Good afternoon, my name is Cyrus Paraka, and this is Stephen simmer or from Henry Ford Hospital in Detroit. And we're here to run the virtual demonstration for the hands on session for the church or fellows course. I would take it. Well thank you for joining us this afternoon. We have a great course for you this afternoon and so we'll start by kind of just going through upper endoscopy, how to hold the upper scope, and then take you through some interventions that you'll be learning throughout your fellowship, you know injection clip placement biopsies, and then into other things such as banding and polypectomy. So here we have the adult gastroscope, and how we, you know how you should hold it is with your hand with your arm positioned outside of the umbilicus here. And then you have these knobs here. This is for the scope manipulation of the tip. And then here you have the suction button is your first button here, press it down that will suction the lumen. And this is your water button water as well as air insufflation or co2 insufflation. So you just kind of hold your finger over it that will inflate the lumen, and then you hold it down a little bit more and that will provide button water to clean off your scope. And so, as you get familiar, you know with the gastroscope you'll be able to, you know, do this as kind of second nature but you know familiarize yourself with that make sure you all your buttons are appropriately adhered to the gastroscope before you, you know, go into the patient's stomach. So what we'll start off with today is taking a look at how to inject as well as place clips. So we can start off with injection. And with that, we use, there's a couple different types of needles that we can use. This here is the Olympus needle master, and it is inserted through the gastroscope. And you can see here that it's the working channel length so that is to go through an adult gastroscope. This is the channel size so it will fit through here. So why would we use, why would we want to use an injection of a medication so there's different indications for that. One of those is for bleeding. So if you have a patient that has an ulcer in the stomach or in the duodenum, you want to treat that with, you know, dual therapy, so you want to use two modalities to treat that bleeding ulcer. One of those will be epinephrine injection, and you want to try and do that in a four quadrant formation around the ulcer, let it diffuse into that area, and then use a double another modality such as cautery or clipping. Another indication for this is to lift up a polyp, or something that you want to snare off. And this is a way to separate the polyp from the deeper layers of the, of the GI tract. So in general, the GI tract has four layers, the mucosa, the muscularis mucosa, the submucosa and the muscularis propria, those are kind of the main layers. And the objective of the injection is to inject fluid into the submucosal space. Now this what we usually inject is a solution that sometimes has dye has a dilute amount of epinephrine. And so that will push the polyp up from the underlying submucosa in so that the mucosa is up higher, you can then get a snare over that polyp and remove it potentially in block. That's what we call endoscopic mucosal resection. Yeah, that's great. Yeah, I think knowing those layers are really important. And when you do an injection, the the only layer that really expands and acts kind of like a sponge is that submucosal layer. And so when you're injecting anything, if you see expansion or lifting, you know that that fluid is getting into the submucosa. So if you're using some other esoteric injections, like injecting botulinum toxin for gastroparesis, for example, and you see a lift or a separation with that injection, you know, you're delivering that into the submucosa rather than in the muscle layer. And getting that delivery, I think you'll demonstrate the delivery in a little bit, it can be a little bit tricky. And we'll go through some of the techniques for that. Are you ready for the needle? Yes. I'm happy to answer questions as well, by the way, feel free to reach out to us. We'd like this to be interactive. So if there's questions you have, please feel free to do so, to ask us. So this, different needles have different ways of working. But in general, there's some, they often have a way where the needle pushes out. Let me see if I can get a little better. The needle pushes out and then comes back in. You always want to have the needle handed to you or hand the needle with it back in rather than out for obvious reasons. And they have different mechanisms in terms of how they will stay open or stay out. This one just kind of holds itself in place through friction. In general, with any device, the straighter the catheter, the easier it will be to traverse through that catheter. So if you have a lot of twisting and turning in the catheter, it may not work as well. And if you're injecting a solution, this is ORIS solution, which is a colloid solution or ORIS gel, which I more often use in the setting, a colloid solution, where you really want to have a prolonged lift to protect the muscularis propria, a hot snare EMR or ESD, for example. And so, but this may be a syringe of any kind of saline solution. It screws into the needle. And typically before passing through the endoscope, we prime the needle. So we have the needle out. And then we'll inject, and I'm going to put it down a little lower so it doesn't inject onto me. We'll inject until we get fluid coming out of the needle, like so. Then we'll pull the needle back in prior to handing it. So I would encourage everyone to practice teching as well throughout your fellowship, understand the way devices work, because everyone has a little bit of a different trick. One of the other devices, for example, this needle, the, I think this is a car lock needle, is that correct? The way the needle gets secured to stay out is a little bit different. It doesn't just push out. For this needle, in addition to pushing it out by pushing down, in order for the needle to stay out, it'll spring back. You have to actually screw it in at this level to secure it, and then unscrew it to unlock it. So different devices have different little tips and tricks. It's worthwhile spending some time learning them. Confirm the needle's in, and I'll hand it back over to Dr. Sivu. Okay. Well, here we have, I'm going to introduce the needle into the scope, but I want to get a good area, a good view of the stomach. So I have an idea of where I'm going to inject, and I find a stable position, and then I push out the needle. And you want to just be mindful that on some of the other catheters that we have, there are markings that you know where you will be when the forceps will exit the scope. However, there are not markings on this. You just want to be mindful that you don't go too fast, and the needle comes out, or the catheter comes out without you knowing. Steven, I appreciate that you were looking at the monitor as you were advancing the catheter. There's a tendency often to look down at the catheter and not realize that you have 30 centimeters of catheter outside into the lumen pressing against the stomach wall. So I think it's an important thing also, the way you are putting the needle out, I think it's very important to remember when you're putting something out, to be looking at the monitor directly at the lumen, so I appreciate that you did that. Thank you. So there's not any specific target here that we need to treat, such as an ulcer or something that we want to inject, but I'll just take a look at this fold. You know, it's in a stable position, and when you advance a catheter over the gastroscope here, it will come out at this location here, at around the seven o'clock location, so you can see as you push out there, you can see the catheter coming out, so you always want to be mindful when you do have a specific lesion that you want to target, that you want to position your scope so that the catheter is in the optimal position. So you also want to be mindful that that needle is going to come out a little bit outside of that catheter, and so you don't want to be too close to the mucosa. So when you're ready, you can say go ahead and put the needle out. Needle out. So you can see the needle out there, and so as you can, you have the mucosa, you, we want to remember those layers of the mucosa, and we want to go through the mucosa and into the submucosa. So what I usually do is give a little bit of a pop to get through the mucosa and then ask them to inject, and based on how deep that pop went, I will withdraw on the catheter. There's more than one way to do that. I'll let you demonstrate it, and we can talk about different ways of getting into the submucosa. Perfect. And I appreciated that as, if you're teching, you want the endoscopist to speak up and tell you the command very clearly, and what you should expect as the endoscopist from your tech is to repeat back that they are doing the request that you asked them to do. So if he says needle out, you would expect the tech to hear it and say needle coming out, and inject, and then injecting, and if you're still injecting, injecting, injecting. That kind of closed-loop communication is really important to avoid any miscommunication, lack of delivery of drug, and adverse events. Okay, so we'll demonstrate that here. You want to be sure you're in a stable position, take into account patient breathing, that sort of thing, and so get nice and close to the mucosa, and then just give it a little bit of pop here, and then pull back just a little bit, and I'll tell, and why don't you start injecting? Injecting? And I stop when I see that it's not, that it's going in the surface. I'll say in Steven's defense, this is dead pig stomach, and it tends to be much more difficult to get into the layers. Some people will inject as they advance until they see an expansion. I often do it the way Steven does it as well, put the needle in and start injecting. If you don't see a lift, it's either too superficial or too deep. In this case, because it's such tough tissue, it's too superficial. So we'll try again. All right, go ahead and start to inject. Injecting. I'm injecting. We're not seeing much. We're seeing a little bit of a lift. Still injecting. Okay, you can go ahead and stop. Stop. And so there was a little bit of a lift on the mucosa here. I think it's sometimes hard to get that feedback of, you know, with that tissue. You know, if it's like we were talking about, it's a pig, dead pig tissue, so it's a little bit harder to get in than, you know, normal mucosa. So if you're having trouble, maybe we can demonstrate the other method of, as I push in the catheter, we can inject. That's one way of seeing how far you're in those layers, and when you see that blub, then you stop. I also noticed, Stephen, that your angle of injection is optimal here, around a 15 to 30 degree angle, where you'll maximize the amount of potential target you have of submucosa. If you're looking at the layers of the GI tract, and you, let's say this is the mucosa and submucosa, so mucosa and submucosa and muscularis propria, if you come at it, mucosa, submucosa, muscularis propria. If you come at it at an angle like this, your target is this big. If you come at it at an angle like this, your target is a larger potential target. So coming at an angle gives you more of a chance of getting into the tissue. You can't always do that. You don't always have the luxury, but if you can, that angle that you chose to come in, I think, was an optimal angle for injection. So we can try again. I'll see if I can get into a different spot here, so we can see a little bit more. There is a lift there. It's just harder to see in this model, but there's clearly a blue tinge, and you can clearly see that it's lifted and separated there. Yeah. So maybe we can try this area here, and see if, and just demonstrate that, where you start injecting as you're inserting the needle into the tissue, and then we can potentially see that lift in the submucosa. All right. So needle out. Needle out. All right. Go ahead and start to inject. Injecting. Okay. Go ahead and stop injecting. Needle back. Okay. So you could see, as I was going in, there was a lift on the, on that kind of distal aspect of it. And so I think that those are kind of the two ways that you can inject into the submucosa when you're trying to, you know, get at that, at that polyp to lift it up, so you can snare it. Good. All right. Excellent. Nicely done. Thank you. So now that, you know, we've demonstrated injection, let's try some clipping. So here we have one of our larger clips, the Resolution 360 Ultra Clip, and that's by Boston Scientific, and you can see some of the specifics on the, on the label here. So it's a, once it's open, it's 17 millimeters, so that's good for, you know, a large ulcer that you need to get around and try and get those, that normal mucosa on either side of the ulcer to kind of bring that together. And so this clip can be really useful in those situations. This is different than the standard clip, which has a smaller jaw. Yeah. All the clips, every clip has a little bit of a different, slightly different features. So knowing what clip you're using and its quirks are important. For example, this one, when you deploy it, you close and open it up again to push it out, whereas other scenarios don't require that. You just close it without opening it up to push it out. They rotate in different ways, I'll give it to you in a second, but they do open and close like a forceps opens and closes, and it can rotate if it's straight left and right. The other thing to know about a clip is, that's important is, if you look at the jaws of a clip and you close it, if you look closely, you can see it's not flush. There's a space between either arm of that clip. And that's a really, I look at that as a potential space where tissue should go into that space. So in other words, when you're doing a clip closure, you want to make sure that you're actually grabbing tissue, and I think we'll demonstrate some ways of getting more tissue rather than just a superficial grasp. But keep that in mind that every clip that you use will have a little bit of space between the jaws. There you go. All right. So again, when you're putting this device into your scope, you want to be mindful about where it's going to come out in the lumen. You don't want to be too close to the mucosa. You don't want to have any trauma as you're pushing that clip out. So like before, we're just keeping an eye on the screen as we're pushing it out, watching for that clip to come out. And again, it'll come out at that seven o'clock position like where the needle came out. So here, so we can see it and we can kind of turn it a little bit. What I like to do is get a sense of where I need to put that clip and then get it oriented so it's in that position. So when I go to where I need to place it, it's already in the position that it needs to be. I don't need to turn it around at all. So I'll just imagine that there's an ulcer here that needs to be clipped. So I'll come off of it a little bit and I want to try and be as stable as possible. And it does seem like it's in a pretty good position where if I open it, it will kind of come out in a good position. So I don't think I need to turn it in this case, but that is always an option. And you want to kind of see, you can see the length of the clip there. When it comes out, that's the length of the clip that will be when it's deployed. So you want to keep that in mind. So when you have a good position, you tell the tech to open the clip. So go ahead, open, opening. Then I like to drive in the scope a little bit, get in the position that I want to be in. And then I want to push out my clip so that like Dr. Paraka was saying, you get that tissue into the clip that into that potential space. So I want to try and drive in as much as I can and also push, give forward pressure. And then I say close, closing, we'll close the clip. And then if it's in a place, if I don't like the position, I can have him open and read and I can readjust. If I do like the position and I want to close the clip and deploy it here, I tell him deploy. And so go ahead and deploy. Deploying and this tight squeeze until you feel a click, sometimes takes you to click and then you have to push it, open it back up to push it out like that. It's out now. One thing I'll mention, Steven, is that how you position the clip similar to how you position the snare is partially dependent on your angle of approach onto it. And this straight on is ideal and pushing forward is ideal to grasp that fold. But if you have something that's at six o'clock and is oblique, often similar to placing a snare around a polyp, you'll have to come up, open it above the lesion that you want to grasp and then deflect down so that you have, instead of having a straight on grasp of tissue, you come obliquely and get tissue to kind of push up into that space between the jaws. It's really dependent on the situation, but you're trying to end up with something similar to what you see here, which is actual grasping of tissue. And needless to say, there are some ulcers that are too big or fibrotic that clipping won't work. So you have to also be selective about what you've been using this modality for. This is ideal and it was a very nice demonstration of actually capturing tissue, but keep in mind that sometimes, often it requires coming obliquely and deflecting your tip down into similar to a snaring polyp. Yeah. It's also helpful to kind of think about the trajectory if you are doing this for an ulcer to kind of imagine the trajectory of that blood vessel and place your clip accordingly to where you'll get maximal hemostasis. Right. Right. So we've demonstrated clipping and injection. And so we have biopsy forceps that we can use. Now these are, you know, a Boston Scientific biopsy forceps. These are a little bit unusual in that it's a hot biopsy forceps, you know, the majority of biopsies that you'll be doing are with cold forceps. It means there's no cautery attached to it. These are used in certain settings where you want to stop bleeding in certain scenarios, but for the vast majority of times where you're biopsying stuff in the, you know, things in the stomach or colon, you're going to just use a cold biopsy forceps. So for historical reference, when I trained as a fellow, we often use hot forceps to manage polyps. Smaller polyps would grasp with the hot forceps, tent away from the base, step on the cotter until we saw a ring of cautery around the base of the polyp and then remove it with the idea being that the cautery would kill off the polyp. It has come about demonstrating that that's not adequate. And so it's largely gone away from that usage, but it still can be used, as you said, for cauterizing vessels. When you look at the jaws of the forceps, you'll often also see that it shows that there's, that it opens just as regular forceps, but some forceps will have a needle in the tip of it, which will be there explicitly to try to get more than one bite of tissue. In other words, you bite tissue a one bite, and then that tissue gets stuck onto this needle and then you can bite a second bite to get two bites instead of one. This one, I believe has no needle in it. So this would be a single bite intent forceps open it. No one wants to use hot forceps anymore, it's a deterrent, oh I see, thank you. Pay attention to the packaging. We'll take off this tip and as expected, there's no needle, there's no needle in that jaw. It's just straight forceps. I'll hand it to you closed. This particular brand of forceps has markings on it. You want to talk about the markings? Yeah, so the markings, so these are helpful because you can see how far you are to where when the biopsy forceps will get, will exit the channel. So there are two markings on this, these forceps, this one here, the first one is for when it will exit the gastroscope, and the second one is when it will exit the colonoscope. So keep that in mind. And so, you know, you should still have your eyes on the screen and know where you are in the stomach, et cetera, but you want to also be aware that this will tell you when your forceps are about to exit the channel. All right, and so the same principles when we're taking forceps apply as to when we were doing the other maneuvers. So again, take note of where the biopsy forceps exit on the screen, and then you want to find your location and then maneuver the scope so that it's, you know, in a good position to where you want to take that biopsy. And so I'm going to just try and take a little biopsy of this fold here. And so I'll have them, I'll have my technician open and then I can either put, you know, push my scope into the lumen where I want to biopsy, or I can push out the forceps. It depends on the positioning of the scope and where you, you know, how stable your position is. So conventionally, it's the same idea here where there's potential space between the jaws of a forceps that you can also get tissue into the jaws of the forceps if it's, for example, in the esophagus or tubular area where you can't get on phosphate with it, you can laterally put, you put the forceps adjacent to tissue and then deflect into it as well. Similarly, you know, as a way to get the tissue into it. But conventionally, this is most commonly how we use the forceps, right? So go ahead and I'm going to push out my forceps. And then once I'm in position, I'll have him close. So go ahead and close. And then I'm going to pull back on the forceps and it'll take that bite. And like we were saying before, most biopsy forceps, the cold biopsy forceps will have that needle. So you can then go out again and take, you know, a second bite with that first one stuck in the needle. You want to show a lateral bite, like opening, deflecting laterally? Yeah. So go ahead and open. And then you can just kind of deflect like that. Go ahead and close. And then sometimes you can gather a large bite that way too, because you're pushing a lot of tissue into the forceps. But yeah, okay. All right. Go ahead and remove that. So I'll send that off to pathology. Benign dead pig stomach tissue. I'm not going to resonate with the clinical scenario. All right, good. Do you have any questions at this time about injection, clipping, or biopsies?

upper endoscopy techniques

gastroscope manipulation

injection techniques

bleeding ulcers

clipping techniques

biopsy forceps