All right guys, we're back. Thanks for holding on for us. We're back to talk about some of the other skills that we're practicing out in the Bioskills Lab here at the ASGE Center. We're going to start with a couple of basic endoscopy skills and techniques. What do we have up first? So let's see, is there anything on the stomach? Okay. So you switched over to a porcine stomach model. This is a really great teaching model. While the shape is a little different from a human stomach, the layers of the stomach and the form and function of the stomach are very parallel to a human stomach. So this is a great training tool. Something that if you work with any of your industry partners, any of the reps from the different companies that may supply your endoscopy unit, this may be something they can set up for you locally. And this would allow you to practice these different techniques that we'll try here today. One of the fundamentals of lesion removal and mucosal resection, which is a big part of colonoscopy obviously, also comes up with upper GI endoscopy as well as the saline lift or the mucosal lift, submucosal lift. So what we're going to try here today is to demonstrate use of one of several different commercially available injection needles. So a good time to bring up the point that reusable scopes like this Fuji scope, like an Olympus or Pentax scope that you have in your unit is a big investment on behalf of your hospital system or your GI practice that you're a part of now as a GI fellow. So if you want to treat these things with care, they're certainly worth more than my car, just one individual scope. So important to take care of things. One of the things that any of us can do to damage a scope is to actually put out a needle or a tool in the scope channel. So in general, tools are designed to pass through the scope channel without causing any trauma. One of the things you need to be careful of now that you're going to be driving an instrument, an expensive instrument like this, is that the tools are sheathed, that things are moving through easily and without an issue. If you're having trouble pushing a tool through your biopsy channel or working channel of your scope, please let your attending know that they will thank you for this. This is an opportunity to catch either early scope damage or certainly to prevent scope damage instead of just jamming a tool through. With this tool in particular, you can see here on the endoscopy screen, we've gone to live endoscopy. Here's a needle that you can see sticking out. So Daniela, if she's working with me as her technician, would ask for a needle out. And this is going to allow her, I'll let her talk through what she's thinking about when she does a submucosal injection. So one thing to keep in mind is you don't want to have your lesion at the end, like let's say your lesion is right here. You don't want to be injecting this far away, okay? And so you want to be as close as you can to your lesion. So let's say the lesion is here. So then you want to be as close as you can so that you can actually see the needle. So needle out. »» This is something else. You know, I remember being a fellow and I remember feeling guilty about telling someone what to do. So do not feel guilty giving commands. And you don't want your communication with your nursing or technician team to be really drawn out. It shouldn't be, hi, Daniela, can you please put the needle out? That would be great. Thank you. So we're looking for short commands in the endoscopy unit because we need to communicate quickly with each other. So she said needle out, needle's out. »» Yep. And then you want to try to do like a sharp stab. Again you don't want to be pushing and doing like this where you cannot see. You want to do a short stab, the needle went in, but you want to do a short stab, go in. And then again, you may be too far in into the tissue so you can start injecting. So you can inject. And then you can retract the needle as the injection goes so that you make sure that you're in the right plane. You want to be in the submucosa. And you want to see your lesion lift. So just make sure you're adjusting your needle as the tissue lifts. »» So this bulge we're seeing in the mucosa here is actually fluid dissecting through the submucosa and lifting the mucosa off of the muscularis and allows us to have a nice safe cushion for then performing a resection maneuver or otherwise. What other things have you been injecting in clinic? »» So let's say you have maybe an ulcer and you want to, it's bleeding and you want to inject some epinephrine and you can do that. Or sometimes when you're doing colonoscopies there's a polyp that is hidden behind a fold and it's a big polyp, you want to refer for EMR, then you can tattoo to kind of localize where this lesion is and then facilitate your advanced endoscopist when they go in so that they can localize this lesion. Important to note, the carbon spot or spot ink that you'll use for tattoo can cause submucosal scarring so you want to be careful not to inject in or around the tumor itself with that. There are different commercially available prepackaged, but these can also be mixed in your endoscopy unit if you're set up to do so, but prepackaged submucosal lifts that are designed specifically for mucosal lift. These are different than tattoo which are also often prepackaged and allow you to tattoo an area, both of them require a submucosal lift. In both cases you're looking for this nice mucosal bulge or lift from that fluid dissecting into the submucosal planes. Again be careful when you're doing these that they aren't near a lesion. If you're doing a tattoo that can cause issues for your advanced endoscopist when it's time to do resection later. You may want to consider injecting saline first, make sure that you're not injecting through into the peritoneum because if you're injecting a tattoo into the peritoneum that may cause peritonitis, it's very uncomfortable for the patient, it's difficult for the surgeon if they need to go to do surgery. So things to keep in mind, make sure that you're in the right plane before you inject the tattoo. Great. So the needle back please and then you bring, you see the injection, once the injection is done you basically bring the needle back and then you bring the catheter out of your tunnel. So this will be a skill that you'll perform for sure during first year. Again wonderful tool for delivering epinephrine, for delivering tattoo and then also mucosal lift if you're doing an EMR technique resection or ESD later on in training. The next tool we'll look at will actually be, do we have a biopsy forcep on the table? So your go-to, this is actually a jumbo biopsy forcep and we have a therapeutic channel. One thing, you know you can look at your scopes, look at your scopes and near the handle there's going to be a little triangle on both the Fuji and the Olympus scopes and that little triangle is going to indicate a size for your biopsy channel. So if you look at our scope here, you can see upside down and I'm sorry for that, 3.8. This is a 3.8 millimeter channel. That allows us, if you think about, and you have to now that you're an endoscopist, you have to think about French size. French is just three times the millimeters so certainly this accommodates 10 French tools. No problem at all as a 3.8 millimeter channel. This is a therapeutic channel so it allows us to place 10 French stents, stent catheters through the scope stents and other tools that are 10 French in diameter. So some of our larger tools in endoscopy. This may not be your go-to scope for diagnostic endoscopy where you may be using a smaller diagnostic 3.2 or 2.8 millimeter channel. The other thing I wanted to mention is you see a lot of these tools bring this kind of mark so that you know when you're getting to the end but be careful. Sometimes you know different brands of scope, different forceps or different other kind of tools. There may be a little bit of a difference so be careful when you're coming close so that you don't poke into the mucosa and cause trauma. I have seen biopsy forceps perforate in a very ill colon with IBD. So these speed bumps that are sort of or rumble strips that are built into the forceps are just a good reminder, that's a great point, that the instrument is getting close to the end of the scope and it's about to come out. So then try to target your lesion, right, where here we don't have a specific lesion to target but make sure when you're going to do a biopsy that you're actually on the lesion so that you're getting the adequate biopsy. And then again in close communication with your tech, can you please open the snare and then you push on the lesion. You want to make sure you're grabbing enough tissue as well. You may suction a little bit to bring the lesion closer to you and then close the snare. And then you pull it, bring the tissue out. You may get, you know, different, you can get two pieces of tissue if you want on a regular forceps. Sometimes the jumbo forceps may even handle more than two pieces. But this is not going to be your regular to-go forceps. So anyway, usually you take two pieces in some, you know, certain conditions like celiac disease you may want to consider taking just one bite. And then your tissue will go into formalin. Certainly biopsy, you know, the biopsy maneuver is something you'll do hundreds if not many thousands of times during GI fellowship and during your career. So again, this is a good opportunity just to hammer home short commands. Open, close. Open, close. You'll be taking a lot of bites over time. And again, this biopsy forcep, lots of different flavors of biopsy forceps. They all do about the same thing. We have pediatric biopsy forceps. Those are just a smaller caliber. They really are not associated with less bleeding or anything like that. So I don't think that that's something you have to worry about. But if you have a pediatric channel, if you're using, for example, a ultra-slim transnasal scope you may have to use a pediatric biopsy forceps because that may be all that fits through the scope. These jumbo forceps are wonderful if you're doing kind of very small polypectomy. If you need to get good samples of something, these probably take a slightly larger sample than your standard biopsy forceps. But otherwise, forceps tend to be forceps. Yeah. The other thing is you can also ask your tech, how was your sample? Did I get a good sample? Was this a good piece of tissue or do you think I should get another one? That's a great point. So always, you know, again, keep close communication. Your techs and your nurses are very helpful. They'll help you out throughout the procedure. So you want to have a good relationship with them. Again, I'll just remind folks in the audience, if you have any questions, please go ahead and throw them into the chat. We'll do our best to answer them as we go here. We're going to move on next to CLIPS. So through the scope CLIPS, wonderful, wonderful addition to the endoscopy unit. One thing I'll say, there is a caveat to that. These tend to be the most expensive. This is the biggest spend of any endoscopy unit. So I lead the endoscopy unit at Mayo Clinic in Rochester, Minnesota. This is by far the costliest device in our endoscopy unit. Not piece per piece, but in sum total, the inappropriate use of CLIPS can really be a big burden on an endoscopy practice. So be thoughtful about your use of CLIPS. You want to use them when you need them. There's no question about it. They have saved lives and are super helpful, sometimes for hemostasis, for closing perforations, and then to prevent bleeding for prophylaxis in select patients who've had mucosal resections, EMRs and ESDs and the like. CLIP function is a lot like biopsy forceps. There's two basic commands of open and close. There's the additional then command of either fire or deploy. And so most of the CLIPS that you'll be using in practice have the ability to open and close. Some of them, like this, this is the resolution 360 CLIP from Boston Scientific, is rotatable. So you'll see, once we do open the CLIP, targeting our tissue of interest, we'll actually be able to rotate the CLIP for ideal positioning. So here's our open state. And you can rotate. Yeah, it's it. There we go. Let's see. So you kind of like need to jiggle it a little bit so that it rotates. I don't know why this one is not rotating. Making it look hard. There we go. I can see it's kind of rotating. So anyway, so depending on where your defect is or what you're treating, you may kind of move your forceps, I mean your forceps, your CLIP in the orientation that will help you close the defect or treat the vessel that you need in the best way. So let's say the lesion is right here. Then you want to open the CLIP. And then I'm actually kind of in a retroflex view, but here. So you'll bring your scope closer to the lesion. Once you're in that lesion, you can push your CLIP out. Again, you may help yourself with some suction. And then you'll ask your tech to close the CLIP. If you don't like it, you see that your lesion is not completely taken care of, that your visible vessel is actually, you know, to one side of the CLIP, you can actually reopen the CLIP and reposition. So for example, here, and let's say, oh, it was actually higher up. And I can reposition myself and close the CLIP where I intend to treat the lesion. And we can deploy the CLIP, gets deployed. And then you take the device out. You can try to help your tech by try to pointing the scope kind of on their direction to make it easier for them. Because if you're in this way, you can imagine for the tech, it's a little bit difficult to go all over you to take the device out. So in a patient where we're going to treat using a mechanical hemostatic like a CLIP, in a patient where we're going to treat with a CLIP, I'll use that CLIP to actually initiate hemostasis. So if I see that that blood vessel is still bleeding after we've closed the CLIP, I won't fire and I'll find a new position. So that's a good opportunity to cut down on your CLIP usage. Make sure that you're really picking and choosing where you fire these, that they're doing the job that they need to do. Again, be a bit of a steward for your endoscopy unit and certainly for patients. These CLIPs tend to add up. It's not impossible, but it's fairly uncommon to only use one CLIP. So once you go down the CLIP pathway, unfortunately, it means you'll probably be using a couple of them. So again, just be thoughtful when you do use these. Since we don't have any questions about CLIPs, we're going to move on to cautery therapy next I believe. You want to show the coag grasper first maybe? So we're not hooked up to use the coag grasper over our shoulder just yet, but this is something that I wanted to show you. This is basically a twist on the biopsy forceps. So this is a really neat, really neat tool. This one in particular is made available to us from Olympus. They make a great coag grasper that is basically a gentle biopsy forceps. So I'm going to put it against my jacket here. So you can see it's basically a biopsy forceps and this allows us, this does spin, it does turn very easily. And you can see here we're able to close on a lesion, provide a little bit of traction. So you're going to tent that tissue that you're treating. So I'm going to grab my coat here. So this will actually grab onto the tissue if we have a visible vessel or a little spurting vessel. We can actually grab it, tent that away, and then we'll stand on our coag pedal. So that's the blue pedal with your electrosurgical generator. And apply therapy. You'll see some bubbling. There's essentially desiccation of tissue with coagulation energy. So the tissue is dried out, it'll boil, and that tissue dries out and that's what coagulates and stops bleeding vessels. So this is a wonderful tool, particularly in third space, advanced resection, but is also a great just day-to-day bleed team tool. So if you're responding to a GI bleeder and it's a forest 1A vessel and you can see spurting blood from a visible vessel, this is a great tool. It's kind of like a sniper rifle. This really allows you to hone in on one particular area and apply treatment just to that one area. So that's compared to some of the other technologies we're going to look at.

endoscopy techniques

Bioskills Lab

mucosal resection

biopsy forceps

coag grasper