The first of which is APC or argon plasma coagulation. So this is probably one of my favorite tools in endoscopy. It can be used for a lot of different things to induce scarring in the GI tract. So particularly for gastroenterovascular actasia or GAVE, for tumor bleeding. So if you have a metastasis to the GI wall, any other lesion that's bleeding in the stomach esophagus or really throughout the entire GI tract, this is a great tool. Has some reasonable data for malignant bleeding as well. This is a technology that allows us to spray a plasma form of argon gas and coagulate tissue, desiccate tissue at a very predefined depth. So the beauty of this is that it's incredibly safe when used correctly. When it's not used correctly, unfortunately this becomes one of the more dangerous instruments that we use in GI endoscopy. So like we saw with the mucosal lift, the gas which is pumped through this catheter at a fixed rate that we're able to control on our electrosurgical unit, that gas can actually dissect. So if you touch with your APC catheter, the mucosa, that gas can dissect into the submucosa. It can go anywhere. One of the places it can go is to the serosal or outside of the GI gut organ and can cause a delayed perforation thereafter. So this is an important tool to know well and to use well. We love it for AVMs, so superficial lesions involving the mucosa. So AVMs, bleeding AVMs, certainly again for gave and other places where you'd like to be able to paint or have more widespread treatment, wide field treatment of coagulation therapy. And then always make sure you're on the right setting, right? So you want to make sure you're on the stomach setting. If you're in the stomach, if you're in the small bowel, you don't want to use the stomach setting because the setting is actually more aggressive. So again, you don't want to cause a perforation or any issue for the patient. So just make sure you're on the right setting. So just trying to find an open space. So here we're on an argon flow rate of 0.8 liters per minute. That's a pretty standard clinical dose. And then we're using 40 watts. We'll see how that connects. Our tissue is not living tissue, but still usually does a pretty good job of affecting the current. We'll go ahead here. So again, you don't want to be touching the mucosa, but also you don't want to be further away than 10 centimeters, I mean, 10 millimeters away from the mucosa because otherwise the effect will not conduct. And then again, be careful with your scope. You don't want to do this with the probe inside of the scope or too close to the scope so you can damage the scope. And besides that, the imaging becomes kind of black. You cannot see. So make sure that the probe is set a certain distance from your screen and that you're not touching the mucosa. So then you'll hit on the blue pedal and you'll see how these kind of... So it's a plasma form of argon gas. So it's really neat. There's an electrode in the end of the catheter that in a way kind of ignites or turns into a plasma form, the argon gas that's injected ahead of you. So a couple of things to note with APC, again, number one, never touch the mucosa. We're going to do that for you today and show you what happens when we do touch the mucosa. But this is what we're looking for, a very defined superficial treatment of the mucosa that causes ablative coagulation of that area. You are, when you are using APC, you are injecting a certain amount of this argon gas into the stomach and it is not absorbed like carbon dioxide. So you have to be mindful of your insufflation of the stomach. I'm constantly fluttering on the suction valve to bring out that gas and smoke as we're using APC, particularly with very wide field APC, it's important to manage that. We're going to go ahead here and show you why we don't want to do mucosal touch APC. And we may have to turn the energy up a little bit. I'm going to give you a little bit more juice here. So this is more of a flow rate and wattage that I would use for a bariatric procedure like a TORI or transoral revision. If you touch with this kind of energy, you can see there's a lot of energy being deposited in that one area. We may actually be able to see transmural injury just on the stomach itself here, but we'll see what we can do. So actually in a human tissue, when you do this, there's kind of like a bleb. It's actually very scary. Yeah. You can see the bleb forming. Yeah. We've got a little bit of a bleb forming. Again, in living tissue, this happens much faster and is pretty dramatic. Argon gas will fill and dissect through that submucosal space. It carries with it the electricity and treatment. And this is not meant to be that sort of a treatment. This is not a cutting tool, not something that we want to be sending out into that space. And so it's pretty easy to get a delayed perforation. When we have these issues, especially in the cecum, which is a very thin organ, very thin part of the anatomy or the duodenum, I'll often clip this area if we see that we had a submucosal injection because of mucosal touching with APC. So again, I don't want to discourage folks from using it. This is a wonderful tool. It's really effective. Again, great for AVMs, tumor bleeding, GAVE, and any other lesion that's in the superficial mucosa. Yeah. If you have this coagulative injury and you see that injection into the submucosa, you might consider placing a clip over that area that you treated just to prevent any delayed perforation or leak that could happen from that area. Some people may actually inject before doing APC in the small bowel, for example, just to give you a cushion, again, for when you use the APC and try to decrease any kind of adverse event. Some of you may be lucky enough to have hybrid APC at your facility, and that's exactly right, so that you're just getting that superficial mucosal layer. I think it's not unreasonable. Certainly some in our practice who will always inject into the submucosa before treating in the colon and small intestine just to reduce that risk of delayed perforation. And I think we have the coag grasper. We can go... No, sorry. We went already through the coag grasper. That's right. The gold probe. So gold probe is really a cornerstone treatment. I think the very, very first bleeding therapy that was available for endoscopy was a laser. Turns out that's a dangerous tool to use in any clinical setting. It's actually making a comeback for lithotripsy and some other applications in the GI tract. But soon after the laser was the gold probe. This is a bipolar device, so the electricity flows in and out of the same device. We don't have to have a pad. So while we do have our stomach here on the table padded, that's something that is not necessary with this device. So this is a great device to have for coagulation, for thermal therapy on your travel cart, your bleed team cart, because you don't need a lot of supplies. You don't have to remember much with it. I will say it has this gold foil that's wrapped around the catheter. You can see it there, kind of like a candy cane. And then that gold actually extends out to the tip. So it's hard to see here, but you can use any portion of that gold leaf in order to cause a treatment. So you can push the catheter up against a lesion. And sorry for us jumping around. You can push it up or you can lay the catheter against a lesion and cause a nice treatment. Another little trick, this is off-label and not specifically what the device was intended for, but I'll sometimes use this as a water pick. So if we have like a stool impaction or a bezoar in the stomach that we're having trouble breaking up, you can actually hook your foot pedal up to this, turn it all the way up high, and then use this as a really fine water jet to help break up foreign debris and foreign bodies. Again, using this, fairly straightforward. It's going to be your blue pedal again. Curious what you think. Standing on something for eight seconds feels like forever. It does feel forever. For the most part, people underuse this device and they probably don't treat for as long as they should. So this is something where you have to really be intentional about counting out all of your eight Mississippis, sometimes even more. Like with the clip, where I like to see that as I close, I've achieved complete hemostasis if I'm targeting something that's actively bleeding. With this device, I also like to see total hemostasis when I'm putting pressure on that blood vessel that's bleeding. If I have hemostasis just from pressure, then I'll go ahead and stand on my blue pedal and provide those eight seconds of treatment. That's going to cause, again, coagulative necrosis, a thermal injury, and desiccation of that blood vessel that results in hemostasis. So this is a great tool. Most companies offer a bipolar cautery device. So no matter which one you're using, they all work about the same. They come in two sizes, usually seven French and 10 French. Even if I have my therapeutic channel scope, I like to use the seven French because it allows me to suction around. So definitely I have wonderful, very, very talented colleagues who will only use the 10 French device. I personally think the seven French does well in every situation. So we're not going to hook this up to energy, I don't think, today, but we'll just show you what this device looks like on endoscopy. And we'll do a simulated treatment, and it will show you, you really can, it's hard to cause issues with this device. So this is something where you're going to put a fair amount of pressure against whatever you're trying to treat. So if we imagine that there's a bleeding blood vessel kind of on the lower right side of the screen here, we're going to put a fair amount of pressure on that lesion. You can use your scope, like you can see here, we're tenting the tissue down and we're depressing the tissue pretty significantly. You want to bury your probe down into that bleeding. Once we've shown that that's going to cause the bleeding to stop, we can go ahead and apply energy. Again, this is a cornerstone, you know, bleeding treatment. And again, you want to see all of the gold kind of rings out of your scope so that you don't damage the scope. Great. Yeah. We'll take this tool out. I think that concludes the thermal therapy portion. I don't know if there's any questions in the audience about thermal therapy per se.

Argon plasma coagulation

endoscopy

GAVE

thermal therapy

complications