For the next talk, we're going to be discussing troubleshooting for bariatric endoscopy. And I am from Brigham and Women's Hospital, if we can pull this up. And at Brigham, we actually have a separate bariatric endoscopy fellowship, which is separate from the ASGE advanced endoscopy fellowship. And raise your hand one more time if you have used the overstitch device, or touch it, or do some, not from yesterday, but like, wonderful, wonderful. So as you know, I mean, it is a very useful tool, but there are a lot of steps. And that means there are also a lot of steps that could go wrong. So it's important to not only know the steps on how to sew, but also how to get out of trouble if that happens. Here are my disclosures. So the goal for today is to review common suturing device-related issues and how to prevent, but also how to troubleshoot if that happens. And here you can see right now, the suturing device, there are two generations. On the left-hand side is called the Gen 2 device. This is mounted on a double-channel scope, I believe most of you have it. But when you go out into a community or private practice, sometimes you don't want to invest in a double-channel scope. So now, Boston Scientific has a newer version of the single-channel overstitch. This one is called the NXT. It's an upgraded version of the old XX version. The unique feature about the NXT is two things. Number one, the helix, now you can control it yourself as an endoscopist. You don't have to rely on the nurse or assistant. It's called a Helix Probe. Additionally, with the NXT, now you can fully retroflex 180 degrees. So that allow you to sew in the fundus or do anti-reflex procedure. For today's talk, we're going to go over the Gen 2 overstitch, which is more commonly used in the U.S. So we're going to do a little quiz. I know about a third of you have used the overstitch device before. So let's name the parts of the device. Let's start with this. You can just shout it out. What is this? Needle. Exactly. So nickname is Needle, but if you go by their book, it's technically called Anchor because they don't want us to say that we drop the needle in the patient's body. So they say we drop the anchor like at the end. But we're going to go, we're going to use Anchor, Needle, sorry. What about this one? Yeah. So it's called Anchor Exchange because, you know, that part is anchor. This one is attached to the anchor, so it's technically Anchor Exchange because you can change it back and forth between the right and the left side. But usually people like to call it kind of Needle Pickup because you use it to pick up the needle. This one is Needle Driver. I saw Grace was saying that, or Needle Body. And then this should be easy, the blue line, Suture, exactly. And right now it is a 2-0 suture and it's also non-absorbable. In the past, the company used to have the absorbable and non-absorbable, but right now it's only non-absorbable. And then, this is easy, what is it called? Helix. Okay, wonderful. So you kind of know the name and we're going to refer to them a few times throughout the talk. All right, so some of the people were able to use the suturing device yesterday. Usually the way I think about suturing is that there are two steps in one cycle of suturing. The first step is that you want to load the needle, which means you put the needle from the right side to the left side so you're ready to sew. And then the second part of the suturing cycle is to take a bite, which is when you pass the needle from the left side through the tissue and then back to the right side. And on the left you can see my hand, like what I'm doing with my hand, and on the right you're going to see what happens to the device. So we first load the suture with a needle and suture. So you close the handle, and we're going to go through this doing the hands-on, and now you load it. And then you move to the area you want to sew, you close the handle to advance the suture arm through the tissue, and then advance the catheter to pick up the needle. So now it's back to the right side. So that's one cycle. All right, so as you can see, there are like seven parts of the device, so a lot of things can go wrong. We're going to go over the common ones. So I'm going to play the video, and then I'm going to ask you to identify what went wrong here. So here, I mean, this is a tour procedure, as you can see, and you load the needle. So the needle's on the left side. And now you want to take a bite, but this happens. What's wrong here with this picture? Yes, right? I think everyone was saying the same thing. It's bent. So if you look at the metal piece, the needle or the anchor is supposed to be kind of like parallel to that tower, but it's not. So it's a bent needle. And this happens quite a bit. And why did that happen? So the most common reasons why this happened, especially when you're early on into your suturing learning curve, is that when you close the handle to load the suture, there's still the needle pickup staying outside of the alignment tube, and then you close it. So the needle gets bent when it hits the tip of the needle pickup. So how do you prevent it? So to make sure that this doesn't happen, anytime before you close the handle, you always want to look on the right side. Make sure you pull the pickup back in into the alignment tube before you close the handle. Now, if it happens, and it will happen when you start sewing, how do you get out of it? There's three different ways, depending on how bent the needle is. I'm going to play the first video. This one is easier to fix. So one thing you can do is try to kind of like close the handle back and forth, back and forth. And sometimes that tension from the suture can kind of re-bend the needle back so that now you can grab it with a pickup. So that is your best case scenario, if you can try to re-bend the needle. Or alternatively, on the right-hand side, if it's very, very bent and you cannot get them to meet, so you cannot pick them up with a pickup, then you try to close it and make sure that the needle or the sharp part is at least covered by the tower or the alignment tube. And then you can just run the device, because the suture doesn't have a knot yet. So it's still running through the tissue. You can just pull everything out, but make sure you close it so you don't scratch the esophagus and then come out from the mouth. And then after that, you can open, and then you can try to remove the needle. All right. So teaching point number one, make sure that you pull up the pickup so that you don't see it on the right side before you close the handle. All right. Let's look at case number two. So this is an ESG case. You can see that we placed probably five, six stitches. And now you close the handle. You're trying to load the needle, which means you're trying to put the needle from the right side onto the left side. And then this happens. What went wrong here? Exactly. The needle got dropped. I mean, you can tell that when you do ESG, this is not done yet. You still want to take more bites. But the needle got dropped accidentally, too prematurely. Why did that happen? And this will happen, especially early on. So what happens is that when you try to load the anchor, you close the handle. But the needle and the pickup haven't really aligned. And then you push the blue button. If that happens and you push the blue button too prematurely, then you end up dropping the needle. So anytime the needle is on the right side, if they're not in between the needle driver and the needle pickup, if you push the blue button, you will drop the needle. So to prevent that, if you're still like doing your cycle, you're not sure where the needle is. Is it on the left? Is it on the right? You can always push the blue button. You can always open the handle and then figure out if the needle is on the left or on the right and then restart the cycle. So solution. Solution is easy. Basically, it's gone. Right? So you can't continue sewing. The needle is in the patient's body. So basically, you already dropped the needle. You can just pass on the singe and singe it. But if it happens to be like if you're doing a tour, for example, and then if this happens kind of like towards the end, you might not want to singe that yet. Because if you singe that, you reduce the size of the outlet significantly and then you cannot go around with the second suture. So another option is to drop the needle, come out, use a Kelly clamp to clamp the suture, and then start the second suture and then do whatever you want to do. Do like the perfect pattern that you want to do, singe the new suture, and then go back and singe the first suture that was accidentally dropped. All right. So teaching point number two, do not push the blue button prematurely if you're unsure if the anchor is engaged with the needle driver on the left side. And we can go over that during the hands-on as well. All right. Case number three. Oops. Sorry. What is wrong with this picture? Looks like everyone got it. This is perfect. So the suture, if you follow the suture, the purple line, you can see that it's wrapping around the tower of the suturing device. And you always want to pay attention to this. You don't want to keep sewing because you might end up sewing the suturing device to the tissue. So why did this happen? So usually this happens when you're working in a really tight space. So let's say if you're trying to sew the esophageal stent, or you're doing a TOR procedure in patients with Roux-en-Y. So basically, the space is tight. You have to torque your device around so the suture ends up wrapping around the tower. Prevention. So basically, when you're sewing, you want to pay attention to how much suture you have on the screen. If you have too much suture, the suture is going to end up making a knot or wrapping around the tower. So you want to take off that suture slack. And the easy way is basically just from the cap here, you can just pull the suture, this one line. So you pull the suture. That will take the slack out from the body. However, if it happens, you can get out of it. And usually this is, it works 95% of the time. So you can just write this down, like these three steps. So you're going to see it. So usually when you close the handle, the profile of the suturing device becomes smaller. So you close the handle, usually partially, and then pull the scope away from the tissue out from the mouth, and then rotate the whole device clockwise to the right side. By doing this, usually the suture will come out from the tower, and then you pull the suture out from the scope. This is how you get it out from wrapping around the tower. All right, fourth case. Looks like this is another ESG. You're taking a bite. You pass the needle from the left side to the right side. You got a red out, so this is a full thickness bite, which is good. And now this happens. What's wrong here? I think some people ran into this yesterday as well. Yeah, the helix got stuck. And usually I told my fellow that the helix is actually one of the most dangerous devices as part of the overstitch, because if you go too deep, especially with the Gen 2, the helix can go outside, and then you start grabbing organ like spleen or whatever outside the stomach. So it's very important to kind of go over that with your tech or whoever is assisting you with the helix. So stuck helix. So usually this happens when you apply too many turns to the helix. And sometimes when you get a novel assistant, they spin it. Like if you look at the helix, you have the blue thing at the top. Instead of turning it one at a time, sometimes they spin it. And when they do that, you end up putting in like 17 turns. Then it goes in too deep, and then you cannot get it out. So to prevent it, you want to count the number of turns on the tissue helix with your assistant. So usually with our fellow or the nurse, we always say, okay, let's do 1, 2, 3, 4. And for human stomach, usually four turns should be enough, unless patients have bad gastritis. Ash pylori, sometimes you might need five. But four turns is good, usually in the sore area. But once you move up to proximal body, usually three turns should be enough. Solution. So this is kind of like troubleshooting, but usually if you turn counterclockwise and the helix doesn't come out, then try clockwise. So try the opposite. And sometimes you can get it out because maybe they turn it too many times when they try to come out. You can go up on CO2 insufflation. So by having more insufflation, that kind of thin out the tissue. So you can pull the helix out. And then last solution is to kind of close the tip of the helix and then pull the helix gently. So kind of yank it out. This is not recommended during your first few cases, but sometimes you need to. So you close it and then you pull it. And sometimes that will release the helix from the tissue. Additionally, after that, you always want to go back. If it looks like there are a lot of tears, you want to take another bite in that area to make sure you don't have a perforation. So teaching point number two, do not apply too many turns on the helix. Count the number of turns when you go in clockwise. And then when you try to release the helix, use the same number of turns. All right, last case. So this is singeing. And here you can see on the right, this is a TOR case. You did a perfect purse ring TOR suture pattern. And now you're singeing it over a CRE balloon. And this happens. This is a tricky one. So basically, you can see the white plastic area at the tissue. It doesn't get released from the singe catheter. So the singe device got stuck on the tissue. And this will happen. It's rare. But let's say if you do up to 50 cases, you're going to run into one out in 50 probably. And it depends on the person who's helping you. So it's inability to release the singe. And the reason why this happens is because when you're singeing, if the catheter is not kept straight, it can break so that the handle doesn't communicate with the end of the singeing device. Additionally, if the second step of singeing happens too abruptly, you can also break the mechanism. So I'm going to show you the video of how singeing works. So when you do singeing, there are two things that happen. The first step, when you squeeze the handle gently, what happens is that the singe keeps being pulled, and then it locks the suture in the middle of that plastic singe. And then after that, I ask my assistant to do a harder squeeze. And this is when it will activate the cutter to cut the suture. So you have to go slow. If you go too fast, then the singeing device hasn't had time to do the first step, which is to secure the suture between the singe. But you try to cut it, so you break the mechanism, and that's why the singe got stuck. If this happens, the way to get out is that you want to cut through the handle, so the plastic handle, and then try to get the coil catheter inside. Then use that wire handle to grab the coil catheter, and then pull really, really hard. And then you will activate the cutter. Usually if you have a Boston rep in the room, they know how to do this. But in case you don't have a rep, this is what you do to release the singeing device from the tissue. So teaching point number five, make sure that you keep the singeing device straight and go slow when you're singeing the device. All right. So in conclusion, endoscopic suturing is a wonderful tool. It has several applications. Troubleshooting is as important as understanding the device. And when you start sewing, start with simpler procedures or suture patterns, and then gradually advance to more complex procedures or suture patterns. And last but not least, simulation is key. At our hospital, we have the simulator for suturing. You can see Dan, our bariatric fellow here. He practiced a lot on the simulator, and you can ask him why he look like that. But it's a wonderful tool before you start advancing and sewing patients. Wonderful. Thank you so much. Any questions? All right. So I have seen that helix gets stuck quite often. Do you take the helix out, intermittently clean it? Do you do anything extra to prevent that in your cases, especially during ESG? Totally. Usually, I try to take the helix out. I pay attention to how dirty, how clean it is. If you start seeing heme or tissue, I definitely will come out and clean it, because otherwise it won't grab the tissue well. And when it doesn't grab the tissue well, then your assistant will keep turning and turning, and then it's going to be hard to come out. So definitely make sure you come out and clean. A good time to do that is when you're singeing, because you're going to have to wait anyway. So it's a good time to take the helix out and clean it without wasting too much time. And have you suggested them to maybe put two helixes in the kit, the Boston reps? I mean, we don't use the system, so we bought everything a la carte. So sometimes, especially for ESG, I usually use eight sutures. And sometimes by the time you get up to the proximal body of the stomach, it might not work as well, and you might need a second helix. Definitely.

bariatric endoscopy

overstitch device

troubleshooting

suturing issues

Brigham and Women's Hospital