Next, why don't we take the scope out. We're going to demonstrate some tabletop thing and I think our final kind of overall thing that's going to take about 20 minutes or so is a, we're going to, I have a series of things that I like to do. Number one, we're going to show banding. Then what we're going to do is we're going to snare those bands off and cut them off. Then what we're going to do is clip the defect that we have, clip the defect that we created. And then number four is we're going to retrieve that specimen with a net. So we're going to basically fourth show, demonstrate four techniques with this final, with this final set. So here we've got a banding kit, okay? This banding kit that we have again is very different. Every institution has different one. Let me go ahead and take the light, turn the light off, get the kit ready to go. So we've got a Boston Scientific Speedband Superview Super 7. It's important to know this has seven bands so that when you're running out of bullets, you got, these are your bullets here, you got, you got seven bands, that's it. That's all you can use. If you want to do more, you have to get another kit. There's six shooters, there's seven shooters, there's other, multiple other different companies and devices. So be familiar with the one you have at your institution again. Okay. What are you going to do here? Well, you can put this into the, the, the port here. So there's two ways to do it. You can put it on the cap or you can do it metal to metal. I personally like metal to metal, but if you want to use it right through there, that's fine. It doesn't make, it doesn't make a difference. So, so what she's basically going to do is pass that down. Now other, other, the other banding kits have a, have like a fish hook kind of thing where you can just pass that down to, to grab, grab the banding kit. And what we'll do here, you can see it coming out on the, you can go put your scope down. And so here's, here's the actual banding device itself. And so it's basically, you need to have a plastic covering here, which may require someone with nails to take this off or take my gloves off. There we go, it's coming. So you're going to basically take that plastic coating off. Now you have, be careful. Now you see you've got bands on this cap. So you basically have a clear cap. Then you have the band. So this is a seven shooter. Just about every, every company that I know, they have the next to last band that you fire is a clear band. So that's your warning band, that this is your next to last band. You only have one more band left. So if it's a six shooter, it'll be the fifth band. If it's seven shooter, it's the sixth band. So you can count here. You see one, two, three, four, five, six is the clear one, then the seventh one. Okay. So what Lillian has done is she has passed this device through. And what you do, what you do is you, basically you can do one of two things. So number one, you can pass this through and loop it around. Is this the banding kit that you use? I think this is the one that we have, or I think we have the six, we have the six shooter, not the seven. Yeah, six shooter, six shooters is probably the more common one. And each one's a little different. So you basically thread it through and then you open it up. So you thread it through the opening that was there. And then what you're going to do is put this through here. Now I've created a knot. So it's secure to this. And then what she's going to do now is put that on properly. You got to put it on and mount it. So what she's doing is taking this off here, taking the strap, wrapping it around. Yeah. This one has like a Velcro belt. Yeah. I mean, you speak up a little so they can hear you. Oh, sorry. This one has like a Velcro belt here. It's a little bit at an angle. Yeah. That's why, that's, this is why I don't like the cap. This is why I like to go metal to metal. So if you take this out here, one of the things you can do is maybe put this, make sure this sits in first and then what you can do is then secure it, right? And so if you have a nice angle on this, you can then secure this properly without bending it. But I like metal to metal because I feel like it's more secure. If you have it on that, on that cap, it's a little bit more floppier. You see, it's a little more play on that. And I just, I just like that firm feeling. Either way is right. You don't, there's no, there's no wrong way. Okay. Let me just, let me just grab it here and put it in for you. Now in the meanwhile, you have two options of how to pull this up. So how do you pull up the banding kit? So you can kind of pull the string. Yep. So you can either pull the string or you can, sorry, or you can turn it. Let me see. Pull the string. Okay. So she's going to pull the string here and what she's seeing as she's pulling, I'm going to, I'm, I'm showing you the end as she's pulling that. Great. Now stop, stop right up, maybe a little bit more. Okay, good. So now what we're doing is we are now looking at the string and the cap, and then we're also looking at our endoscopic view because we want the string that's on the banding kit to align with the suction channel where the string is coming from so that the string is not. So I've turned the light off by the way, and then I'm going to turn the light back on. And so now you can see, now you can see that the string is not in the way. The string is lined perfectly right around the seven o'clock area for a diagnostic gastroscope so that the string is not in the way. If I had not done that, let's say if I had not done that, okay, and I put the string in the wrong way, you can see here, this is what it would look like. And all of a sudden, if you're looking at the endoscopic view, the string is in your way. Okay? So what you need to do is you need to make sure you take this out and you need to make sure you have it at the right, at the correct angle, and go ahead and just pull that just a little bit more. Good. Did you get anything? Yep. Good. Okay, good. Perfect. So now we've got this mounted, we've got the device attached, and what I want to do just to show it what we're doing is on the outside, let's maybe deploy one and just show what we're technically doing. So let's do this. Let's just fire one on the outside of this tissue. Never done it before. Let's do it. So I want you to go ahead and, so what we're going to do now is we're basically taking this and we're going to be suctioning here. So go ahead and suction. So look at the endoscopic screen. You can see. And usually you want to look for kind of like a pink out or a red out to know that you have enough tissue inside the cap. So I'm going to help you out a little bit. Don't fire it yet. Okay. And you can adjust your dials a little bit too to try to get us perpendicular. And sometimes if it's shallow, you can do like a little bit multiple suctions and then move your scope a little bit. Okay. And now when you've got a good suction, just stay on the suction, stay on the suction, stay on the suction, stay on the suction. Okay. Now go ahead and fire the band. So it's usually 180 degrees clockwise and you hear a click. Do you hear that? Keep going. Do another one. That was the first. Yep. Keep going. Another one. I don't think you have it locked yet. Do you? Yeah, you do. Yeah. Keep going. I am. Oh, yeah. You've got, you don't have this on. All right. Let me suction. There it goes. Yep. There it goes. Now you're going to get it. Yeah. You can see it. Yeah. Okay. So it didn't capture, but basically what you see now is when you're firing this, you're firing a, literally a rubber band. So it's a, it's a little circular, thick rubber band. Okay. So it's primed. It's ready to go. You can go back down into the stomach. Okay. So it looks like, basically it looks like that, and what we're going to do now is we're going to switch to the endoscopic screen and then we can also show her hands maybe as she's firing the band. And what I like to do in this situation is turn up the light source. So I'm going to turn up. So when you have that cap, sometimes it gets in the way. So as she was mentioning, she's going to go tangent, she's going to go perpendicular as much as possible. Yep. Take that fold and suction. Yep. And just sit on the suction. Wiggle. Yep. And I like to, I like to use my left, right dial a little bit to get, to get it in. Okay. Now go ahead and go ahead and fire it. So you're going to, she's going to turn that handle. I don't think it, keep going. I don't think. There. There you go. There you go. Good. And you let go. So you just slowly let go. Put a tuft of air in. Okay. And now you see that she successfully banded that barracks that was there. All right. Can you do one more, another one somewhere in a different area? Yeah. Sure. Maybe here. So again, show them and talk them through these techniques. So you want to kind of get perpendicular to the wall and using your dials and keep suctioning. Sometimes you can wiggle. I like to twerk left and right a little bit, or you can use your small left to right dial. And you're just sitting on suction the whole time. You're not tapping the suction. You never let go. You're not, you're not suctioning and letting go. You are just holding on for dear life. This is a barracks that if you let go, it's going to rupture and bleed. So use your small knob to twist it a little bit here. You know that, like we said, try to get a little more tissue into that channel. Yep. She's sitting on the suction. All right. You want to sit still and now go ahead and fire it. All right. Beautiful. And now when she's got it, she's done, right? Yeah. No. You want to make sure you don't rip this off and rip the band off and then have a worse problem than what you started with. So you want to slowly come off in the same direction that you band it. Otherwise you can pull off the band. Yeah. Like that's a little bit. So. Hold on. And just slowly come off the top there. Yep. Yep. Beautiful. There you go. Good. And just keep going. Just fire all the bands off in different locations. Again, show them. Try to get some folds so you can suction them in a little bit better. So again, kind of perpendicular. You want to make sure you're fully against the wall. I might choose a different spot. Yeah. So you're selecting a spot that has a lot of folds. Something here just for the model. You don't get that luxury when you're in the human. That's very true. So you never let go of the suction once you're on. Sometimes the Varixx might bleed, but that's okay as long as it's still in suction and then you can use your little dowels left and right to kind of wiggle it, get more tissue. So not quite. Not quite enough here. It's okay, it doesn't have to be perfect. Go ahead and fire. So it's still a blue band. And then you want to make sure when you come out that you don't knock off the band, so being careful when you're coming off. Same thing, suctioning, making sure you're perpendicular to the wall. And then again, it's 180 degrees clockwise to deploy the band, and you hear that click. Oh, there's a question. There's a general question about endoscopy. When you scope, do you use mainly torque and just the big dial? Yeah. Just a question about whether the small dial is really used much in endoscopy. When I'm advancing, it's a very, very good question. When I'm doing a colonoscopy, advancing to the cecum, I tend to torque and use my big dial as much as possible. I will often need to use my small dial, but that's not my primary maneuver. I try to torque, use my big dial to get around the sigmoid turns, and then if I'm coming across a really angulated area, then I'll use my small dial to get across. But yes, that's a good point. I try to do that to minimize any sort of torquing and just maximizing torquing up and down, so that way your scope is as straight as possible. And now you've seen Lillian just fired the warning shot. Why don't you come out now? Since you guys are banding still, there's a question about what happens if you accidentally let go of the varix and it ruptures and it's actively bleeding. You beat me to the punch, so I was going to comment on that. So if you accidentally let go and the varix just starts bleeding, you don't panic. What you do is you just advance a centimeter further into the esophagus in the same exact area on the clock face. If the varix was at 3 o'clock and you let go by accident, you just advance a centimeter in the 3 o'clock position and fire a band. It will strangulate the vessel, the feeding vessel, that same varix that's going up and should stop the bleeding. So we have one final band. So we need to take this banding kit off. So what do you do? You don't look at it. You don't stare at it. You don't point it at anyone's direction. You take a 4x4, and then you go ahead and fire that final band. Ready? Uh-huh. Ow. No, I'm just kidding. Nothing happened. So you fire the final band in a secure manner. Now, some people like to use this cap. I find it to be a little tough and unwieldy, so I'm going to take this cap off now. And then we're going to go back down, go ahead and put the light back on and go back down. And then what we're going to now do is we're going to advance and now pretend these bands are now polyps. So what we're going to demonstrate now is a technique for polypectomy. Okay? Uh-huh. And you can see that, you know, these are not holding on for dear life. But go ahead and suction as much as possible. Get all that. We need better imaging. Good, good, good. Good, good, good. All right, good, perfect. So what I have here is a 20-millimeter snare. I just grabbed something that wasn't too big or too small. So we have a variety of snares here. We've got a 10, 15, and a 33-millimeter snare. A 20-millimeter snare is going to be your somewhat standard workhorse snare. Now some people like to start off with the small snare, so the 10 or the 15. Some people like this 20 because it can be used both for cold and hot snare polypectomy. But what we're going to do now is we're going to take this off. Yep. And we're going to put the snare down, and we're going to pretend like we're snaring this polyp. Now I've, in the background, changed my generator settings. So I've changed the generator. You always have to change because, remember, the last thing we were doing was bipolar, or it was APC. And so we have to change it now. I've changed it to snare polypectomy. I've picked a snare, and I've got two settings. I've got a yellow pedal, which is cut. In this particular method, it's a cut. And then a blue pedal, which is coag, which will be for smaller polyps. Now most polypectomy nowadays is cold snare polypectomy. Anything 10 millimeters or less that's a sessile or a flat polyp, we typically just do cold snare polypectomy. For pedunculated polyps, maybe larger polyps, then we use hot snare polypectomy. So what we're going to demonstrate today is hot snare polypectomy for in a patient that has, let's call it a semi-pedunculated polyp. So Dr. Wang has her snare down, and when she wants it to be hot, she'll tell me, and I will connect the generator to the device. Until she tells me that, I won't do that. So whenever you're ready, you can tell me what to do. And then you also want to make sure the polyps you may have not noticed, but they were not at 6 o'clock, so you want to orient the polyps at the working channel at 6 o'clock here. So you can connect. Okay. So what you have to do is you have to connect the generator to the device. Okay. So what you have to do is make sure you push it in, make sure it's got a good contact. Okay. And then snare out. So we're going to open the snare, so it's open. And I'm just slowly opening the snare. Okay. And what she's going to now do is position the snare around the area of interest. So this one here. Okay. Nicely done. Put it around there. Slap it down. And then you want to kind of push the catheter in a little bit so you're a little closer to. You have to close first, so it's going to buckle. Close. So we're going to close the snare. And as I'm closing, she's now pushing it in. Yep. And now you can see I've got it. Now your tech or nurse is going to close this, and they're going to say, I have it tight. And sometimes you should ask them, do you have too much tissue? Do you have the muscle? What do you have? And they can tell you, it feels about right. This is about normal. And so I have it down to two. There's markings on here. They'll say, I have it down to two. It's about two. It's good. All right? And then you want to lift it up away from the mucosa just to see how much you have, and also to make sure that you're not going to. So away from the muscle. Yep. You want to lift it away from the muscle. I'm going to pull it a little bit closer. Okay. And then you can say cut when you're cauterizing, too. So blue button here. Cut. So you see, she went through in about three seconds or so, and you used the right pedal that time, huh? I did. Okay, good. And you can kind of see, this is where it was, and then the polyp's right there. So that was a great demonstration. Now let's do it with the yellow pedal. So that was just coag, just like a standard polypectomy. Now we're going to do a cut and just see what the difference is on this. Okay. Snare out. So you're going to open. Open. She's going to lay the snare around, and then she's going to tell me to close immediately. Close. As she pushes that out. Okay. You have tension? I'm closed. Closed. I'm tight. Okay. And then you can kind of take a look. Clear your lens. Beautiful. Great. And then I'm going to press the yellow button now here. Cut. Two, three, cut. Okay, now let's see what happened. So you can see, look at the difference between those two resection sites. I want you to take a good look at that. So clear that lens, get a really good. So this one is coag. You see all that char around that. So that defect is going to expand and be double or triple the size in about two to three days. If you look left, you can see a much cleaner cut. It will still expand to double the size of this defect over two days, but you can see this was a much cleaner cut. So in large, thick tissue, I like to use the cut setting. So like an EMR or endo cut setting, whereas on the look back down to the initial resection, which is just coagulation, you can see a lot of thermal burn, the white all surrounding the cut. You don't want any of that white surrounding the cut. You just want the cut. So then I'll go back to the other one. That's a much cleaner cut there. All right. So now go ahead and maybe take one more polyp. I'm going to demonstrate this technique one more time. She's going to ask me to open the snare. So I'm going to open it. She's going to lay it around. Now, that's a lot of tissue, so you probably don't want that much. And then tell me to close a little bit as she gets around it. Okay. I partially closed. Now I'm going to close some more. That's a good demonstration here. Good. Now pull it back a little bit. And away from the wall. And she's going to step on the yellow pedal to cut it. One, two, three, cut. And then we can show you what it looks like here. And you can see what the resection site looks like. Beautiful. Nice cut. A little bit of thermal injury there. But that's a really nice demonstration. Now, snares are often used for resecting tissue. But go ahead and let's say that clip that you put on, you don't like it. It's still stuck there. There's some residual polyp. Go ahead and get your snare down. Get it around that. I'm going to open it up. Open. Now these are really dug-ons. I'm not sure we're going to pull these off. So when you're trying to do foreign body, you can now take this. Now I've got it really tight. And she can try to yank it off by not just twisting her scope. Locking her left hand, pulling her scope, twisting it off. These are really, really on the muscle. I don't know if they'll come. But yeah, yeah. We're going to pull it off. Good. Now I'm going to open. Okay. Take that out. Now we're worried about that first resection site that you did. It's got a lot of coagulation on there. I'm a little worried about a delayed perforation or a delayed bleed. So I'm thinking we need to clip that site. So I'd like for you to kind of demonstrate again for one more time. Sure. That's probably the most clipping she's been able to do in a month or so. That's very true. I don't know if we emphasized that some clips are rotatable 360 when others aren't. And so if you find that the first clip you've deployed and you haven't fully closed the defect, and it's an awkward position, sometimes a 360 clip can help a little bit just to rotate the angle. You can rotate any clip. It just doesn't rotate as smooth. Okay. So I like that direction here. Okay. Actually, can you maybe do like 10 and 4 o'clock a little bit? Okay. So she wants 10 and 4 o'clock. So I'm going to go a little bit right about there. Yep. You want to make sure you have as much as a healthy tissue as possible. And then. Yep. Close. Suction first. Yep. Suctioning. Okay. And I'm going to slowly close now. I'm advancing. And do you like it? I do. Okay. So we're going to fire. Deploy. And now hold on. Don't pull it out. And I'm going to release it. So for this, you have to do a release. And you can see now. Perfect. And you know what? I think you've got almost all of it. Then you have to take this out. Do the top. I think you've got to just get one more right on top. Just to get a nice clean defect. So this is why she's showing you how to get a nice. Okay. And then we're going to do. We're going to do a clean resection. And then also closing it to. So if you were to do this, you reduce the risk of bleeding. But you still see an area of top that's that. Maybe on the bottom. Maybe the same orientation as before, 10 and four, or we can open first and then, yeah, and then 10 and four. So she's asking me to go to 10 and four. Okay. And this time I'll try to suction more tissue. You want to get more up top? Yeah. Yeah. There you go. Beautiful. Okay. I'm suctioning. Okay. And then you can close. I'm advancing. Now let's see what you got. Oh, you advanced a little too much there. Let's take a look and see what you got. I don't know if you slipped off the right wall. I think I slipped off the right wall there. Okay, so she's not happy with that, right? So what we're gonna do is we're just gonna, no, don't, don't, don't, don't tent on it. Don't pull on it. You just want to open up. Open it. And then you can- And reorient. So pull off all the way and then reorient. So I wouldn't even necessarily push it out so much. I would just, you've got a really good grip on it. So I would just grab it. And then if you hadn't pushed it out, it would've been perfect. Okay. Slap it on the top. Now suction there. Suctioning. Yep, she's suctioning, suctioning. Now slowly push out just a millimeter or so. Add a little bit. And then close. And I've closed. Now let's see what you got. All right, so she's released her suction. You're just pushing out a little bit. She's looking. And it looks pretty good. It looks good, yep. We'll fire and see. Deploy. So fire and then release. Let's see what we got. And you pull back. Beautiful. Yeah, there you go. That is beautiful. So you see two clips right next to each other, not overlapping. You got that area that you wanted. You have to remember to take this out every time. Done a really nice resection there. Really nice. Yeah, close. Closure. Now we need to go get our specimen. So in our final step, we have a rescue net retrieval device. This is a 30 millimeter device. Most people have something called a Roth net. There's a variety of nets. They come in different shapes and configurations. So know kind of which ones you have. Some are 20, some are 30, some are 40, some are 50. So this one's kind of a more of a, almost like a diamond shape, I would say. Kind of an oval, almost like a standard stair. It came open. So you have to make sure you close it before you pass it down the channel. You'll look and see it's got, it's almost like a snare with a net on it. So you're gonna scoop out your specimens. Go ahead and pass this down the channel here. So where's the resected specimens here? Yeah, I think there's one right there at the blue, so. Again, positioning it at six o'clock. So what we're doing now is we're gonna go and retrieve our specimens with this net. And the reason we do this is, if it's possible to suction this up through your channel, just suction it up through your channel. But if you have a large specimen that will not suction through your channel, it's better to retrieve it with a net so that you don't damage the tissue. So you get accurate histopathological staging and margin assessment. You want the histopathology to be really kind of accurate. Is that still on or is that off? I think it's off. Yep, it's off. Oh, it's off, okay, good. All right, so we're gonna grab that. So how do you wanna approach this? So I like to open from above and then kind of close down. So you don't wanna push the specimen away, right? So you wanna open it away from the lesion. And as she's mentioned, she wants to open it and push it away, push it towards that. Let me just get it a little bit oriented a little bit better. We got the basketball and the hoop there. You can use your dials to look down. Swish. Is that what I saw over there in the corner of my eye? Yeah. So I'm just gonna get a better visualization. I'm gonna close. I think you have it. Yeah, I think I have it too. This is too much what reality is like. Go ahead and push that out. Where you can't really see it as perfectly, but you know you're around it. You know you're on the right area. And you can see we have it fully in the net here. Yeah. So go ahead and pull that out. So we can't pull that through the channel. We have to pull the whole scope out. So what Lillian's gonna do is lock the device with her left hand and then pull the whole thing out. Great. And there you have it. Oh, we got a bonus here. Let's take a look. Oh, the basketball. Let's see what we got. Here you go. I can open it. I got the basketball. I think you got a souvenir for you to take home. In the land of Chicago, it's the Bulls basketball. Now you have to get the disco ball too. Yeah. I know we can't, you're gonna hold it back. We're gonna have to make sure we don't forget the disco party here. There's another question that just came through. This is talking about if you, almost talking about how if you do create a full thickness, I guess, perforation in the esophagus, they're asking about what technique you would use to close that. So a lot of this is gonna depend on a couple of things. One is the length, what caused the tear, how acute it is. So if you're saying you caused a tear during endoscopy, it's a long linear tear in the esophagus, you have several options of how to manage that. Number one, clipping is actually effective. As long as you seal the mucosa, nothing is gonna leak, even though you're not closing the muscular layer or the cirrhosis layer. If you close the mucosal layer, nothing is gonna leak beyond that. So that's one option. Number two is if it's something that is subacute or if it is something that you did not cause and you're going back in, what you can do is you can oftentimes place a stent and seal it, and then you'll need a, go ahead and push that out. You can stent it and seal it, and then a surgeon may have to place a drain. Third, you can suture a longitudinal tear. That's a little more cumbersome. The skill set's a little bit higher, but you can suture the tear. And then fourth, you can do something like over the scope clips, but those tend to work well, I find, not in overlapping fashion, but if you have a defect that's 12 millimeters or less, or maybe even 13, 14 millimeters or less in size, but if you have a long linear tear, then an over the scope clip wouldn't be my first choice. You know, here is the disco ball, Dr. Byrne, you were worried about leaving behind, so we've retrieved it. We're gonna go back in and retrieve your other specimens here. What other questions does the audience have? Because we're, we've exhausted most of the accessories that we have, so I'm happy to talk for as much as you, and as long as you would like. I'm also happy to be very quiet and not bother you. As we go fishing for some of these other, you know, one of the things that can be, that can be somewhat frustrating is if you take out a big specimen in the stomach and you go back and forth, it does require multiple intubations. If you're thinking you're gonna do a large lesion resection, you may wanna communicate to your anesthesia team to do a general anesthetic, especially if you're going back and forth through the esophagus multiple times on multiple occasions. Let's go ahead and take that out. So again, what Dr. Wong was showing is she pushes the snare out, lays it away from the device, from the specimen, and then that way she's not pushing that specimen away from her. And then she'll tell me when to stop, or if she wants me to open all the way. You can open all the way here. All the way, okay. Yeah. You can see now the snare's, the net's already getting a little beaten up, but she's able to expertly entrap that lesion. I'm gonna close. Close. Yeah, there we go. And then pull it closer to you. She's gonna lock it with her left hand. You can see we have everything. So you, again, using your fingers here to lock it close to the scope, and then you can pull out. Yeah. There is a question that came through about if you guys could demonstrate some different like torquing techniques. Yeah. Let's talk a little bit about that. So we're getting our specimen. We'll close. Take this out. So torquing techniques. Can you demonstrate some of the like torquing techniques? How you- Yeah. How you torque in the digestive tract? So I like torquing with my right hand. I know you can also torque with your left hand as well, too. Yeah, so go ahead and just place it right there. Now, go ahead and show them, because they have the camera that they're zooming in on this. If you can show them how you would torque right and torque left. Yeah, so torque, and it's a bigger torque than you'd expect with an upper endoscopy. So you're just basically kind of moving it kind of at the elbow, not really at the wrist, and it's a bigger movement. This is how you start torquing to the right, and then torquing to the left. So that's one way to do it. Yeah. So that's one way to do it. The other way to do it is with your left hand, right? Right. And then so you can, yeah, so this way and that way. So kind of moving your hand to and away the opposite shoulder. Yeah. To get that. So, you know, again, in the era of being more aware of ergonomics, if you have a lot of right wrist strain or strain on your wrist, you may not want to use your wrist as much to torque. You may want to use more of your shoulder or your natural movements. With your shoulder and your arm, rather than your wrist. But there's no wrong way or right way. It's just being mindful of what you're doing. And if I can show. Yeah, absolutely. So the thing that I commonly see in mistakes that people make is when they're in here and they're like, you know, oh, here's this polyp. And I, oh, I need to get it to seven o'clock. Okay. And they just sit here for 20 minutes like this in this position. And it's an incredible amount of strain and torque on your hand to sit here for 20 minutes. So what you need, what the more experienced and endoscopists who need to preserve their hands do is they figure out how can I get that to the six o'clock position without having so much torque on my right hand. So just doing this with my left hand, got it into almost the same position and freeze up my hand. So now I'm staring at that polyp and I'm in that same position that I was when I was doing this. So if you need to get into a position like this, I understand. And it is very tempting as a first year fellow. Oh my God, I found the polyp. I'm in a good position and I can't let go. But what happens is as you get more comfortable and saying, you know what? I can get there. I can rotate back, is being a little more willing to let go, switch it up and to get into a more ergonomically favorable position and a more of a neutral position. And now my hand is free. So I'm looking at the same lesion, the same orientation without having to do that. So the other thing is again, it's not just like this, it's kind of turning your shoulder, turning this around this way. And sometimes you need to do that to get around a turn. You may need to make this crazy turn like this to get in and get around. And then once you've gotten through, you need to recognize, okay, I need to go back into a more neutral position. That's I think the key to longevity and endoscopy is if you're putting in some strain, A, can you prevent putting in that strain on your body? And B, if you do, how do you relieve that strain in a timely manner so that you're not sitting there for 20, 30 minutes? And another kind of related question that just came through is fellows with small hands, any advice for fellows with small hands who are having trouble manipulating the small dial? Yeah, so I have small hands too, wear like six size gloves. It does take some time. Ideally, you can control both the left to right and the up down dial with just one thumb, but sometimes you do have to let go and use the dials in which case you can use and hook. For example, if you have a position, you can hook and stabilize the scope with your pinky and then that frees up your right hand to use the right left hand dial too. So that's a trick you can use if you aren't able to reach both dials with one hand. And it's okay. I know some people say, oh, you can only scope with your left hand, don't let go, don't use your right hand, but I think it's important to find out what works best for you. Yeah. Anything to add? No, I agree. No, it's somewhat challenging because these are universally built scopes. And so if you fall on either end of the bell curve, these scopes are not really designed for you and you're learning how to adapt to those scopes, which you'll get with time. The hope is in the future, there's gonna be more ergonomically favorable designs that will encompass maybe different sizes. Oh, you know, doctor, what size scope do you want? It's not just, do I want a diagnostic or a therapeutic, but do you want a small, medium or a large scope for your hand size or dial? Or even better, rather than using these dials, maybe it's a small shift, or a more of a robotic approach where it's microbe movements that result in large movements in the endoscope. So there's a question on, can you talk a little bit about looping and how to reduce loops? Yeah. So you wanna talk about maybe like alpha loops and how to reduce them? Yeah, I think it would be easier to show outside of the stomach here. So an alpha loop is basically when you have kind of like, like here, I don't know if you can see that here. And then, so what happens to reduce the loop, it's a bigger movement than you think. So usually you start with your, you're holding the scope, your palms down, you want to kind of flip your hands to your palms upward and then kind of withdraw, but at the same time making sure that you're suctioning to maintain visualization of the lumen, because that way you can tell if you're actually moving or not. And then, so if you do this rotation, so again, you kind of rotate and then pull out, you can see how it straightens out. Now, if for whatever reason, you have a different type of loop inside the colon, you don't know, because you can't see, right? So you do the same movement, you rotate and you kind of pull, you can see here that it's not going to reduce that loop. And so you can also rotate your palm the other way and then pull out and you can see how that will reduce that loop that way as well. So it's very tactile based on, you're looking at the screen and then you can see based on feel and visualization if you're reducing that loop. It's also important to recognize when you're forming a loop, you won't have that one-to-one. So normally when you're advancing the scope, you should see yourself advancing on the screen. If you're not advancing, but you're pushing in scope, what's happening is you're just, for example here, if I'm pushing, if this is in the patient, you're advancing, you're just building this loop, it's getting bigger and bigger and bigger because the tip's not moving. And so you can recognize that you're forming a loop that way and then you can pull back or start to reduce. And then once you're straightened out, then ask for pressure, one of the texts to help abdominal pressure to prevent loop formation. That's excellent demonstration. So it's a lot of it's tactile, a lot of it's recognition that you're forming a loop. You're pushing the scope in and the tip's not moving, you're forming a loop. And then, you know, the best endoscopist, we all form loops, everyone forms loops. It's recognition that you've formed a loop and either preventing that loop from forming or saying, I know I formed a loop, let me get past this another 10 centimeters and then let me take that loop out without putting excessive pressure in the patient where you risk a perforation. And the new question that just came in also related to looping was just about the order of rotating and withdrawing. Yeah, you often wanna torque first, either right or left, depending on what, if you have an alpha or a beta loop, and then you wanna withdraw. So you're basically trying to torque and then pull back on the scope to withdraw. Right, so for example, if you don't torque and pull, so if you just pull back, you're not doing anything and then it's harder. So you can see how it's a little bit difficult. If I, for example, if I pull back first and then I torque, it's a little bit difficult. But if you torque and then pull back, it's a lot easier. Great question, though. Good. All right, any other questions? Well, we're gonna wait for- I don't see any other questions. Yeah, gonna wait to see if there's any other questions or anything else that comes through. If not, we've walked you through a gamut of techniques. So we've walked you through biopsying, injection techniques, thermal therapies with bicap coagulation, APC, banding, resection, retrieval. So within less than two hours, we've kind of demonstrated, and clipping, a multitude of techniques. I hope you find this helpful for your own practice. It's nice to see it and to watch it and understand the principles so that when you do that in a patient, it's great. Since you didn't get to have a chance to do this here, I would very much encourage you to do it at another hands-on opportunity, whether that's locally, whether it's a rep coming to your institution. Making sure you get those hands-on opportunities is critical, and it's a lot of fun. It's a lot of fun to be able to do it with other people, and especially if you get to use them in real life, that's great. But as you're building your skill set and knowledge of these devices, seeing as much as you can at a hands-on is very helpful. I see there's a couple more questions that come in. What about scope guide? Is it advisable to use it initially? We have scope guides set up at our institution, especially for first and second year fellows. Sometimes it's good, sometimes it's completely unreliable. Feedback that's not real. There's no harm in it. It just may be a little cumbersome for the room staff to set up the scope guide, but I think it's helpful. I don't know if you used it. Yeah, yeah. It's definitely helpful when you're starting out just to see and learn where you are in relation to the scope, because you can see the shape of the scope and how you want it to be straight like a question mark. Later on, once you're feeling more comfortable, you can then start to kind of ignore it and then feel like, okay, if you recognize you're forming a loop, you can kind of say, okay, am I right? And then you can check the scope guide to see, and then kind of learn that one-to-one feedback and then how to reduce the loop. So it is helpful early on. And then there's a question about intubating the terminal ileum. So it was briefly described in one of the lectures this morning. So what I like to do is I like to get to the cecum, find the appendiceal orifice, and I see that bow and arrow configuration. What we're talking about is a bow and an arrow. So it looks like the C of a bow and then what you want to do is you want to, as if you're pulling back on the bow, where is it going to shoot to? Where is it going to go? It points you into the direction. And so you find that, you use that appendiceal orifice as a guide to where the ileocecal valve may be. Sometimes you'll see, I see the IC valve here, at 12 o'clock, at six o'clock. Then what you want to do is you want to take some of the air out, angle your scope in the orientation of where the TI is, the IC valve and the TI is, and then slowly pull back until you see some ileal mucosa. What I then do is, I don't just push, because if you just push, you'll just lip in and fall out back into the cecum, is I put a little bit of water in and just kind of gently twist and torque the scope to kind of cajole it through the ileocecal valve into the TI. So again, first find your landmark, find the appendiceal orifice, that'll point you to where the IC valve is. Once you know where the IC valve is, deflect your, take the air out as much as you can in the cecum while still seeing, deflect the tip almost in the hook configuration, pull back to the IC valve, put a little bit of water in, open it up, and then kind of cajole it into that ileum. Those are kind of like the ways to do it in a nutshell. It takes a lot of practice to do. It's also extremely difficult to do if you have a ton of loops in your colon. So the number one thing you have to do before you do any of those things is take out and reduce all your loops and have the shortest scope possible in the cecum. That way you have maximum tip deflection, one-to-one articulation deflection in order to angle it towards the terminal ileum. On a related question, getting into the ileum, there was a question about, is that more difficult to intubate the TI when there's a cap on the end of the endoscope? Yeah, it is slightly more difficult because the diameter is a little bit bigger. However, it's possible. There's certainly times I've not been able to get into the TI because there's a cap on the scope. There's some practitioners who use a cap for every colonoscopy. I don't use that. I use it for selective cases. So, but I will say maybe there's some perceived difficulty with trying to get in the TI with a cap because it just adds to the diameter of the scope. But if that's something that you do all the time, it's probably second nature to you. The last question I see, do you see that about just tips for asking nurses and techs where to apply external abdominal pressure? Yeah, great question. I'd say the most common areas of the colon, that loop are in the sigmoid and the transverse. I think there was a talk about it, the reason why I think yesterday. And so I typically ask for a deep pelvis pressure to really target that sigmoid and that can help or kind of mid transverse, but it all depends on where you think that loop is forming. If you're coming forming more distally or proximally. So that's kind of where I usually start out with my positioning for pressure. If you haven't hit the transverse colon yet, you just ask for sigmoid pressure. That's the default, right? Once you're at the transverse colon and getting into the right colon, then you have to have a decision about where do you think you're looping? Are you still looping in the sigmoid colon or are you looping in the transverse colon and you apply for pressure in that area? It's something you just have to get comfortable with. Pressure in the right segment with a skilled nurse will get you to the CECM every time. It's just knowing as a trainee, as a first year fellow, when is it me that's the one that can't get to the CECM or is it a loop or I need pressure? So having that judgment about, okay, why am I not able to get past this area? And if it's a loop that's forming to ask for sigmoid pressure or transverse colon pressure, don't be afraid. If that's what you need, that's what you need. That's now after you've gone through troubleshooting of all the other things about what it could be. The other thing when it relates to pressure, I like to minimize the amount of pressure that I'm asking for. We all need pressure, but just like musculoskeletal injuries for endoscopists, injuries can happen to your techs and nurses. And so asking them for abdominal pressure for 30 minutes is a surefire way that your nurses are, A, gonna develop some sort of wrist injuries or shoulder injuries, and B, not like working with you because you're not considering their ergonomics. And so what I like to do is ask for pressure. Once I'm past that area, I'm like, thank you for the pressure. You can ease up. I may need you back later and then let them go. They very much appreciate that you're attentive to their needs as well so that you're not sitting there for 30 minutes and then they get a wrist injury. There was also a question about, related to looping is just, instead of pressure, talking about changing the patient position, I think specifically on trying to intubate the terminal ilium, like whether you should turn the patient supine. Yeah, good question. If it's difficult to intubate in the left lateral position, a couple of things. Number one, I try to rotate the scope so it's either at six, so that the TI is either at six or 12 o'clock. That way you have your big dial with maximum tip deflection to go either up or down to get into the TI. So that's number one. If I still can't get in and you have a short scope, I will sometimes, now this is not a first year fellow maneuver, but retroflex in the cecum to look for the TI, orient it and try to insert the tip of this colonoscope into the ileocecal valve and then straighten out and then advance it into the TI. So these are kind of some tips. I am someone who does not like to frequently change positions, because again, ergonomics for the room, that people have to pull the patient up and down, put them side to side. So I do that maneuver when necessary, but unlike other people who, before asking for pressure, we'll ask to reposition the patient. I'm not a fan of that because I think that that's just a little bit more cumbersome to do. I don't know if you- Yeah, I was gonna say, I just really didn't want to emphasize deflating as much as possible, because what happens is when the cecum is fully inflated, it's going to really press the IC valve shut. And so when you deflate it, everything becomes looser. And then you can actually see it open up a little bit. And then I always like to see the opening before I try to intubate the TI. So really suctioning out air without collapsing the whole cecum is what gives me the most success. And I see there's a question, a senior in transverse colon, every time he pushes in, he loops. He asked for transverse colon pressure. Instead of asking for transverse colon pressure, he asked for sigmoid. Yeah, so the loop that he's probably forming is more in the sigmoid colon than the transverse colon, which is why he's able to get that patient, that individual is able to advance further. So I think that that's one of those things, just knowing where you think your scope is looping. If you've got a loop that's forming, that's pretty obvious, but then knowing where the loop is forming is sometimes challenging. So even though your scope tip, again, as Lillian demonstrated outside here, even though your scope tip is here, the loop can be higher up. And so if this is me and I'm in the transverse colon, but if the loop is here- If I'm feeding it in. Putting in that pressure here is gonna help minimize and reduce that loop. So it's not always where your scope tip is, it's where the loop actually is forming. There's a question on tips for retroflexion and the cecum. Yeah, so I only retroflex when I have a very, very straight scope and I use a pediatric colonoscope. And then if I can achieve those two things, I'm using a pediatric colonoscope and I am in a very short scope, I will routinely retroflex in the cecum to get an additional view of the right wall, of the right colon in retroflexion. Because as you may know, that's an area where many polyps are missed in the right colon, especially flat polyps. And so sometimes that's because they're behind folds that are not seen in a forward view. I don't force the issue and I don't retroflex in the cecum if I have a adult colonoscope or a very difficult colon where I have a lot of loops to get there, or I'm concerned that I've put so much air in the colon about a perforation. All right, well, we got one more here. There's very few pediatric colonoscopes in my institution. Any suggestions when to use it over a normal scope? Yeah, so what's your preference? Tell me. So it actually changed. When I first started out, I liked the pediatric scope because it was softer and easier on the hands, but it does loop more because it's more flexible. And so I then transitioned to liking adult scopes, but the pediatric scope does allow for more flexibility, retroflexion, and then if you have complicated, complex, large polyps, it's more advantageous. So I usually tend to follow a rule, following whether they have had abdominal surgery, total abdominal hysterectomies, you think there's adhesions, diverticula, if you think it's gonna be very fixed, complicated, or body habitus. If they're BMI, for me, I use like a BMI over 30, 35, and I think, okay, maybe use an adult scope rather than a pediatric scope. And then if they had multiple surgery, you worry about adhesions, fixed angulations, where adult scopes sometimes might be a little bit more helpful. Yeah, I think a pediatric colonoscope, to reemphasize what she had just said, for tiny women, pediatric colonoscope, because they tend to have a lot of fixed angulation, smaller, narrow caliber areas that you need to go through. Number two is individuals who've had prior surgery, most commonly hysterectomy, that can form scar tissue or adhesions in the belly, pediatric colonoscope is fine. And then in larger individuals, adult colonoscope may be more advantageous because they may have a larger diameter colon. Yeah, related to that, there was a second question is, can an EGD scope be used for getting around those really tight sigmoids? It can, the EGD scope is a lot shorter. Sometimes it's gonna be very difficult to reach extent in cecum. With that, I know at Mayo, sometimes we use what we call a green scope, which is an upper for a flex sig, you can get through that. It can be difficult depending on the anatomy and how much you're looping to reach the cecum with just an upper scope though. Yeah, I agree with that. It can be used to traverse the sigmoid strictures and stenosis. If it's, again, it depends on what the goal is. So if the goal is to, just for screening purposes, oftentimes I can get into the right colon with a gastroscope, sometimes really difficult. And so as she mentioned, you may not be able to complete the entire exam, may be able to get past that, but you still then can't complete the entire exam. Then I says, when do you lock your dial? So if I lock my dial, if I'm in a fixed, I'm looking at something and I need to free a hand and I wanna lock it so I can grab something else, or if I'm really struggling with a lot of torque and I found it in a more neutral position, I wanna lock the dial and then kind of not put so much strain on my hand. It's kind of one of those instinctive things. I don't really think through about, oh, I'm locking my dial, I'm not locking my dial. It's more, I'm here, I'm putting a lot of strain on my hand. Okay, I'm just gonna lock it. And then naturally I just reflexively do that. I don't know if you have any other- I agree. I never really lock it unless I'm doing some kind of intervention. I wanna hold it steady and I'm having a lot of torque, or it's just, you wanna minimize if we have one hand to thread a catheter, et cetera, through the channel. And I see a question about a shallow rectum. Same thing in the cecum. If there's a shallow, meaning if there's a shallow, so go ahead and retroflex in this colonoscope and I'll keep it up here. It's fine, they can see it here. So when someone has a short cecum or a short rectum, what that means, and we have some disco ball glitter here on the scope, what that means is their cecum is maybe that big or that big. So when you're retroflexing here, if you look here, that retroflexion requires about five centimeters of scope to retroflex here. So if you put it up against here like that, about five centimeters. So if your cecum is three centimeters or so, or four, just even five centimeters and you retroflex, you're already past the cecum and you're looking at the ascending colon. Same thing in the rectum. If your rectal pouch is not big enough to accommodate this retroflex position, you can't retroflex. So if it's a really tight, small, narrowed cecum, or there's a lot of inflammation, bleeding, ulceration, irritation, I may not retroflex in the cecum. So good questions. So here you go. Are hemorrhoids better seen on retroflexion or forward view? I personally think retroflexion is easier to see hemorrhoids but they can be seen in forward view. Oftentimes it may require a clear cap so that way you can spread the folds and see. And then I see here, small hands and a bit challenging when I try to reach for small wheels. Is there any advice for an endoscopist like me? You were just talking to that a little bit. So I also have small hands. And so if you aren't able to reach both dials with your one thumb, you can, once you find the location, hook the scope with your pinkie or ring finger and that frees up your right hand and then you can use that to move your right and left dials here as well. So that's one option to get away with that. That's a good tip. So yeah, you know, freeing up a hand to then use your other hand to grab it. It's a bit challenging to distinguish anal cushion versus hemorrhoids. Any way to tell the difference between these two? I think it's just one of those things for experience. The more you do, the more you see, it just comes with time. You know, it's, I would dare say that even people who have done thousands will sometimes struggle with cases, you know, is there a hemorrhoid there or not? So don't feel discouraged. That's just something that comes with time and it's never perfect. Luckily, it's not a high risk sort of thing. And so if someone's coming to you with, you know, concern for hemorrhoids and you're not quite sure if you see hemorrhoids or not, you can always refer them to a colorectal surgeon for a diagnostic anoscope. Just so anoscopy is another way of doing that. Doesn't always have to be done within a flexible endoscope. I was gonna add about the small hands because there were a lot of questions about that. There are those dial extenders that are made for the small wheel of the endoscope that I think they don't manufacture anymore, but it sounds like a lot of institutions still have those. So I do know some people that use those, but yeah, like you, Lily, and I have small hands also. And I kind of, I've gotten used to using that little pinky finger technique, but they do have those dial extenders also that I know some people used. Aparna, Dr. Apaka was talking about those a little bit yesterday in her ergonomics talk. And then, you know, telling diverticula from sessile polyp, hyperplastic. Again, this is pattern recognition. This is why you're a three-year GI fellow because, you know, sometimes inverted diverticula are very difficult to tell from hyperplastic polyps from sessile serrated adenomas. And this is what part of your training is. So one is careful inspection with HD white light endoscopy. Two is using augmented imaging techniques, such as narrow band imaging or, you know, enhanced mucosal differentiating techniques. So narrow band imaging highlights a certain wavelength in capillaries in vessels. So you can look at the pit pattern and you can look at the capillary pattern of a lesion to then differentiate, is this adenomatous, hyperplastic? And that's just something that takes time. There's data to show that, you know, people need to do X number of colonoscopies or look at X number of images to then have a reliable imaging interpretation. So that's just something that comes with time and pattern recognition and volume. And then I'll leave this to the course director to answer this question. Will the course recordings be available? I believe this will all, I believe they'll all be available on GI Leap that these are being recorded. You can, I can send you my Venmo and you can just Venmo me $100 and then we'll give you that. No, I'm just kidding. It's a, it's all available on GI Leap. You have access to GI Leap. There are a lot of educational content available on GI Leap. And if you want to donate to Advanai Chandra, that's your choice, but otherwise it's free through this course. Is there a time I should train myself to reach the CECM? Oh, to reach an eight, okay. Again, this is someone who you feel the pressure as a first year fellow, right? Like I got to get to the CECM. I got to get to the CECM. Colonoscopy is a, you can put that up. Yeah, I was just, it is a gradual incremental process. So every first year fellow, first, second month is beating himself up about how many times I can get to the CECM. Getting to the CECM is only half the battle. So there are times when you can get to the CECM in five minutes. There are times you can get to the CECM in 30 minutes. It happens to everyone. So in general, what I tell advanced fellows, those who have done after three years of fellowship for a very easy colonoscopy, you should get to the CECM in five to 10 minutes because you now have to do an EMR or a large polyprosection or some other advanced diagnostic maneuver, which is what you want to spend your next 30 minutes doing. So if you're spending 30 minutes to do that, plus 30 minutes of therapeutics, you're suddenly taking a procedure that's maybe scheduled for 30 to 45 minutes and taking over an hour. As a first year fellow who's just learning, you should have easily 15, 20 minutes to get as far as you need. Some days that means getting through the sigmoid colon. Some days that means trying to intubate the TI. And so over time, the goal is to get to the CECM in, again, seven to 10 minutes on a standard, straightforward scope. I discourage you from putting all that pressure on yourself right now. You don't want to rush to get to the CECM because that's where mistakes can be made. If you don't know what feels right, what doesn't feel right, and you just rushing to get to the CECM and you perforate, that's a much worse day than spending 20 minutes to get to the CECM. So I would say that that's a difficult question to answer at this stage of the game, but by the time you kind of are more skilled, five to 10 minutes to reach CECM on average is a really good case. All right, I think we've gone through all of the questions. So we're gonna conclude this session. I hope you found this to be very valuable. We went through a lot of different techniques and we've gone through a lot of different devices. Some you may have in your institution, some you may not have in your institution. So I'd say familiarize yourself with the devices you have at your institution, which you're gonna be using and learning on. And any parting words, Lillian? No, congratulations on entering the best skilled gastroenterology and best of luck in your fellowships. Thank you, everyone. Thank you. Thank you guys, that was a great demonstration.

endoscopic procedures

banding

snare resection

clipping

specimen retrieval

tips

techniques

looping

training with small hands

intubating the terminal ileum