While we're waiting for folks to type questions, if you have any, we're going to move on to banding. So setting up a banding kit is important. There's a really good chance that the first couple of times you do banding you're going to be in your endoscopy unit, very comfortable. It's going to be for variceal screening or surveillance, maybe variceal banding follow-up from a former inpatient who started their variceal eradication therapy as an inpatient. And so you're going to be in this situation where your nursing team, your tech team may actually be setting this up for you in the room. I would encourage you to go through the practice of doing this yourself. So like with almost everything in endoscopy, if you're not hands-on scope, particularly in this first year of fellowship, ask to be the technician. Ask to be the person who's running the equipment. I think it's really valuable to know how to use these devices can be an important thing. I think if you understand how to use these things, particularly banding, right, you get called in in the middle of the night. And so it can be very valuable to know how to use these devices. Sometimes you may have a new tech and it may become handy that you also know how to set up your tools. So remember when you're setting this up, you should get your cap out. You'll see the end of the device when it hooks to the scope. You can see there's like a metal portion to it. So that goes directly into your, unless this is different. I use a different kind of bender. Yeah, so there are different varieties and actually they're historically the Cook six shooter is kind of the go-to. That's what we use in our endoscopy unit. Boston Scientific has a wonderful device that we're using here today. There are a couple other companies, particularly because bands are often latex bands, we have to have latex free options as well. And so that's where we've seen some different options kind of come to the forefront. So you want to make sure you're tied in this to your scope and it's secure. You don't want this, you know, floating around. So here we have the end cap. This is the portion of the device that has our bands. We're gonna pull some tension so we're slowly reeling in our device and this again it will work and look slightly different. Just spend some time with your endoscopy technician, make friends with your staff in endoscopy. They're gonna be the ones who actually owe huge thanks, so we'll slow down here, huge thanks to the nurses at all the institutions where I train because that's where you're gonna learn to do a lot of this stuff. If you wash lens, does that clear up for you? I was gonna, here, so I don't, and be careful, you don't want to tighten this too much to the point that I'm gonna fire a band into someone's eye. Yeah. So just be very careful when you're tightening your bander. So again, have some confidence. This is an important thing to learn in the endoscopy unit while you're calm and having a nice calm day rather than at, you know, midnight or 2 in the morning when you're called in for an acute esophageal bleed, variceal bleed. So once this is set up, we have our device on the end. Keep in mind, this is gonna change the way you intubate, so the length of your scope is now a bit longer. Fortunately, you can see everything happening in front of you, so we're gonna actually see, making the turn through the hypopharynx, through the upper esophageal sphincter, and down into the stomach. One thing I caution my fellows routinely is not to suction. So if there's lots of clots in the esophagus and stomach, I try to blow CO2 ahead of us, keep all of that out of your scope channel. The wire or string or rope which runs through the channel can actually get clogged up more easily when you try and suction those clots. So do your cleaning first, your exam first. Once you've set up the banding kit, your only goal is to get down and do some banding, is my opinion. So I leave this in a ready-to-go firing mode, and our goal is to get down to the stomach and then get back up to the esophagus where we're gonna place our bands. We are actually gonna place one or two bands first off here in the stomach, just to create little polyps for us to show our next skill. But this is the basic mechanism. You could imagine this little red spot maybe as a nipple sign or a red whale that we're seeing in the esophagus. Those are two different things, by the way. But imagine we see a lesion here. This is a varix. We're gonna go ahead and apply suction. Now I will caution you, if it wasn't bleeding, it's very possible that it will start bleeding. So be ready. Don't jump. The most important thing and the worst thing really you could do is to let go of a varix after you started sucking it into the channel if it starts bleeding. You don't want to lose that opportunity. You don't want to do test suctions to see if it's the right time or place. And then you stay on your suction. You can hear maybe the squealing in the room. That's us staying on suction, letting the tissue come in maximally. Once we're sure that we've gotten as much tissue as possible into that end cap, we can go ahead and fire our band. And you can see here we've created a polyp for our next skill, but this is the general principle and what it will look like. More purplish, potentially a little bloody after variceal banding. Yeah, so we'll place another one just so that again you guys see how this works. One thing I'll point out, this is a good opportunity for that. If you are perfectly perpendicular to the wall at which you're suctioning, especially in the esophagus, you'll actually tent the wall away from you and you won't be able to draw in tissue. So I like to keep my scope, the wheels unlocked, fairly loose and I just tilt towards the area that I want to suction in and band rather than looking directly at it. If you're looking directly at it, it may be hard to get that tissue to come in and get a meaningful banding effect. And you always want to start the lowest you can, so closer to the GE junction. That's right. Pathophysiology of varices, it's blood coming from below trying to find a bypass. We're going to start as low as possible, just above the GE junction, just above the Z line, proximal to the Z line. We'll start our bandings and I'd like to keep them as tight as possible. Again, I want to get all of those, usually or typically, four columns of varices as low as possible in the esophagus and then we'll go from there. You'll see that the color of the band is going to change. So this particular banding system has seven bands and your next-to-last band is going to have a different color which allows us to know that we're about out of bands. There is no law that you can only use one banding kit per patient, so if need be, you can add a second banding kit, come out, install a new one. You can see that white band here is our indicator that we are at our next-to-last band, so there would be one blue band after that white band. And again, when you take the scope out, just be careful with not firing because these can hurt someone. They jump, yeah, if you're not wearing glasses like me. I should be wearing goggles in the endoscopy unit, no question about it. So that's our banding kit and then usually at the end you have to fire all of the bands. I just go ahead and fire them, so we'll show you they are a little jumpy but I'm just gonna fire them here into this into this towel. You can see they've got some some energy when they leave. Great. Thank you. All right. Any questions about banding? Wonderful. So we're gonna go down now and probably the next most common skill set that you'll use in GI fellowship will be polypectomy. So we have a one of my favorite just cold snares here. This is the Legion Hunter from Microtech. It is a purely just single wire night and all snare, very thin, fine snare for grabbing tissue and performing a cold polypectomy. Advantages of cold polypectomy, it's kind of a story that's being told over the last couple of years, where we used to use a lot of electrocautery to cut through tissue. Using cautery in particular resulted in more delayed bleeding. You get coagulation of the blood vessels and there's no bleeding acutely but then as that coagulum or S-jar falls off there can be some delayed bleeding, particularly in the age of DOACs and a lot of anticoagulation being used for patients with atrial fibrillation and otherwise. We see more delayed bleeding today. That's probably been a big part of the story why we've shifted towards cold snaring. So I feel like every year there's a new publication saying that up to 10 millimeters, up to 20 millimeters, up to 30 millimeters. So there are benefits to cold snaring and even cold piecemeal EMR probably well beyond what we're doing routinely now. So what you'll see here, we're gonna pass this snare. It also opens very much like a biopsy forcep. So this is an open-close mechanism. So here we're open. You can see the snare up on the kind of top center of the screen and there's the snare closed. Again, as with any of our other tools, we want to pass it into the endoscope in a closed position. And then from positioning wise, oh I think they have a question. Oh yeah, so when you, so yeah, so here I made it a little bit different. So I went kind of tangential just to make, just because the tissue is different. So question is, can you repeat how we should orient the scope when placing a band on a varix? And I think, you know, the way I think about it is if you're looking down the tube of the esophagus, I'm gonna orient myself just slightly, so maybe 45 degrees off-center in order to orient myself towards the area that I want to suction in, but I don't want to be directly looking at it. So if I went 90 degrees from that tube, I would essentially be tenting or holding the esophagus, not allowing that tissue to come into my end cap. So let's say, so if the varix is down here at 6 o'clock, you want to be kind of tangential so that you can suction and bring that tissue. You don't want to be directly on top of it like this. Obviously I cannot show it very well here, but anyway, you don't want to be completely 90 degrees on top of the lesion because then you may kind of push on the lesion and not help you bring that lesion in. So we can throw the cap back on and just reiterate that point, but that's a good question. Yeah, the reason why I was looking 90 degrees is I was in the stomach, so it was just in a different area. But yeah, you should be not directly on top of it, otherwise you'll have difficulty bringing the tissue. And then, so when you're doing polypectomy, you always want to try to bring your lesion to 6 o'clock. Your channel is at 5 o'clock, so that's the best location for you to remove a polyp. So that way, sometimes you may need help, for example, here to hold the scope with my pinky so that I can use my right hand freely to manage the snare. And this is not easy at all to learn. The polypectomy curve, it's actually a long curve. So I would encourage you to try to, you know, again, try to go as much endoscopy as you can, even if it's upper endoscopy, colonoscopy. Every single maneuver will help you at the end of the day to, you know, improve your skills with the scope. It's so true. You know, I think of APC, it's a very, the argon plasma coagulation we were doing before, it really requires very fine tip control. So that's one of my tests I have my fellows do. They need to be able to continuously paint an area with APC before we move into sphincterotomy and cannulation for ERCP. So having tip control, fine tip control, very important for some of these more advanced maneuvers, including polypectomy, which we'll show you here. Yeah. And same thing, you want the lesion close to you. You don't want to be working on the lesion back there where, you know, I can't even see what I'm doing. I don't know if I'm taking the whole polyp out. So you want to make sure that you're close by to your lesion. Try to work the snare around it. Ideally, you should have one to two millimeters of, you know, healthy tissue around it to make sure that you're taking the polyp completely and you're not leaving any residual tissue. So one of the techniques is you actually push your scope tip so that you get closer to the lesion and then you close the snare as instead of like, you can also push the snare, but you know, sometimes it might push the lesion away or make it harder. So if you can push the scope a little bit and then push on your snare and then you can ask your tech to start closing. And then this is going to be a cold snare. So once your tech is, you know, tight on the snare, then you can instruct your tech to cut through the polyp. We broke the snare. Really? I guess so. Maybe the tissue is too... So we have thick, cold porcine tissue here. So we're going to try another snare for you. That's not a typical performance of that snare. Let's see what we have. Let's see. This is this one, maybe. Perfect. Braided. So this braided snare is also a great option, a little, little grippy. So the braid of the wire can also sometimes help if you're slipping over polyps, you might move to a braided or spiral type snare. Can you close the snare for me? We also might have gotten the band. I'm not sure. Yeah, I'm going to go above the band maybe this time and see. Otherwise, I may grab the wire too. But Daniela showed excellent technique kind of hubbing the kind of crotch or bottom part of the snare down at the base of the polyp, making sure that you're getting all the tissue you need and not a lot more. So you don't want a lot of extra tissue. I'll try to stay above the, yep, you can close. Okay, if you feel like you're tugged, you can cut. Hopefully, we'll go through. So the downside to cold polypectomy is then, you know, sometimes it does take a little bit longer. And then some snares, this one, for example, was built to use an electrosurgical generator or electrocautery. You can see by the plug here. Sometimes you'll have a little more tissue than can be done with a cold snare. Certain snares like the one we were using first were designed for cold snare polypectomy as a nice thin wire really made for cutting through tissue. I suspect we got hung up on the band. And that may have caused the breakage of the snare. But here you can see we're closing and we might do a couple of continuous closes like this to try and cut through. Again, the fact of the matter is sometimes with cold and it's not dry yet, but partially dried tissue, it can be a little hard to work our way through. But these are the basic and mechanics of polypectomy. Really important point you made about keeping it at six o'clock, really positioning yourself for maximal success, and for visualization of your polypectomy, which is important. And then on the other hand, this actually may happen in real, like in humans, in which the snare may get maybe too much tissue and you're not able to cut through it. So sometimes, you know, opening the snare, closing the snare can help you. You know, not completely removing the snare out because then you'll have difficulty noticing where the margins are. But just opening and, you know, moving it a little bit may sometimes help you reorientate a little bit the tissue, release the muscularies from below you, and then you can kind of cut through it. So sometimes, you know, if muscle is through it, which is very difficult really to get that with a cold snare, but if that's the situation, just by opening and closing, sometimes it releases that muscle tissue and it can help you go through the mucosa. Here, it's just the nature of the tissue. It's just that the porcine stomach is thicker than the human. Let's see if we have another snare here. The other one is too big. It's like, there's a 30 millimeter one. This may be good. Let me see if I can get this out of there. Move it this way. So we'll work on freeing up our snare from the tissue here. There you go. We'll try another snare, see if we can achieve a polypectomy. And then we'll show one of our tools, which is used for foreign body retrieval, including polyp removal. This may be good, have to be real. Okay. Another nice thing about snares, I heard Dr. Jaju mentioned this, I think it was yesterday during the didactics, is that snares are predetermined sizes. So you'll see printed on the packaging, you know, pretty clearly there's a, right here there's a description just showing the size of the snare. So this is a 13 millimeter, when open diameter snare. That allows you to start to develop an eye and really an eye for judging size of things. So the polyp size, we're often very far off, you know, from reality. So knowing that this is a 13 millimeter snare, we might say that this polyp makes it about halfway across the snare. So maybe this is about a six millimeter polyp. That would also make sense because a 10 millimeter snare that we started with made it over the top of this polyp with no issues. So it must be smaller than 10. I think my, close will be, I think we may be on top of the band. So let me open a little bit. Let's see if we can, yeah. There we go. See if we cut through here. I think it's just the stomach, the porcine stomach is just so thick. Yeah. If you pull, will it? Let me see. So this is something I don't typically do in clinical practice is to pull the snare and use that to help cut the polyp. I think we're going to try to do that here just to see if we can pull ourselves through this tissue. Still tight, huh? It's pretty hard, yeah. Our electro-surgical generator in the room is not set up for polypectomy. So we probably won't be able to use assistance from that. I was not able to go through, but actually felt something, but no. No problem. So we'll move on to the Rothnett and we'll just give you a sense for how that device works. Push my scope. Yep, you're right. It's like almost there, but. Let me see if I can rotate this a little bit. Anytime you're doing cold snaring and you find you're really having trouble working your way through that tissue, that can be a sign that you do have the muscularis. So while it's very uncommon, that is possible. And so I always think twice, potentially go for a little less tissue to work our way through the mucosa. I'm going to open the snare here. We'll try and work our way off of this polyp we created with the banding kit. While we are working on that, I'll show you, there are different variations on the Rothnett. Dr. Roth, I understand, still lives in California. This is a neat device that he invented. There are now other companies making other versions of his original Rothnett device, but this is a rotatable tool that allows us to capture foreign bodies. So it's essentially a snare, a large snare, you can see here, that has a fine mesh work net that's built into the snare. And so when we close this over polyp tissue, so you can place this, for example, onto a resected polyp tissue, and then we can close. It's like really stuck, stuck. Can actually close this device onto that polyp tissue. So it'll grab foreign bodies. Certainly have colleagues who use this for foreign body removal from the esophagus with food impactions. I personally think that's a mess, and I prefer to push the food into the stomach in almost all cases. But if, again, try what you're attending wants to do. If removing something piece by piece is the goal, this is a great way also to retrieve tissue. That's important for determining the histology or type of lesion that you've removed from the GI tract has important implications for when your patient needs to come back and see you and follow up for a follow-up procedure. So capturing your histology pieces, your polyp pieces is important. If you're using a biopsy forcep, obviously the tissue comes out with you with the biopsy. If you're using a snare, you need to capture that tissue. So it either is done with something like this, a snare net, or if it's small enough tissue to fit through the biopsy channel, you'll actually place a trap on your suction that's gonna be on the processor behind you. And that trap is designed to help capture the tissue as it comes through your suction system before it enters the container or evacuation system at the wall. So again, you can imagine a collection of maybe it's a patient with FAP and they have many multiple polyps in the stomach here. We've resected multiple of them and they're too big or there's too many for us to be able to suction through the channel. You want to be careful. There have been case reports of removing lesions or multiple lesions through the esophagus causing a perforation at the GE junction. You want to be careful not to grab too much of that tissue if you really do have a massive collection. But if we have a modest two or three one centimeter polyps here, we could capture them placing the snare over top of them. They tend to collect in the fundus or if the patient's, you know, left side down over here in the left side of the stomach due to gravity and you can capture them in the net and it'll look something like this with tissue kind of poking through the side holes. And then you'll bring that up to your scope and then you'll bring the mouth both together. This is an important technique for endoscopists to learn. You want to go ahead and describe? So when you have the tissue you bring it the closest you can to your scope and then before you go out you actually grasp it with your, you know, your pinky. I usually use two or three fingers to keep it tight so that you don't lose or, you know, cause any damage. So you just bring it carefully back. So for GI stent removal, for foreign body removal, certainly for tissue removal, this is a common technique where you'll pinch that catheter with your left hand holding it to your hand so that you are removing it without leaving the catheter far behind. This allows you to ride the CO2 to insufflate and really distend the esophagus as you pull that bolus out so that you're not causing any trauma. Great. I think one of the last devices that I see on the table that we'd like to show you is the I thought we had a raptor forceps. Oh, let me see. But actually I see mostly clips. Since we don't have a raptor or large grasping forceps, we'll go back with the banding kit and just demonstrate for whoever asked that question. Great question about how they position their scope in the esophagus for esophageal banding and we'll do a little demonstration there to wrap things up. You see the cat? Okay. So this smart banding kit is what we use for patients with a latex allergy in our hospital system. This is just an alternative device to the one we showed you, the Boston Scientific latex-free device. The Cook Bander, which we use for most of our patients, does have latex bands. So important to note allergies before you go ahead with those procedures. We're just going to go ahead and place the cap on here. And I'm going to do it on the esophagus this time. So important to note on endoscopy here, you can see the strings are right in our face. This is why we're intentional about placing those out of the way. So here we're just simulating how we would perform variceal ligation. So we'll excuse them being in the way, but that's something before intubating we would have made sure to get that out of our way. Here we're looking down the barrel of the esophagus. You can see things opened up. So we just made it to the stomach and again, it can be pretty dramatic when there's bleeding. So you want to try and mark those landmarks, know where the esophagus transitions to the stomach so that when you go down and maybe start bleeding during the banding portion of the procedure, you know what your landmarks are. You can do the banding a little bit blind. So let's imagine this bump up here at 12 o'clock is one of our varices. So you can see we're looking just slightly towards the varix. And this is where we would go ahead and maybe even slightly less you could probably look. Yeah, even like this so that there's just a glimpse of the opening or lumen of the esophagus down below. Here we're going to apply suction and we'll see how we get tissue. You can see you let it in. Another trick if tissue isn't coming in is to let your big wheel go all together. So to stay on suction and go ahead and let go of the big wheel and that'll usually again cause your scope to relax. You're not looking at the scope perpendicular at the esophagus perpendicularly and that'll allow that tissue to kind of relax and come into the scope. You can fire your band and that's how we would do our esophageal banding. Not uncommon to use four, six, sometimes an additional banding kit. And I'm going to show you the difference when I do it facing that 90 degree position. So you see here I'm putting a lot of pressure on the tissue. So if I suction you see the tissue has more difficulty coming in when compared when you're in this position, you know, like not a 90 degrees into the the area you want to suction but more tangential view. That's great. So you can see there's a very clear difference on on how the tissue comes into your scope into your cap. Well, thank you all so much for joining us. Thanks for your questions and good luck with your fellowship. Thank you. Thank you.

endoscopic procedures

variceal screening

esophageal banding

cold snare technique

tissue retrieval

foreign body removal

scope positioning