A large, lobulated, hyperplastic-looking polyp extending from the GE junction down into the stomach in a patient who was post-gastric bypass. And we started the dissection. This is well into the dissection and really encountered a lot of bleeding. So here you see a bleeding vessel. And one of the first things that's important to do is to not panic. Here you see me actually place the cap on the vessel and suction. And then in time to have enough time to get the coag graspers down. There you could see that, I'm just going to pause that for a second, that while I have coag graspers on what I think is the blood vessel, clearly you see it's still bleeding. And what's really important to really effectively coagulate these vessels is to accurately target the vessel so that you're bringing both sides together. So I actually let go and I reposition and then grasp it. And here, I haven't even applied energy yet, but just by tamponading it, you can see it stopped so I know it's the right spot. And then I'm using settings of soft coag. You wait several seconds while it bubbles to really know that you've created coagulation. However, there was still a lot more bleeding. And here, just to demonstrate for one second, again, using water irrigation and your cap and really being patient can actually show you the source. So this is a split vessel where both sides actually have been open. Probably one that was grabbed by the knife, but not grabbed all the way through. And that was an SB knife that we had been using in that situation. So here, again, there's a lot of clarity that comes from just irrigating in order to be able to visualize the source of your bleeding. Here we're, again, we use a different knife. Here's the IT knife. And bleeding is starting. And just when you think, I think if you had seen throughout the procedure, I'm just going to stop that for one second. We had kind of seen those vessels, seen those vessels open, but not bleeding. And there's some who might think that, well, if it's not actively bleeding, then you can leave it alone. But likely what happened is that pressure built up a little bit and you can see that these vessels are a couple of different vessels likely coming off of a larger vessel here. So it's important to make sure that you actually treat any of these visible vessels. Sometimes you really just have to throw your arms up and surrender to the procedure. I would say the bleeding took up most of the time during this procedure. Now because of the concern of other underlying vessels that could be open and the tendency for GE junction lesions to bleed, the resection beds to bleed, we decided to close this lesion. Now this is another version of suturing. This is the X-TAC system by Apollo, where you actually, the tacks are attached to sutures. You place them on all sides of the lesion, so you're not taking a full bite through the actual mucosa. You're just screwing the tack into the mucosa and that's attached to a running suture. And then at the end, so I'm going side to side here, distal to proximal. At the end, we will cinch this just the same way you do with a regular suturing system. So this is the fourth tack going on, and then we'll see the device, the cinching device come out. And there you see that, and then we'll cut that and we'll close this.

surgeon

dissection

bleeding

control

X-TAC system