All right. Welcome everyone. Welcome back. This is the virtual hands-on demonstration. We wish we could have you here in person, but we'll do our best to relay everything that we're seeing and showing and doing in real time so that you get the maximum benefit out of this. My name is Vinay Chandrasekhar. I've been part of the first-year fellows course since 2017, so it's great to be back year after year, and it's a pleasure to be with you this afternoon. Here we have Lillian Wong, who's one of our GI fellows, and we're both at the Mayo Clinic in Rochester, Minnesota. Lillian is a third-year fellow, and she will be doing an advanced endoscopy fellowship at Beth Israel next year. Anything else you want to say? No, I'm really happy to be here. So hopefully we can give you the maximum amount of benefit and learning through this virtual modality. So thanks for coming. So we're going to work through a handful of devices and techniques today, and we're just going to kind of walk through. We have the ability for you to ask questions, so if there's something that we show that you want us to show again, or if there is something that we're not showing with the device that we have in our hand, please let us know, and we'll get that feedback, and we'll be able to demonstrate that. To start, we're going to just go in. We're just going to go ahead and get started here, so go ahead and get the scope down. We'll loop it up. We have a variety of devices here today. We've got, just to let you know, as Lillian's getting set up, we've got some biopsy cables. We've got clips. We've got snares. We have injection techniques. We have thermal therapy, including bipolar coagulation and argon-plasma coagulation, as well as banding. So we're going to try to run through all of these different techniques, and show you kind of what the participants who are here are experiencing in real time. So as we switch over to the monitor, see if you've got the endoscopy view of Lillian going down the esophagus. I'm going to go get some gloves here to help behind you. Go ahead. Keep going. So we're going to get down to the stomach, take a look around. One of the first things that we want to do as we're looking around here in the stomach is kind of get a lay of the land. So as you can see, instinctively, when there is some mucus or some debris that is on the lens of the camera, she's instinctively clearing her lens, which is holding down. If you want to show them just the technique of how you clear your lens, it's the air-water suction and holding that all the way down the bottom button here. So when she does that, you can see on the screen, you see a flush of water cleaning the lens of the camera. And then the other thing she's going to do is suction. So tap on some suction, and that will help take away some of those particles that are on the camera lens. So you take a look around, and we see we've got some unique devices here in this stomach. I don't know if someone's having a disco party or what that is, playing some basketball. So we're going to take a look around here. So to start off, one of the things I think we should do is we're going to open up a biopsy cable here. So we have... I just grabbed... I'm not trying to be promotional in any way, but just so you know what device we're using, we're using a Radial Jaw 4 from Boston Scientific, a large-capacity biopsy cable, and we're going to open that up. And one of the things that we tell folks is to really play all roles in the room. So if you're not able to scope, be the tech. If you're not able to do the maneuver, you want to try to get your hands on, try to be the nurse in the room. That way you have an understanding as to what everyone is doing in the room. And what we're going to do here, these are labeled not for human use, so they're packaged a little differently. I'm going to give you the biopsy cable. And as you can see, it naturally opens up. So we'll want to close that biopsy cable. So you'll want to make sure you close it before you run it down the channel. And what you'll see on this particular device is you'll see that there's markings. So there's markings here that will indicate in the room when you're reaching the length of the extent so that the device is about to come out the channel. That way you minimize running it through the wall of the stomach of your esophagus. So go ahead and run that down the channel. And as Lillian's doing that, she'll tell you, you know, kind of go ahead and pass it down all the way down. She'll see here, as she sees the black part, then she knows to slow down. So Lillian, I'll let you run this show. Maybe show them a couple of biopsies in the stomach, and then we'll show them how to biopsy in the esophagus. Yeah. Sounds good. Okay. So once you see the forceps come out, you want to kind of pull a little closer. You never want to biopsy from afar. You want to be as close to the scope as possible. And then I don't know if you can see that clearly there. And as you can see, the working channel comes out at 6 o'clock. And so you want to kind of position where your target is. And communication is key when you're trying to perform any intervention, talking with your tech, you know, when opening, closing, et cetera. So here, we're going to just take a biopsy of this fold, I suppose, and can open, and you advance the scope, and then you can close. And then you want to pull on the catheter in one quick motion to take that out there. And then you can see where the biopsy site is there, too. Great. You want to show them one more right next to that? Sure. So advancing. Once you see the forceps, you pull back a little bit, and you can aim open, close, and take. And you can see again right there. So that gives you a pretty good bite. And you can see, these are what we were talking about, the black marks, as they enter into the channel, they delineate when the device is about to exit from the channel. That way, you don't run the device down too fast into the wall of the stomach or into a defect that you weren't anticipating. So what we'll do is we'll take this out, and then she'll come back into the esophagus, and then demonstrate a technique of how to biopsy in the esophagus. So the esophagus, as you know, is a very narrow organ, and you want to be careful not to cause any injury or perforation with that. And then so what the technique for biopsying in the esophagus is a little bit different than in the stomach. And so again, you're advancing the forceps, watching the screen until you see the forceps come out. And sometimes you can feel that resistance a little bit too, so you know when you're coming closer to the forceps coming out of the scope. You want to keep your lumen in the center at all times. And as she's passing that down, I'm just making sure that my hands are closed so that it doesn't open up in the channel. And so you want to be careful, you don't want to shoot through, otherwise you can cause some perforation injury. You want to bring the scope back a little bit. And so with biopsying in the esophagus, you want to have the forceps as close to the scope as possible, and you want to have good bites. And so here you can push out the forceps, open it a little bit, and then pull back so it's closer, and then you use your small, your dials to look up or down, and then once you have it kind of perpendicular to the tissue, you push out, you can suction a little bit, and then close, and you can see what tissue that you've gotten, and then again pull back, and then that's how you take a biopsy in the esophagus. So that was an excellent technique. Can you show them how, if you just biopsy and you don't use that technique, what it looks like here? Sure. So this is what we're going to show you what not to do. So when we open it, so you just basically push it out, and then open, and then you put in, don't turn for a minute, just turn like, you know, like there, okay? So if you're here, and this is what, this is a common mistake that people make early in their, in their training, then you biopsy here, you see you're getting a very superficial bite here. You see that? It's a very small bite, whereas if she were to take the technique, she'd just take that same area that I'm just looking at there, and then you're going to take a look down. Yep. Yep. And suction. And you suction here. It's important to suction, to draw up the folds of the esophagus, and then close. And there it bounced off. You got to get it closer. Yeah, exactly. Now turn into it. Yep. You want to keep that back. Turn into it. Look down. All the way down. Yep. Perfect. And then use your suction, and then about push it out slowly, and then close. You can see, you get a better bite. It's still bouncing off the tissue there, but you can see how you're getting more perpendicular, which is actually much better than getting a tangential bite. There you go. Yep. And it's really kind of driving it in there. Okay. And then close. Now that's a good, really good bite. In the esophagus, it's very difficult to get, go ahead and take that bite, it's very difficult to get a good bite unless you exhibit that technique. So again, this is really true for any thin tubular structures, whether it's in the esophagus or if you're in the colon, and it's very thin and tubular. So you're getting really good bites of tissue here from our porcine model. This is what you need. If you get really kind of scanty tissue, you'll have some inadequate specimens when you send it to pathology. So that's kind of biopsies in a nutshell. Not the most exciting topic, but actually fundamental to what we do in GI. So now that we're all starting off on that level playing field, we'll go ahead and move on to other devices, unless people have questions about biopsy cables. So next, what we're going to do is, I've got some devices here. Go ahead back down to the stomach, perfect. And we're just going to walk through some of these things. I don't know if I necessarily have all the equipment, but I think I should. The next thing we're going to do is we're going to inject. So again, here we have an injector needle. There are a variety of injection needles. And this needle is a Boston Scientific Interject Clear. Every packaging should tell you on the package, the size of the device, the length, and what's the minimum channel that's required. So here you can see this is 240 centimeters in length. What that means is that that can go through both an upper endoscope and a colonoscope. It's a 23 gauge. The minimum channel diameter, it's about 0.6 millimeters. And so it can go down basically any device that you have. It does say the minimum working channel is 2.8 millimeters, which is about the length of the working channel of a standard diagnostic upper endoscope. On any device, it'll tell you, if you look closely enough, the length, the minimum working channel that you need. So go ahead and pass that down. So Lillian's going to demonstrate the technique for injection. And what I will do is I will draw up some saline here. Now injections commonly used, now Lillian, when have you used injection? What have you used injection for? Basically for lifting up polyps to have a better margin. You can also use injection to place a tattoo if there's a difficult polyp, or you can only respect to piece limiting in sections rather than on block on one big section. Those are the two main things that I've used them so far in fellowship for. Yeah. So those are the common things. So tattoo, injecting epinephrine into a bleeding vessel to help stop bleeding, tamponade. We also often inject for, as you mentioned, for polypectomy, for flat polyps or laterally spreading granulomas or adenomas where you can't see the margins very well. And so injecting a little bit of a saline cushion into the submucosal space, tinted with some dye, either indigo carmine, methylene blue, that will help delineate the margins of the polyp so you can better see it. And so what you see here is that she's advanced the injector needle to where she wants it to be. Now I'm going to walk you through a few things here. So I just pulled out many of these things, especially when you're talking about needles, they have safety devices. So this came up with a clamp, so you have to remember to remove this clamp, otherwise the needle won't work. And remember when you are the physician with the device in the channel, you are in control of that device. Even though someone else may have it physically in their hands, you are responsible for that device. So as you can now see on the endoscopic view, when Lillian has where she wants it to be, she is going to be the one telling me when to open and when to close. So what we'll do is we'll have her tell me when she's in a position to open and close, and I will show you, I will demonstrate that technique here. So we'll show you both the endoscopic screen and what we're doing with the hands. So I suppose we can try to inject anywhere, I suppose here, lift up this flat area. So what she's going to say to clearly communicate that is, what are you going to say? Needle out. Yep, needle out. Right, perfect. So my job then at that time is to advance the needle. And in this particular device, you advance the needle by pushing the device in, okay? I turn it to lock it into place. Now the needle doesn't move. I can't pull it in and out. So when she says needle out, I basically push this into place and spin it and lock it. Now it's locked, okay? The needle is out. Sounds good. And then when you inject, you want it kind of in a tangential angle and a rapid jerk as well. So maybe I can see that very well. There you go. Perfect. And then rapid jerk and then inject. So you can see I'm injecting now in the pig stomach. This is, you probably wanna be in a different location so people can see where we are. So I'm gonna just pull this back. Okay, now a couple of things. Number one, you don't wanna be perpendicular. Number two, there's multiple different techniques for injection. And we'll walk you through some of these techniques right now. So the best technique is what Lillian's demonstrating right now. So go ahead and tell me whenever you're ready and I'll go ahead and do it. Needle out, please. Needle out. Thank you. You wanna pull that needle back a little bit and then drive it in. Yeah. Okay. Now, and then, or you're not in yet. The pig stomach is really tough. So you gotta push it in more. Push your scope in, yeah. There you go, good. Okay. And then inject. Okay. It's still not. No, it's coming out, hold on. So what you need to do, I think, is get really close. Yep, now look down. Yep. Beautiful. This is kind of not exactly how the human stomach is. It's a lot easier. It's more supple. But now you can see. Go ahead and plunge it a little bit more. Plunge it. There you go. Inject. There you go. So what she's demonstrating is we're injecting saline to find that semi-costal space. And- It's coming out. It's really tough here. You can't stop, yeah. Let me take a look. Yeah. Let me see if I can help you out with this. I think if it's been out for a while. Well, yeah, no, it's, here, why don't you hold this? We'll reverse roles here. Let's see if I can get a more thinner walled area and say needle out. You go out. And then what I'd like to do in this particular sit, is maybe go a little bit more perpendicular. Just for this model. You don't want to go terribly perpendicular. And now I pull back just a little bit and inject. I don't think you have any more saline in here. Okay, good. I pulled back because I thought you were out. You can just fill it up. I don't think there's any saline in here. It's just air. You can fill it up. Okay. All right. I got it. Take the syringe off and you can fill it up. So I'll demonstrate that technique again. So while we're filling up the saline here. So I'm going to go in, look left, get really almost perpendicular to the tissue and advance. Now, one of the things that people, the way you're supposed to do a tattoo, the way it's indicated is you inject with saline first. Okay. And inject. Injecting. Okay. And you can see that same thing's happening to me here with this model. But what happens is what you do this and you find, there you go. I'm about to get a blood there. Go ahead. Injecting. Yep. So you see it starting to lift there. You see that? So stop there. Stopping. Stop with, when you inject like this with saline, now you know you've found your submucosal plane. So there's the mucosa, submucosa, muscular is propria. Then you've got the serosa adventitia. So once you found that submucosal plane, then you switch this syringe for the injectate. So you would take this off and put tattoo in there and then inject and inject tattoo. Then you know you're fully in the submucosal plane. Okay. So go ahead and inject. And you're delivering that tattoo into the submucosal space. Injecting now. Go ahead and inject. The other thing you can do is what I just did. And I don't know if you saw that because we had, we struggled for a little bit is you plunge and then you pull back to the submucosal space. Okay. The reason is, go ahead and stop injecting. Needle back. Stop injecting. The reason is because if you put the needle out, you see this needle, it doesn't look very long, but that is enough to puncture through all the wall layers in certain tissue structures, particularly the small bowel, the duodenum, maybe even the right wall of the colon. You can puncture right through. And so when you intend to inject and get a submucosal lift, you may actually get a, inject the peritoneum or retroperitoneum. So you want to make sure that you're in the submucosal space, which is why those techniques that we just highlighted are important. So you inject, you basically plunge. And if you've gone too far, you pull back a little bit into the submucosal space. The other thing you could potentially do, it's not a favorite technique, but it's something you can do, especially in thin walled structures, is you can ask your technician or your nurse to go ahead and inject while I'm still in the mucosa. So go ahead and inject. Injecting. And then as they're injecting continuously, you then advance it into the submucosa. And when you see a submucosal lift, you know you're in the submucosal space. So these are different techniques. It's not really working out here with this model, but these are different techniques that you can use to help inject into the submucosa and know where you are. Okay? All right, go ahead and take the needle back. Needle in. I'm going to take this back from you. Got it. So in summary, when you're injecting, you can inject first with saline to make sure you're in the submucosal space. Number two, you can put the needle out in the mucosa and inject as you're advancing the needle. Number three, once you've gained some familiarity with depth and feel and the way it's supposed to feel, you can plunge the needle in and then back away till you reach the submucosal space and then inject. Most people do that third option, but if you look at the way it's really intended for tattooing and you want really focal delivery of the agent, you're supposed to inject a saline bleb and then fill that bleb with whatever agent you want to then inject. Any other comments about injections in general? I think you covered everything. Okay. All right, so now we're going to move on. We've got, I asked for some other stuff to be in here that wasn't in here, so we're going to play around with some other things here. Let's do, I think next on everyone's list, let's do some clipping, okay? So here I have a very common clip that you may see. This is a Boston Scientific Resolution 360. Again, on this, it will tell you the length, 235, so this clip can work both for upper and lower endoscopes and colonoscopes. And then the working channel, minimum working channel is 2.8 millimeters. Again, you should know what your working channel is for your scope, because 2.8 millimeters is the channel size for a diagnostic gastroscope. So we're going to open this up, and we're going to place a clip. So why don't you go ahead and find an area here that you want to selectively target. As you're opening up the device, all of these devices are really constrained in their packaging, so you want to make sure you don't whip people that are around you. So you want to kind of slowly unfurl the device. And that way, you want it to be as straight as possible, so that when your endoscopist is passing it down the channel, they have the maximum reflex with the one-to-one motion with opening and closing. It articulates the way it's supposed to. If you have large loops or kinks in this, it will be less likely to be as responsive. So I'm going to give you this clip. And what Dr. Wang's going to do is she's going to pass that clip down, and my job is to just make sure that we don't open the clip in the middle of the channel. We don't want to, again, disrupt the channel, injure the channel as we're passing it down, or damage the clip on its way down. Some clips may have a sheet, others don't. This one did not come with a sheet. And what she's going to do, you can already see her instinctively turning it. So what we'll do is say, let's just demonstrate how this works, okay? So if you want me to open. Yep, open. Okay. Now what you can do, now before you do anything, I want to demonstrate, if you don't like it, suppose it opened up like that, and you want it more in a different configuration. How do you tell your nurse or tech how you want the clip positioned? Yeah, so you can use the faces of a clock, and say, for example, nine and three o'clock, they know what you're looking for, or by degrees. I like the faces of the clock, because it's pretty universal. Yeah, so I agree with that. A clock face, I think, is the most clear and succinct way of telling your nurse or tech the position of the clip. If you say things like horizontal, vertical, people should know it, but in a situation where you're dealing with bleeding, and you need to clip on right away, just being as clear and concise as possible is important. So as she has informed me, she wants it nine and three. To rotate this, there's two ways. She can rotate this herself here, or even better, this device has a rotating mechanism here that allows me to have one-to-one motion. Now if it's really kind of bent, it may helicopter, meaning it may spin very fast, but for rotations, it'll often go one-to-one here with that movement. The other thing I want to show you is, as you have it on nine-to-three like this, watch as the clip closes, what happens. So if you stay still, and I close the clip, look what's happening. The clip is shortening. So as you close, the clip is being drawn back into the sheath and shortening. So you have to be aware of that as you're deploying clips, because you may think you have the area of interest, but all of a sudden the clip has shrunk in a sense, and it's closed, and it's not on the target tissue. So why don't you go ahead and get to an area that you want to clip, and then we can talk about what you're going through and what you're thinking about. So any of those folds that you had right in front of you are fine. I like this one. Okay. Okay. So what are you gonna do? So you want to make sure it's open and kind of anchored on one side of the fold, and then you can make it, this one you want more perpendicular as much as possible. So here I'm just looking down a little bit more, and then you can have, communicate with your tech to close. So I'm gonna close, and what she's doing instinctively is as I close, you see her hand is pushing that device out a little bit further. So she's instinctively pushing that clip out a millimeter or so, because she knows that that clip is going to retract. So you have to accommodate for that. So a couple of things that I like to tell people is I'm gonna open back up, is number one, and some other things that you did instinctively, but we should articulate them is go ahead and go back to that area. Okay. Now you found this area. She's got a really good purchase. So she doesn't really need to do anything, but what she can do is suction, tap on the suction, draw up the fold so that you get more of the folds within the clip. Okay. Then you can then close. So we keep suctioning here. Suctioning. And then you draw more of the folds up and she's pushing out slowly as I close. And that way you get a really good purchase on that Mucosa. So clear your lens. Now we don't have to do anything. I haven't fired the clip. We haven't lost the clip. If you said, I don't like this, you can always open it back up, but I think this is a perfect position for what you want. So you tell me what you wanna do now. You can deploy. Okay. So I'm going to then deploy this. So the way I do this is just push all the way down and you hear that audible noise. So it's a very satisfactory audible noise. And then with this type of clip, I can release. And then you can see now, the clip has been deployed on the fold, perfectly deployed in a great location. So go ahead and take that out. Okay. So that was a resolution 360 clip. Again, we're not paid by any single company to have this, just happened. I'm just using whatever's in here. This is a different clip, which is in the same family. This is a res 360 ultra. The ultra has, you can see a little bit wider jaws. So this one tells me that it is 17 millimeters on the jaw face. So it's gonna have a little bit bigger purchase. So we'll just go ahead and open this one up and fire that in the same vicinity of the one you just fired. And that way we can just see how they compare. We'll talk through those same steps again. So again, when this comes out, it comes flying. So you just wanna make sure you carefully open it and make sure you get all the loops out. Thank you. And what we'll do is, you'll see here, as she's demonstrating the technique, working it down the channel, we're gonna pass it all the way down. We'll open this up and she'll walk through the same steps, suction as she's gonna lip one of the clip, sides of the clip over the area of interest. And then she will suction and fire and push it out as she's closing. Okay. So you can open clip please. Thank you. And we'll just put it on this fold here. You want me to rotate it all or are you happy with that? You can rotate maybe like eight and two a little bit more. Okay. There, there, eight and two, there this way. Yeah, I think so. That's good. So you can see she's doing all the work. She's taking one end of the clip and then using the other end of the clip to negotiate around the fold. Okay. And you're gonna suction. Yep, suctioning. And you tell me when you want me to close. You can close. And she's telling me to close. So I'm closing here. Perfect. And then if I'm happy with that, then I can say deploy. Okay, so I'm gonna deploy. There it goes. And then push it out of the channel just a little bit. Perfect. So we wanna make sure the clip has exited from the device. Otherwise, sometimes what happens if it's still attached to the device, if you don't release it, it will, you can pull that clip off that you've just successfully deployed. So you wanna make sure that you've let go of that clip before you back away. Okay? Yeah, I'll take this off. All right, so we've gone through a couple of clips. Any questions? I don't see any open questions. Everyone's happy? All right.

endoscopy techniques

biopsies

tissue sampling

inject saline

submucosal space

placement

endoscopic procedures