All right, should we set up the band together? Yeah, so what we'll do now is, those are the thermal therapies that we've demonstrated today. Obviously, send some questions in if you have it, but if not, we'll move on to the next device that we're gonna demonstrate, and that's the banding kit. So this is the Boston Scientific Band Kit, and it is attached to the end of the gastroscope, and we'll demonstrate how to do that now. And it's important to know that there are seven bands. And it also tells you how long it is, or what scope it fits over. So it's worthwhile, especially if you have a colonoscope you're using, it's worthwhile to double-check that the device you're using is long enough to go through a colonoscope. Some of them have a photograph of a stomach, so you know this is a gastroscope-length device, which is nice, 1650 millimeters, 1.6 meters or so. And you need a minimum of usually about, usually most colonoscope-length devices are about 2.3 meters on average. So looking to, and so you can look, if for some reason you wanted to do diverticular bleed or something like that with a colonoscope, this would not be long enough. So being aware of that ahead of time is important. But most of the times we're doing this for variceal bleeds in the esophagus by far. So you've cleaned off the bleeding, very calmly are in the ICU, there's blood everywhere. You're worried about the patient who's bleeding out in front of you, and you calmly open up the packaging. Take your time. There's always a little bit of panic involved. So being comfortable using this device ahead of time and not flailing is important. You don't really wanna panic. You wanna be calm and in control at all times. You're the captain of the ship when you're doing endoscopy, and you need to instill calm and confidence in everyone around you. This is our banding, our bander band. It's in a separate package. Different banding kits will work a little bit differently. The principles are the same for all of them, but the way you set up the device is a little bit different. So being comfortable with one in your unit is important. So you have a string that connects to this banding kit. There's seven bands on this. This white band is the second to last band. So it's a way to signal to you when you're almost done with bands that you might need another kit. There's a plastic wrapper around this. That's kind of, that red line is where the plastic wrapper attaches. Don't let your tech take that off until you're ready. Sometimes they'll take it off right away. There's a reason to keep it on, and that's when you're twisting to make sure you don't accidentally flip it off. There's also a black line here that lines up with your accessory port because where that string comes out, you want it to line up in such a way that it's not gonna obstruct your view. We'll show that in a little bit. There's a loop on this, and there's a loop on the tip of the wire that connects to the handle that turns. Here's our loop for that, too, on the tip there. So when we pass it down the scope channel, Stephen, do you usually leave the biopsy port cap on or do you usually take it off? I usually leave it on, but I know that there is some variability with how that's done. There's no one right way to do this. I do this way as well, largely because I feel like the stem seats better when you have that rubber to kind of secure it in place. It feels less wiggle room, and I think there's probably better seal with suction when you're trying to suction tissue in for variceal banding. I suspect that part of the reason people take it off is because historically, this biopsy port cap was reprocessed. It was something that was reused, and so if you have this thick stem going through the biopsy port cap repeatedly, it's gonna create a leak at that site. But since now everything is disposable, you don't worry about that, and so it's not essential. But there's no one right way to do it. There's more than one way to do it. I think it's just important to have a good reason why you choose one way or the other. The reason I choose it is I feel like it seats better and I feel like it seals better, but it works fine either way. So what we did there was we fed that metal wire through the channel, and it came out the end of the endoscope there, and I've pushed this banding, this apparatus into the channel and then Velcroed it on here. So it's seated well here, and then- Why don't we turn the light off? Sure. So turn the light off so that it doesn't blind you when you're putting this on or your assistant when you put it on. The next step is to tie these two loops together, and the way that's done is you put a loop through the loop. Oops, what the? Uh-oh. Trouble. There we go. Put the loop through, and I need bifocals because I can't see what I'm doing. There you go. Yes. Got it. Always pleasantly surprised when that works. And then you open up the loop on the string, and once you have that opened up, you put the band or cap through, and it ties a nice knot so that this string now is connected to this wiring on the crank on the dial for the device so that when it pulls it back, because this string is kind of looping through the bands, it'll pull back and push a band forward or release a band forward so that when you've captured tissue in this potential space between the tip of the cap and the tip of where the scope seats, you'll then be able to capture it by ligating with a rubber band. So once that is attached, I'm gonna pull back on this metal string. Resist the temptation to turn the crank here. Can we get some lube, Stephen? I usually like to put a little bit of lube on the tip before pulling it all the way back. Just so that the rubber on the, just a little bit, just so that the rubber on the cap doesn't have too much friction against the rubber on the tip of the scope, just put a little bit of lube on the tip there. And again, because that black mark matches with the biopsy port cap, I'm gonna look to where the accessory channel comes out and line it up so that when he pulls it down, it's seated on there. The next thing I think is important is to be sure it's all the way down. So I'll grab it with my fingers like this and push down with my thumb. To make sure it's all the way down. It's all, it can't move anymore. And then Stephen, before tying that down, let's put the light back on. And when you look at the endoscope view, what you'll see is that the string is coming out around seven o'clock. If you look at it on the scope view. And so, and those triangles are where the string goes back and forth through the bands. So I leave the plastic cap on in case we have to rotate it a lot so we don't inadvertently flip off rubber band. But somewhere in the kind of left lower quadrant's good. And then he's putting some tension on it so that you don't create an extra slack so that the crank goes one-to-one on the bands. And then I feed that wire through this slit in the apparatus here, and that will keep it in place. And then now I'll take off the plastic now that we're happy with its position. And we're ready to go. That's the problem with putting lube on it, is I'm not gonna use my teeth for this either. Here we go, I got it. All right, thank you. And so, you know, you wanna just be mindful when you're going through the oropharynx, the upper esophageal sphincter, that you're careful because you have this attachment on the end that's thicker than the gastroscope. So you just wanna be mindful of that when you're passing it into the esophagus. Yeah, often the catheter tip will, if you're not used to it, get hung up on the edge of the larynx. And so you wanna make sure you deflect in such a way that it doesn't hook on the larynx at all. It gets down to the piriform sinus to go down. Steven, one of the things I like to point out with banding, so if you're doing a variceal banding, are you typically banding from proximal to distal or distal to proximal? So you wanna band distal to proximal. Why is that? And the reason for that is that these veins are fed from the stomach. And so it's due to portal hypertension. And so that is backup of blood from the portal vein. And so that's being fed from the abdomen. And so as the veins come up into the esophagus, those are coming from the stomach into the esophagus. And so you want to band distally, but also once you've placed a band, you aren't able to drive the scope past that area. And so you wanna band as close to the G junction as you can initially. And in the case of gastric varices, grade one, you can band those as well. And so you wanna band distal and then work your way proximally. And often if you have a bleeding vessel that's not right at the G junction, if you band the feeding vein distal to it, it'll stop bleeding. And then you can see where the vein is disrupted. The other thing that I think I noticed when I work with different fellows is variability and awareness of what's gonna actually be captured in your bander when you suction. So for example, if you're back in the esophagus, Stephen, wouldn't mind pulling back. Yeah. If you're back in the esophagus and let's say you see a vein, sure, right, say six o'clock, five o'clock, maybe we shouldn't can suction some of that junk out of the way. When you suction tissue into your bander, I think one of the things that you wanna do from a variceal perspective is to be sure that you're deflecting towards the wall that you wish to target. Because if you're just central in the esophagus, whatever collapses first is gonna go into that cap and that potential space. You wanna deflect a little bit. So let's say if you come back a little bit, Stephen, and let's say you want 12 o'clock, you deflect up, you don't necessarily need to be on FOSS into the wall, but that plastic cap at the top of the bander is gonna inhibit tissue coming in proximal to the scope. Right, so in other words, and it's difficult in this model to get good esophageal banding, so we'll look at the stomach, but tissue distal to that cap is gonna come in preferentially. So if you had a bleeder that's right on the lip of the top of that cap and you tried suctioning, you would suction mostly tissue distal to that cap. And if that's okay, based on what you want to do, that's fine. But if you wanna capture that centrally, you'd have to pull the scope back. So keep in mind that more tissue comes distal to the tip of your cap than proximal. And so you have to start a little bit higher than you think you may need to if you wanna have it centrally captured. And the other thing is that when you do banding, you wanna make sure you have as much tissue as possible to get a redout, to get full use of that potential space between the cap and the tip of the endoscope. And so holding suction down, not letting go is critically important. And if you're not getting a lot of tissue where you're worried that the band may pop off, pulling, pushing, torquing left and right to allow more tissue to gather in, I think is a really important step to be sure. But I don't know if you've been in a situation where you've suctioned and then let go. And have you had any situations where things have bled more after that's occurred? So it's a little bit nerve wracking when you don't feel like you have enough suction in there to replace a band, and then you let go of the suction and you kind of see the mucosa there. I haven't had a situation where that's subsequently then started to bleed. I think for the most part, if there's not enough mucosa to suction into the cap, then you've kind of probably deflated the varices, distilled to that. But that is definitely something that you wanna keep in mind. Yeah, you're creating negative pressure with suctioning. So if you have a thin wall varix that you then let go of, either accidentally you forget to keep your suction on hold, or you put a band on and you don't have enough tissue and it pops off, there's a risk. I have seen that happen where you take a situation where there's not bleeding and then create bleeding. So when you start, keep going until you're ready to deploy. Don't let go of suction until that band is deployed and you're comfortable with it. Except in situations you discussed where it's just scarring and you're not worried about bleeding with letting it go. Especially your first band or two, I think it's really important. Yeah. And one thing that I'll take note of is when I've gone in before I placed the banding kit on, I take note of all the landmarks that I think that are important. So where is the GE junction? What centimeter is that at? Where is the red whale sign that I thought I really needed to target with a band? So I want to keep a mental map of where all those locations are when I go in with my scope the first time. Because sometimes as you can see on the scope here, it's not always the easiest to see when you have the banding cap on. And in the event that something starts to bleed, you know you have that mental map, you know where the GE junction is, you know where you are based on the location and the amount of scope that you have in, because a lot of times you won't be able to see. That's a great point, Stephen, thank you. So, you know, normally in the setting of a variceal bleed, this would be done in the esophagus, but just given kind of, it's a demonstration here, we'll be doing it in the stomach. And so, you know, you want to get up against the mucosa. And as we were talking about, you know, you want to kind of oppose the cap to the tissue, but, you know, you want to leave some area for that tissue to suction into that potential space. So if you're on FOS, sometimes what I've noticed helps is you can start suctioning tissue, you don't get a lot, but the moment you pull the scope back a little bit to release that tension, you get a lot of tissue in. So just being aware of the physics of what's happening with cap deflection against tissue, I think is important. Yeah. And so once you're in a position, you know, you want to, especially the first few times that you do this, the instinct is to grab for the, you know, the dials, because that's what you've been doing in all the other, you know, endoscopies that you've been doing. When you take your hand off the scope, you go to the dial to, you know, maneuver. You just want to make sure that you're going for this, the banding device and not the dials. So just something to keep in mind. And then, so you get a position, and you kind of want to try and get as much tissue as you can in there. Keeping in mind, this is usually done for bleeding. You want to, if there's any high-risk stigmata, you want to try and get that into the banding cap. And then you just, you hold down suction. You'll see tissue come into the banding cap. And when you think you have a lot of tissue, you've suctioned effectively, then you will turn this device. You will hear and feel a click, and that's indicating that the band has been deployed. And then- And you can watch on the screen, and you'll see the blue, and for this device, the blue band moved forward too. Yeah, you'll be able to see that blue kind of come around and deploy onto that mucosa. And then you just want to come back and inspect it. So here, so I'll suction up a little bit, and you can kind of adjust as needed. And I'm going to deploy a band here. And he did not let it go of suction until the band was deployed. Yeah. Be careful not- Keep that suction. Yeah. And it doesn't hurt you to keep holding it even after you've deployed the band for a little bit, just to be absolutely sure. And then carefully withdraw the scope off of it so you don't inadvertently knock it off too quickly. Although that's pretty rare to happen. So that's the banding sequence there. And then you have those, the seven bands in one kit. That sixth band is white, so you know that you have, you've used your second to last one. You have one more band. And then, you know, can demonstrate one more here. And then, and then if there's any questions, we can address that. So again, you want to get up against the tissue and suction in. Keep the suction applied and then twist. You'll hear that click. And then you slowly come off of the mucosa and you see that band has been deployed around the tissue. Very nicely done. All right. And then you inspect it and then, you know, deploy more as needed. And the, you know, you want to deploy enough, especially in variceal bleeding cases where the bands are completely deflated and those are completely eradicated. Should we snare one of these off? Or a couple of them off? Yeah, that sounds good. Here, why don't you, is there a snare over there we can use? Whichever one you want. Different snares have different characteristics, not just a- That's cool. This is cool. Let's do something hot. There's different diameters. The packaging will tell you a lot of information. We can use that one. Yeah. This is a small oval snare. It's rotatable. Although for the most part, you won't need, most of these, if you know how to manipulate a snare over a polyp or where you want it to go, you don't need to rotate it, but it has the option if you need it. It tells you details like the length is 240 centimeters, which means it's long enough to go through a colonoscope. The channel, the diameter is 2.4 millimeters. Our channel diameter is 2.8 millimeters, so there's plenty of space. The diameter laterally is 13 millimeters, not lengthwise, but laterally is 13 millimeters. So it gives you a sense of the length. The shape is oval and has a little notch tip. There's different shapes. There's hexagonal shapes. There's crescent shapes, oval. Some have a braided design. Some are monofilament. Some are stiffer. Some are softer. There's different circumstances where you may favor one over the other. In this case, I personally like for hot snare, using a little bit of a smaller snare to avoid over-capturing tissue. And so I often actually will end up using a 13 or a 15 millimeter snare, either an oval or hexagonal shape. And then this opens and closes just similarly. Open and close. Sorry, open and close. And so getting comfortable with it is helpful. It has a little notch tip. It's a little extra kind of place to kind of grab for closure around tissue. We can also use that notch to kind of deflect yourself into place. And needless to say, I think, you know, if you look at how this opens and closes, the snare goes out and it goes in. I know this sounds very obvious, but keep that in mind. Your sheath will not advance. The snare tip will go towards the sheath unless you have forward pressure on the sheath against the tissue wall, then it will advance against it. Regarding post-banding care, what is your recommendation regarding diet? NPO versus clear liquids versus soft and NG2 placement contraindicated for 72 hours. Also any recommendations for post-banding esophageal pain management? What do you think, Steven? Yeah, so I think, you know, generally these patients are intubated in the ICU, but I think, you know, if it's someone that you've just done banding on, then I'll usually have clear liquids for about a day. And you can tell the patient that sometimes there can be some pain after banding, although a lot of times that doesn't happen. So I'll usually do clear liquids, NG2, but I think at least 72 hours, you know, potentially longer if able, but you don't, especially in someone that's just had a variceal bleed, you want to be as cautious as possible. I think 72 hours is reasonable amount of time to let those scar. Any recommendations for other post-banding esophageal pain management? I think, you know, just advancing diet slowly is tolerated. You know, a lot of people will give, you know, a Meprizole or Protonix, a PPI. You know, I don't know if that will really help in terms of the pain. I think it's mainly just that you're causing ischemia to those areas. And so, you know, other avenues of pain management, you know, if these patients are in the hospital, you know, a short course of, you know, opiates, you know, limit that as much as possible, but sometimes they do have a lot of pain from this. Ever use viscous lidocaine in this setting? I don't know if I've ever used viscous lidocaine, but I think it would be, you know, reasonable to try. So going back to the, so this is a rotatable snare. So it has a little dial to rotate it if you want to. Often, you don't need to do that if you know how to manipulate a snare, but it's nice to have, nice little extra tool to have if you want it, if you need it, if this is a snare that you're using. When you're closing a snare around a polyp, you have to make sure that you remember that the laws of physics don't become suspended when you're doing endoscopy. They still apply, right? And so some things that you really want to be sure is wherever you position your snare, you want to think about where the catheter sheath is and where the tip of the snare is. And that plane between the sheath and the tip of the snare should be parallel to the plane, that's going to be the plane that you're going to cut through. So it's got to be parallel to the plane that you want to cut through. And actually, if anything, press down a little lower than the plane of the polyp to make sure you capture, not just that you actually grasp tissue instead of scraping it or going obliquely, and you want to position it so that it carries a cuff of normal tissue around the polyp because you want to think like a surgeon or you want to get an R0 where it's actually going to have no polyp left behind. You want to completely remove it. And the best way to do that is to remove normal tissue around the polyp as well. So if you're going obliquely or, you know, obliquely, or, you know, if you're just pressing and hoping for the best, you may not get the capture that you want. So often it's not just pushing or pulling the snare that gets you there. Similar to clipping or biopsy sometimes, and often for snaring especially, it's getting that scope deflection either with a scope portion or dials to get it in that plane of action that you want to do. Here, because with a bander, the plane that we're going to want to do is beneath the rubber band. And so I will have you demonstrate how to get the snare position where you want it to go. There's all sorts of tricks you can do to get the snare where you want it to go using that tip to deflect against the wall of tissue and flipping it laterally, for example, or up and down. Oh, we have to take this bander off. I'm sorry. Why don't we take the whole thing off? Take it out and we'll deploy the rest of the bands. Thank you. Okay. So again, I think a lot of lateral deflection helps you a lot more than just pushing and pulling. So having a comfort level, spending time, you know, learning how to create torsion, especially with your left hand and your body rather than your right hand, so you have your right hand free, is very, very important for any even kind of mildly interventional procedure. And Steven has a really good mastery of that and it makes it look really easy, but it takes some time to develop that skill. And where are you positioning the polyp here prior to removing it? How are you deciding where to position the polyp? So, you know, ideally when you're taking out a polyp, you want to at the six o'clock position, you know, the snare will open and you'll come down over that polyp. But unfortunately it doesn't always work out that way. But the best that you can do to get that in an ideal position so that when you open your snare, then it comes out to where that is, you know, that's the best orientation of the snare in relation to that polyp. And that's because their devices come out of the lower half of the screen as well. If you're trying to snare something in the upper half of the screen, then you're kind of going across your visual field and it makes it much more difficult to remove. But it doesn't mean that there aren't situations where you, you know, wouldn't remove a polyp at a different clock face than six o'clock. But that's the reason why we kind of make that our ideal position for polyp positioning. So I'm going to try and inflate this up a little bit. It's not holding air because you perforated it with the bipolar. That's right. That's a bad joke. Sorry. The only kind that I have. And sometimes if you're in a position and you want to keep it there, you can always lock your dials. So I might lock that my small dial on this. In this case, it just kind of removes one variable if you're if it's if you're finding yourself drifting. There might be a leak elsewhere in the stomach, to be honest with you. That may be part of part of the problem here. Sometimes when these are closed, the suture line leaks. Okay, so I'm just going to push my snare out a little bit and just see kind of what orientation my snare is going to come out and then kind of adjust accordingly. Sometimes it doesn't come out you know straight, it'll come out you know with the opened sideways to the polyp. So why don't you go ahead and open there. Opening. Okay, so you can go ahead and sometimes I'll bring that after it's open I'll bring it back into the channel. So all I have to do is when I'm in position I'll push out my snare. So we'll see about this one here. So I don't know if I'll be able to get it in you know the perfect positioning where I will be able to just kind of slowly close on it and deflect down. I think what I'll try and do is get my snare out and then have to deflect down on this polyp. And since this is a little bit more on FOSS you will likely have to push the catheter a little bit more out against the wall to get it to be parallel to the tissue. Sorry I closed a little bit. Yeah, so I think I like my positioning right now and so I as he's closing I'm going to try and push my catheter out to meet the snare as it closes around the polyp. But resist the temptation to just continue to push because you'll make it harder on yourself. So I think maybe even deflecting down a little bit Stevie make it a little bit more. Should I close? Yeah, go ahead and start. I'm going to go slow and a good tech will also kind of wash the screen. Now I don't know if I may have some rubber band here. Maybe not. I'm trying to just deflect. We're definitely underneath it here to see if yeah if there's any band. You know just to kind of see if it tends up and what Dr. Almunzer was talking about yesterday. If you want to see if that that whole tissue moves and do you have muscular is appropriate or is it just kind of that top area? Can we before cutting through can we look at the the the cautery settings? This is an Irby Vio 300d settings and we have an EMR setting. EMR settings may vary depending on the device. This is that 313 setting which is honestly came about as a result of that's the area code of Detroit. That's how I started using 313. But it also kind of mimics the old school Irby generators sphincteronomy settings which is the reason why I started doing it a long time ago. We didn't have this to start off with and it works well but there's three main numbers here with this this particular cautery setting. Three is effect three cut duration one cut interval three. Effect three cut duration one cut interval three. So when you step on a pedal you're going to hear an alternation between a high pitched beep and then kind of a lower pitch grumble. The high pitch beep is delivery of the cut high energy cut current where you'll have movement of the snare closing around the tissue. So the higher the effect the more cautery goes into that blended current in between those pulses. So the high pitch pulses is cut current and this time in between is a blended coagulative current. So if you wanted no coagulation in between cuts if you want it to be as low cautery as much as possible if that's what you wish for you would set the effect to one. Effective three has kind of a modest amount of cautery in between those cut currents. The one for cut duration is how much time is spent during that cut peak that high pitch beep. So this is pretty short if you want to have more of a traverse something that's a very fibrotic polyp like a like a thick hyperplastic gastric polyp you may want to have more energy delivered. I'm actually going to move it up to two because this is dead plate stomach and it's going to take more cutting to do this. I switch it over to cut interval and it's at three which tells you how much time there is between the pulses. So if I wanted that time between pulses to be shorter I would drop it so one is 400 milliseconds between cut pulses two is 560 milliseconds and so on. So it's set at three why don't we we can leave it at three that's fine. So we have a three two three because it's a expanded peak stomach and and and so we'll see how it goes in terms of cutting through the tissue. Okay and so with this we're going to be cutting primarily and so we're going to use that yellow pedal and so so you want to just keep that pedal down and that will apply that blended current of cut coag and count we often will count the amount of pulses that it goes through as an estimate of how much energy required to cut through tissue. So for example for an esophageal EMR if you get one to three pulses with a 313 setting again it's partly dependent on what your settings are what this actually means then we're quite confident we haven't cut muscularis propria but once you start getting to five or six pulses you're worried that you're cutting through a lot of thick tissue with a lot of resistance like the muscularis propria you may have a perforation so that's part of why we would do this so we have a nice kind of secure tight closure to minimize the amount of cutting surface there is with delivery of energy so I'll let you get going. All right so as always when you're working with someone communication is key so I usually try and just count it down and be very clear with him when I'm going to be cutting when I'm going to be applying pressure to the pedal. All right so how about on a count of three you can start to close now I'll I'll apply the current so one two three two pulses when we look at the what are we looking for at the base so we've taken it off you should really look at the base immediately what are we looking for at the base of a polyp per second typically for a lot of times when we do hot snare we'll be doing an EMR we'll be injecting not always but an EMR so with often with some blue dye as he demonstrated before so what are we looking for at the polyp base after we've done the resection so I think you're you know you're looking for a few things you don't want to see you know number one any remaining polyp tissue so you want to make sure that you've resected the entire polyp you want to look make sure that there's a nice coagulative mark in that area and then also you want to make sure that the layer underneath it that you're in you know submucosa you don't see any muscle to to suspect you know a deeper injury that's part of the benefit of of lifting with some blue dye indigo carmine or methylene blue or this o-rise is that that layer that's being injected lifted and stained with blue dye is that submucosa layer so if you look at the base and you see a nice blue dye and you're still not sure what the layers are you have some comfort that's probably submucosa if you're not sure you can actually inject into the base or adjacent to the base to see if it expands and if it expands that submucosa that's overlying the lesion if instead you see what's called a target sign where you have multiple levels leading to a a bright white spot in the center uh whether or not there's a frank hole there that's high risk for muscular appropriate injury and you really should be closing that that area and thankfully there's a lot of options to close uh any area that you suspect is at risk for delayed perforation or delayed bleeding of course as well or immediate perforation and so you know we're looking at the site here and in general after cauterization is applied for polypectomy you know we'll place a clip to prevent post-polypectomy bleeding but that is the demonstration of the of the hot snare polypectomy do you have any tips for pedunculated polyps this is a sort of a pseudo polyp we've created but this mimics what we do for sessile polyps typically what about for pedunculated polyps so you know I think with sessile polyps or with pedunculated polyps you need to assess how big you know the polyp is and you have to think about a few different things you know when you're when you're talking about a pedunculated polyp there's a feeding vessel through the base of that polyp and so that's generally why cautery is used for those pedunculated polyps and so you know what I generally like to do is to kind of go distal to the polyp open my snare and then close the snare on it as I'm kind of coming or I'm starting proximal and then kind of coming distal as I'm wrapping that snare around the pedunculated polyp and then prior to that based on how the if it's a very big polyp you know I've seen people clip the base of it before they they snare it or they sometimes inject in that area before they snare it to minimize bleeding and then you know the same principles apply as to you want to make sure that you know the the snare is taut around the polyp you're not getting any you know other mucosa in that polyp or in that snare before you apply the cautery yeah it's important to make sure that you get down far enough on the stock to create a good margin of normal tissue so the pathologist can reassure you that the margins are clear occasionally you'll find I just had a young gentleman who's 27 years old with a six centimeter pedunculated polyp that contained adenocarcinoma but I got a very very big deep stock uh and so we're very confident that uh that therapy was definitive without need for surgery or chemotherapy getting a big stock margin is really really important and you can get really close to the base uh of that of that stock uh to remove it there's a lot of wiggle room there's a lot of comfort in terms of perforation risk with pedunculated polyps the bleeding risk is the thing you worry about for larger thick stocked polyps and sometimes what I'll do is I'll put an endo loop ligating loop like a plastic kind of like a plastic tie at the base or clip it ahead of time or clip it afterwards but in general they tend to be bigger and often a little scarier they tend to be left-sided usually sigmoid but they also tend to be easier to remove with a margin because they have that stock to work with yeah I think I don't know that we have anything else for today um so I think that was an excellent demonstration of of a survey of different techniques related to endoscopy we reviewed techniques on injection clips biopsy thermotherapy with APC bipolar coagulation banding and polypectomy tips and hopefully this has been helpful to everybody I want to thank the organizers for having us be part of this course Dr. Simra I think he did an excellent job and I'm grateful to have been able to do this with you he's our current therapeutic endoscopy fellow and a real superstar so I'm glad they've been able to learn from from his skill and his experience well thank you everyone for you know tuning in today I was you know I'm honored to be here and to be a part of this thank you Dr. Paraka and all the other organizers of the event for having me here

endoscopy

banding kit

calmness and control

gastroscope attachment

polypectomy

snare placement

post-banding care