once resected, the specimen can then be removed from the cap. The area is then re-examined, and we see a full-thickness resection with over-the-scope clips inside you. This is the specimen removed. Sometime later, the area is re-examined to check for local recurrence. As we can see with high-definition white light endoscopy, there is no evidence of local recurrence. Virtual chromoendoscopy is then undertaken to further exclude local recurrence. Chromoendoscopy is then employed to further evaluate the duodenal bulb. As we can see, there is no evidence of local recurrence and biopsy specimens are obtained to confirm this. In conclusion, FTRD can be utilized to resect duodenal bulb lesions. Balloon dilation can assist in the passage of the FTRD. We have a lot of video to go through, so good job churning down all of that, including a complete follow-up endoscopy, like, you know, 20-30 minutes, so good job. Yeah, no, that's a great job with editing everything. I think I learned a lot from it. I think you could have maybe focused your discussion around neuroendocrine tumors in particular, but it's not a wrong choice to discuss small bowel tumors. I really love the picture of the device explaining the components to it. It definitely arms you with the understanding of what is occurring during the actual procedure. So I really appreciate those things. Just like the other one, I think there's maybe just a little lull in the middle and a few little editing choices with bubbles that you could have excluded. So quick comment. You know, different editors, I think, may differ in terms of how hardcore they are about this, but the proper terminology is a non-exposed endoscopic full thickness resection because FTRD is a trademarked name of the device. It's kind of like, you know, if you were to say you would not put wall flex, for example, into the title of an article. You would put, like, self-expandable dental stent. Just, you know, kind of a small brief point there, but that's one of those things where, from an editorial side, it's one of those things that, depending on how anal the editor is, it may result in, like, automatic rejection. Just like PHI. Especially that figure. Is that a commercial figure? Yeah. The gastrodial FTRD. Yeah. This actually. Yeah, like, I think for the ASGE, for, like, you know, the video plenaries and stuff, right? I think Eisenberg's nodding his head. If you were to submit that video, it would actually be rejected. Yeah. Same thing with PHI. Right. Be very aware of that. Be careful when you submit that. This one actually is published in Video GA as a part of a series, and that was one of the things that we had to be very careful about is naming the brand name. Right. So we took our own pictures of the device and explained it similarly to how you would. Yeah, like, when I published a video on the Boston Scientific ProKnife, I actually went to great lengths to put, like, white out the name on the device. There are certain things, like the Irby APC, where it's unavoidable, because Irby is, like, right in your face as you put the logo out. It's, like, you can't do much about that. They're not dumb. You can't do much about that. But, like, you know, but say, like, FTRD, you know, I think just realize this because you don't want to put in, like, six to eight hours producing a six- to-eight-minute World Cup video only to wonder, oh, I wonder why I wasn't chosen, whereas the reality was something extremely, you know, extremely basic where, you know, you basically lost, like, really, really good video because of something so technical. What did you guys think about the, sorry, the words flipping in? Do you like that? I think, you know, we talked about this a little bit in the initial video. Just keep it simple, like, just show the slide. It's fun to be creative and make things look pretty, but don't use the Star Wars, like, you know, paid-in text for your subs. Just keep it simple. So if you're actually going to use a copyrighted image, make sure you get the copyright permission from wherever you got it. You can use a copyrighted image. Just make sure that in, you know, the bottom of that particular slide that, you know, copyright permission obtained from blah, blah, blah. Okay. The other thing I would mention on that particular figure, you were kind of talking about the technique of how the device works, and you had those blue arrows at the first image. And as you were talking about each step, you know, you could have moved, maybe you didn't even need those arrows, but you could have moved those arrows to illustrate, you know, each step that you were actually talking about. And then, you know, an editorial thing, you know, the diameter was in some of those, the first two things that you mentioned were millimeter cubed. It should have just been millimeter, right? It was the reference. It was the reference. Oh, reference. Okay. Great. Any other questions or anything? Yeah, what's the name of the FTDR, the brand name? The generic name. The generic name is a non-exposed endoscopic full thickness resection. That's the technique. Because endoscopic full thickness resection can come in different flavors. There are exposed versions, which is basically a polite way of saying perfect suture. And then there's the non-exposed way, which is the device-assisted full thickness resection. I really liked the video, and I agree with everybody about showing the device outside the body. I would say that if I were going to organize this, you can do it in a couple ways, but your title sounded like it was going to be why you need to do the dilation in order to use a device for this particular disease set. So in my mind, I was setting up to say, okay, why I needed to do this particular thing, while other situations I don't need to do the dilation. So I think a little bit more of an explanation of why you needed to do the dilation. And also to say, you know, this comes in the device and sometimes another area where you might need it is when you actually pass through the oropharynx area. So just a quick thing to mention that I think would round out the discussion more so that the reader or the viewer can understand, you know, when would I need to do this dilation situation and when do I not need to. And then how you progress where you actually talk about how the device is used. And then thirdly, you know, for what disease entity and an educational part of that. And you can organize it any other way, but I think a little bit more of the discussion as to why you needed your device or a sort of change into just a device would have been a little bit more of a rounded out presentation. I love the dimensions you showed and contrasted to regular. I think what you're trying to show there is how hard that device is and how you can seriously damage things with that device. And I think just bringing that out a little bit more. So the person watching it can learn that part of it. Yeah. Awesome work, everybody.

video editing

endoscopic procedures

feedback

bleeding vascular malformations

incisional therapy

full-thickness resection

subtitles

audio quality

educational content