Chapters Transcript Video Archbold LIVE! Case 3 - Gastric ESD Originally Broadcast: September 29, 2022 | 8 AM - 5 PM ET Case 3 features a Gastric ESD performed on a 3.5 cm adenomatous gastric polyp with high grade dysplasis without deep involvement. All right. Welcome back. We're about to start our third case of the day. This is a 63 year old male who was developed for dyspepsia. Postprandial abdominal pain and weight loss of over £40. He had had a recent normal colonoscopy performed in E. G. D. With the finding of a 3.5 centimeter mucosal gastric mass at the greater curvature. This was biopsied with up with focal high grade dysplasia. As the pathology results patient underwent an endoscopic ultrasound with findings consistent with a gastric lesion that was limited to the mucosa. This is a 3.5 centimeter adenomas polyp with high grade dysplasia without deep involvement in the stomach plan is for a gastric E. S. D. All right. No ph Alright so this is the lesion and this is something that we don't get frequently in the US. Which is an early gastric lesion. This is what you're supposed to learn is DEON. Um But in the US. Unfortunately you have to do some colon when we published the learning curve that I had. Even on my second or third year, the column legions were dominant in the mix of cases and the first two or three years. Actually, interestingly the sub epithelial tumors were dominant. Things like cash annoyed. So, you know this is a nice lesion that you're supposed to start with. It's not in the very proximal stomach. These are very difficult. It's in the mid stomach. Even better when they are distantly down here. But mid is okay. So this is this is one of these infrequent lesions in the United States now because high grade displeasure as the mayor here that we're gonna use the this is we're using a food disco food. The scopes are a bit floppy er than Olympus scopes. Maybe because of this. The retro flax better here. We may not need red reflection because it tends to be towards the greater curvature here versus posterior wall. Can see atrophy of the mucosa. This worries me. Elderly patient with a trophic looking because you tend to get not such a great lift and you have fibrosis for unclear reasons. Even though this polyp hasn't been manipulated much except for the biopsies. So, we'll see how it lives because the lifted. They're not so good. Ah So there are many ways to do this now. All right. So, you can do um you can do a circumferential incision and use traction to the opposite world. Will work great here. Okay, Because it tends to be a bit on the gravity side and it's a heavy tumor. It's like a bulky tumor. So, you might need good traction. And you can use the prodigy wire from May tronic. You can use the I do my own loops. Little nylon loop with two clips can work. Have to make a big loop two centimeters because you see the distance from the world. Unlike the colon where you can do 111 centimeter looks smaller. That's why the product it doesn't work very well in the colon due to the proximity of the loom. And I have two centimeters and three centimeter loops, even the two centimeters for the colon is just too long. So I'll make my own. I'm gonna show you this on the next case. Other strategy is you do a pocket or slash tunnel technique. So you do an exit incision right about there, you do an entry decision right about there, you tunnel underneath. That keeps stability on the scope, you exit on the other side. And then you can get the two lateral attachments with her with the same knife. But this can be difficult with a short knife. We're gonna use a short three millimeter knife. The lateral ones. You could use this hook knife that is five and hooks well. Or you can use a seizure knife works great for lateral attachments. You just have to make sure you have a good margin because the caesar knife tends to bring you more towards the specimen. So you need to make a good margin if you're gonna use the caesar knife for the lateral assessment. Um Final strategies to use a device such as track motion. We're gonna try to use it here. I don't like that, it's on a turn but we'll see the track motion. It's good that it's on the six o'clock to seven o'clock track motion. The worst position you could have would be probably the two o'clock or one o'clock, two o'clock because the device is big and it needs to go out the big channel of the double channel. So that means it's always on the right of the view and the knife is on the left of the view. So you, it's best to have lesions on the bottom left quadrant of your view for the track motion. So we'll try to get the track motion here okay with a double channel scope. But first for that, you have to make a c compressor incision and free nap of the flap to be able to have enough to grab with a track motion. You can see here. Um you can do zoom to look at patterns. Very nice. High level zoom here. And you can do, sorry, you can do the N. B. I. Equivalent with his um the blue laser imaging be alive. Very good views. I mean, I don't see any evidence of cancer, like the japanese have this concept of a demarcation line for gastric cancer. Um we don't see any demarcation line with a change of pitch pattern. Okay, so it's a very high level zoom. Now I'm gonna go down on the zoom. I think I'm going down the zoom. Hold on. Okay, what am I doing? No, I'm going up. How are you? Okay, let me get off the zoom. And again, very good. Imagine with A. B. L. I like monochromatic imagine. Very nice. Doesn't use a filter like N. B. I. Does. So you tend to get a brighter kind of N. B. I. So very nice. But here we don't have anything any bit pattern that is significant to show. And it looks pretty good. And listen to my westernize and we're better at the colon and the stomach for sure. So. Okay. Alright so we'll do the circumference incision and then try to use as our traction technique to speed up PSD will do the track motion grasshopper through the double channel. Alright so let's try to inject and see. Well actually no let's try to mark in that column. We don't always mark the market is clear in the stomach I think especially when it's on a turn. And as you are doing your incision you make very close to the tumor. It's good to have some marks to follow. Okay so and you can use any number of currents here. Very nice. Like the good you should be very thin, you should use soft coagulation usually. No but in this nasty gastric mucosa we can try forced and if that doesn't work you can try spray. Um So we can we can and then we need at least a one centimeter margin here about a cup's worth of margin. So we can try they're forced and see how that works in this new cause like maybe that not bad unless it slaps off. Let's see reasonable. So I'm gonna continue with forced see here there's something here that it's hard to know if it's intestinal matter pleasure or not. Um Probably is probably intestinal at that place but we'll go just outside of it. See here I'm gonna have to reinforce this. So there are other little patches of intestine with pleasure here. This is getting a little nastier and has amusing and it's on the gravity side. Maybe a little spray here right there and we reinforced that one too. I was right And reinforced that one with a little spray. Yeah, spray. Like I say it's all better and then go there's a fold here. I hope it doesn't contain vessels but there's a fold here. Dr Kumar did the U. S. I think so a vessel. Anyway we have to be careful on this side. The stomach usually one side is more vascular than the other. The one that is either closer to the greater curvature or the lesser curvature because that's that's where all the penetrating vessels come in. I think the marketing with spray is a bit like marketing with a pc. Just have to be careful because it can easily go too deep. Well I should go on the outside here right here. You may think I'm making a big margin but vascular tumors near the greater curvature can be very vascular so You know the minute you coagulate a vessel at the Mucosal incision that you're doing repeatedly because it won't stop bleeding that goes five of your margin. All cooked and shriveled. So you know it may not look as big as it seems if you get a bleeder. Okay, well let's do a little tighter formation right here. There's a lot of vascular movement of this area. I saw them moving around. Okay, we're a little close over here. I'm gonna try to go outside the marks. I don't know. Okay, so now let's clean the knife a little bit with a brush because this is the pro knife from boston which injects through the knife through a tiny hole um Similar to the hybrid knife, but it doesn't use a pump. There's also a knife from Micro Tech that also has a little hole in the front except an even smaller hole than the Boston one. Um So these are the three injecting knives through the knife. And let me have the Olympus J knives. Do a hook that inject through a catheter. The flash knife from the injected through the catheter. The catheter injectors that inject reporting the catheter much weaker injection than the ones that inject threw the knife and much weaker than the hybrid that interacts with the knife with this very high pressure pump. A pump with a hybrid here. It would be five millimeters long, very thick and you can perforate much easier. Um So it's excellent for poems IPO and where you have a straight tunnel where you choose here. There will be parts of the dissection where perpendicular to the wall like here. This is where the perforation is most likely to happen because the depth will be the deepest over here. So especially if we cannot get good injection because of all the stomach atrophy. So we have to be careful. So we're gonna use the pro knife. There is two millimeters. Three millimeters. Maybe two is good for the color. For stomach mucosa can be fixed. So we use the three millimeter manual injection. We'll use the gel. Okay we'll use the gel. Um Okay and see how it goes. And generally you injected this talent first. The proximal end which is usually the easiest last a lot. This area here is not gonna be easy. Um See this if you inject this area from the front. The back will become very difficult because I can hardly keep contact with the wall here. So this particular area, you definitely have to cut this tall to proximal um The rest is debatable. But here we definitely have to start distancing. You don't want to start with a difficult area first because look how tangential I'm getting the right lift here can be problematic. So you want to get to it after you already have lift going and the proper depth of injections. So we want to start really. Maybe from here and come to their by lifting lifting, lifting backwards. So let's start with the needle injection to try and find the correct depth. Instead of situations you can just inject with a knife you make a little hole in Jack Cut in Jack. But here, I'm just not even sure how well it's gonna live. The greater curvature generally is the worst lifting area of the stomach. So there's a question about how to take control of a large flat lesion behind the clonic fall. Which might be a question. I have to get control of religion behind a colonial old retro reflection. Retro flex. Whatever way you can do it. There's the Olympus. Very nicely retro flexing colonies. Disco the 1 90 tl I. Or something called which I'm gonna use on the next case for the colonies day retrofit has a short bending portion similar to gastric scope as opposed to the double sized bending portion of the colonial. So it does a nice tight retro reflection. Or you can use a gastric scope. And if it's you can get it there, you can get it there. You can get it there with a dill uman so that reflection for U. S. D. A. Would be key If it's a very hidden lesion. Anything else could you lift enough to get it off the fall? Yes, but again, you can use the cap to push the fall down and inject you lift that. You can do that. That that would be the two obvious choices really? Alright so we can try and start here. I can go into the hole. A lot of movement. He's paralyzed, right? Very well paralyzed. Okay. It's it's it's really vascular movement. It's not respiratory I don't think so. We can build. Yeah, very jerky movement. Okay so we can inject right there and I'm injecting the whole so that there's bleeding. It's gonna be where I'm gonna cut you. Inject inside of the hole and there's a bleed. Then coagulating the bleed. It's gonna lose your margin, which is terrible. So. Yeah. Exactly. Exactly. Okay. Stop. Let's see what what happened. Not bad. I would say. Not bad. Okay let's start to inject here now, wow. Right, difficult stability. Okay there inject. And then when exactly pull the needle backwards because otherwise the injection will go away from where you're injecting because you're not letting the to expand because of the person. I'm not basic. But with the meat, the lift starts, you have to put back on the middle. Because if you keep the compression of the sub mucosa? I'm not puncturing the to avoid bleeding. I'm just squeezing the needle onto the southern coast. So if you keep the pressure on the injection will go away from your injection point. Yeah. As the lift start you have to take the pressure off but still keep contact. Okay, inject. See I'm taking the pressure off. Inject. Inject inject. Okay um Alright so we can we can start the incision and see how it goes. Looks very bloody. And we can see something vessels everywhere here vessel vessel more vessel. We have to use dry cat for sure. And we have to move glacially slowly so that knife has time to coagulate as it goes. No rapid cutting. Did you clean it? Because the spray tends to clog the little thing We are dry cut 5.0. For those that are keeping track of the Carrots we use so five similar to everything I do like the poem was probably drunk at 5.2. So drag at 5.0. Making a little functions and make sure I don't run into a vessel immediately and then cut a lot of movement. Though this is gonna potentially be a problem. A lot of movement. Okay, The other thing you can do is deflate the stomach a little that may take it off whatever vascular structure is pulsating and it will make it pliable enough. Where with a cap, you can mold it to your desires. So even with the deflation, still a lot of movement. Now you can use the injection of the knife. Inject their inject hard. Now you have to inject. Okay, surely. Where? Surely, No, this is a learning curve. You've got to inject to the point where, you know you may blister your hand, otherwise it's not gonna go inject. Surely do injection. So. Okay, and Jack hard. Okay. Mhm. I'm using precise here because there was a little bleeder. Okay, now, I'm very tangential. Again, suck the stomach down so I can bring it more vertical. I'm gonna try. This is not injected with a needle and try to inject with a knife. But again when it's good injection go, no I'm not doing it. Go go go go go go go. Okay. Yeah but see it's bleeding. So that's that's where the advantage of the puncture is. Because it's not a slice. I can leave it right in the puncture and do precise. Hopefully it's gonna get it. Find that the water pressure technique. See the incision Now I'm gonna lift and inject under that bridge of mucosa inject exactly exact hard. You got to tell me how many cc's, I know what the speed of injection is. Obviously injecting gel through this knife is painful and hard work. But we can manage. I'm gonna just cut here. All right. Change in water. It's a part here. Yeah. See we're already losing margin over here. What happened? We're losing margin. So I'm gonna go outside the marks here. So there's a question about how does how does priors you know use of heat or scarring effect or impact your dissection? Well adversely any prior manipulation goes there's more scar tissue. Many studies that have shown that it prolongs the S. D. Increases the risk of perforation. So yeah so other instances whether to make it impossible to do it or what sort of issues might one run into. Well impossible. No that's the failure rate. Even for experts that do manipulated lesions would be, Well proficiency is 90% successful on block excision. That means for a proficient person that should fail to do an unblocked excision by S. D. Less than 10% of the time. Now if you get to master it this should be more like all right. 1, 2%, 3%. And usually it happens either because the position is impossible or because the severe fibrosis either way or usually for which we are master. It's usually both bad position and fibrosis and possibly a complication either to that that makes things very hairy like Perforation in an impossible position. Maybe with bleeding in the perforation. Something really. Here there is the master. These are the 1% or 0.5% that you may have to abort. See how this is trying to eat up my margin there. Um This is where you can use the forceps to stop it because the more I use the knife the more I'm gonna lose margin. No this is not a force that this is a small co a grasshopper. We need to be very precise. I need the small koa grasshopper. I don't lose any margin unnecessarily. Is this a colonic one plus a small one. Right. Oh look at this. It's stopped by itself. No. Okay well no it's not a colonic one. A small one before. Mhm. Right. Alright. We'll stop myself and give it enough time. But we have a feeling you may need it more than one so might as well get it going. So, yeah, I mean, there is some argument to be made for using the hybrid knife despite being big and fat. The injection is gonna be massive and that may be a lot of help open because I'm not getting a satisfactory injection here. Close. No open. Close. Close. Alright, so, let's continue the cut. It looks kind of ugly because I'm using a lot of coagulation. But you know better ugly than having to deal with the bleed and lose, you know, half an hour trying to I'm thinking I'm beginning to have recurrent thoughts about using the hybrid knife. The lift is very pathetic with the gel because I think of the type of sub mucosa open. And maybe the knife is also partially clogged. And we need good lift here. So, I'm gonna give it another try here. But I need to be able to inject that will at very high power. Okay. Okay, well, fine. Let's clean this. I'm using precise not even dry now because it's just so many vessels. Inject Jack. Jack. I got a little dry there. Ah He's bleeding anyway. Exactly. All right. What the building now. Inject, inject inject. Okay, There's a vessel there. There's a missile there. The vessel everywhere. So, this is under the new cause I can try to eat up my margin again. Okay, give me the forces. Yeah, I think this side is the vascular side. This is where the angle is right. This is where that fault was. I mean, look at this artery there. To the right is the artery and to the left is the vein. The dark red is the vein. And see the minute I throw water it collapses. And the right failed one is the artery right there. I can't zoom in I guess. Huh? Doesn't work well. Okay, let's do it. Which which 1? What are you giving me? No, the smoke grasshopper. It's me. Okay. Right, okay. This is not a small car grasp. Okay, but it's okay. Just leave it. This is the big car grasshopper. Okay, so that's done now. What to do with this here? Um I would use the small one because otherwise I'm kind of coagulated too much. Let's continue the incision for now. Give me the knife when I leave it for later and I need more exposure. Mhm. Back. Okay? How funny. And Zach. Nice, Exactly. Mhm. Ah. Exactly. Alright. We made that turn. That was probably the most difficult part of the incision. And there's a big vessel bundle where that fold was right there. Okay, let's continue now around, inject Jackson Jackson. Jack Jackson. Jack. All right, okay. Exactly. Uh Well, even with precise sex, we keep getting these vessels here. Sure. Oh, man, yeah. Okay. We need the small forceps the small progress for that's a nice cherry. Right there, pulse. Odile quickly. I'm getting dirty on the water lost. Too much time on this. Well, I'm dirty water. All right, and it's on the gravity side. Tiny other but the department open close close, right. Yeah, it's not working Well, we had that window. We just So is this something where you inject your step? Tried? Very interesting one. Buzz. Uh some gravity covered by bloody water. So or we don't use your I stood here. There's has to be able to see because it's going to be covered by this. Oh, that's it. These things. You have to work fast. Had a view for about five seconds, 10 seconds by compressing with a cap and isolating the leader cannot put the forceps in those 10 seconds, then you cannot. So why don't you compress it with the cap to stop? Yeah, but it's an art. You know, I was compressing it, but I would still get a little spurts out. No, but in this in this situation where on gravity have two options. Turn the patient on the maybe right the cubit, get everything off. And then, you know, you have you find it and you stop it? I ran out of section ran out of section. Can I change the world? So we have run from pure stat. Is this something that you could actually inject in the area and see if it would be effective section trying out so you have to dry it out before you inject suction. So you wow. Well, if you don't want to turn him that we have to empty the water. Sometimes the bleeding slows down because it forms a clot so it may give us an opportunity to stop it. If he keeps bleeding without clotting, you really have to turn the patient before you go to turning the patient, would you try to maybe spray it with some happy or there's a hole in a 1.5 millimeter artery? You know, it's not gonna stop. I don't think I guess that's a desperation. I mean if you run out of other options, I would spray, I'll be sure in case it's contracts enough that little latter to slow it down. But usually if you take the time to turn them you then can do it. Yeah. Oh this is a not a typical situation for greater curvature is the lots of vessels and that's what slows you down in the storm are bleeding and all those up on miss trials or training for training trainees in the S. D. The most frequent time that the the trainer has to take the scope from the training is inability to control bleeding. That's the most frequent cause for the trainer taking the scope from the training gonna be pretty annoying. Okay, let's see where we are. Let's see where we are. Let's see the tree, This is one after he's doing a number. Yeah, we're gonna have to turn the base and this is not stopped. I'm inflate the stomach first on. Don's count. You would never done horrible. Turn 2040. Huh? Wait, Let Me Flight 1st. Hello? Hello? Yes. No. Okay. Now the question is, did it stop enough to um I think it's locked the door. No, maybe not. Okay. Give me the hot forceps quickly quickly. The key word is quickly here before I'm covered with bloody water quickly. Okay, well you have another five seconds I think before. I can't see it anymore. Wow. Are you connected? Okay. People have the wrong way because that's where it is soft. Right? Not the Tampa. Another little no, impressive at the very top. Open gloves. Okay, open slowly if it opens, wow. Uh huh. This guy has got me in trouble. It's still losing that. Okay. Yes. Okay. I'm gonna use the hybrid knife. Yeah, we need to have more robust injection. Otherwise we're gonna be running on all the big vessels much in trouble. Okay. Hybrid. I thought I did a generous margin but with this kind of bleeding, it's not so generous. No. So the hybrid. So, so there's a publication but that says the how the vascular charity works. So you have big trunks, right where they enter the muzzle and then the arbor rise everywhere. So you do what you do is the best at the plane where you get the trunks that you can coagulate and then you have to deal with all the branches. But that involves a robust injection. Let's go. I think we're getting all the branches now. I think that's what's going on. We'll see. Okay, open. Okay, let's try this injection now. Okay. Also it's a thicker knife that it's more I'm hoping that that will deliver the goods here. I'm doing precise circle regulation with a very fat knife. So that's our best chance of not having to deal with leaders. All right, so far so good. That's continue lots of precise. It's gonna look ugly, but I don't want to have to do with leaders. All right. This side should be relatively a vascular because the other side must be closer to the penance right there. That's why. So, this side hopefully is gonna be better. We'll see. All right. Also with this now, if you can suck better. There's 2.4 mm instead of the father knives. Like I have to stock all this. Okay, we're gonna have to do the other side. Now let me spray. All right, Well, now I'm pre treating with spray for every card. Right. And then shit bleeding. Close the knife close the knife. It wasn't nice. Okay, where's it coming from? I guess from multiple places. One like that Margaret. Give me the hot forceps forces close. So the vessel hiding to the right there. Okay, what would I do? We're gonna try to calculate it like that. Well, it's not like that squared up another small lottery our plan open close, wow. I don't want to stop actually, that's the bottom side. Now that's the bottom side like that. All right. Let's continue. So there's this question about what diameter and length of the hybrid knife is the optimal choice for robust induction and graduation length of hybrid knife. The hybrid life only comes as a five millimeter long night. There's the I. Type which is straight and the has a disc. I use the eye type for more precision because you can see exactly what the tip is gonna cut. Um You can try and use a technique that makes the hybrid knife more like a dual knife by only exclude excluding half a knife. So you can try that. But you can try. The problem is it tends to not stay there like you can try go back and then go in and then go back and try to keep it at the length of these two or so like that. Yeah. Leave it there. It may not stay like every time you bend the scope there is relative movement of the knife in the Catheter so it may not stay there. But some people do that for poem too. They use half a knife. That's good when you cut like here, you know obviously we don't want to pay for it. So you know using half a knife here. You know maybe useful. Thank for coagulation really. You need to cook a vessel. So you need a lot of surface area. So you can use the whole knife, the side of the knife. It's also a fat nice on the side of the knife decreases the current density. So yeah. So you use the side of the knife And the length. You can use a good length 23 mm at least. Now let's go the other way for 10. All right here. Ryan stable. Oh, okay. Yeah, vessels everywhere. Okay, give him the forceps. The artery is everywhere. Hello, Neil. Let's go. Okay, so we're gonna use the forceps. So the hot forceps here is better because half margin. I'm all the way out there. So I don't care if I have a bigger footprint on the coagulation. I care about cutting it on the first shot instead of looking for it. So the force is bigger. You can grab at the approximate location and hope you get it open. I want to close. We get it. Yes, Galvin close. Alright. I almost want to dissect with the force. Save us time with all the regulations we have to do. Let's inject decide some gel because it's not that we aren't fast with the muscle that the Khyber knife is not injecting. Well, if I try to make a deeper hole to inject, I'm prepared for it. It's I'm completely perpendicular to the muscle. So let's inject the needle, create a cushion on this. This is the highest risk of perforation is here because of our own fast location. Okay, I've been okay. Go, go, go, go. Okay. Now not a great injection. Let's see how about here. Open. Okay. Now I'd like to do this side. Lots of movement. Okay. That inject. Yeah. Nice girl. Okay. Stop. How about Okay. Nice. Okay. We have somewhat decent injection here. How about care inject. Now know they're inject. So. Okay, inject Children's is pregnant, exact exactly. Okay, now we're gonna do here. Go to that. Inject. Okay. Nice. My God. I think we're good. Okay. Okay, give me the knife. Let's take the opportunity to empty the water. Yeah. Don't run on. Run out on the section again. Well, let's let's take an opportunity to clean the knife too, I think. Thank you. After I'm done with all the bloody water. There's a lot given the section in this section to bring. I'm gonna talk to the biopsy channel. Can you push the scope in a little to the pool? Okay. Thanks little more. Okay. What happened with my it's clogged you got it all. Is it coming? My section is weaker. Okay, connected that. Clean the knife. I mean, given the scope or, wow. Okay, you can spray. Right. And uh Okay. Where were we? You believe in me again. Okay, let's go. What happened to my scope? Okay. Okay. Let's go wrong one. Let's go open. Okay. Let's inject What's wrong with the injection. I'm not getting anything. Well, it's there. Not much, Huh? I'm not sure why this is happening. Okay. Oh, right. Mhm. So is this all bleeding? Because you're not in the right point. Well, is it just that it's more vascular? That's very thin that trophic cause us. So, I think we're going deep when we do the incision and we're getting some trunks and we're also in the greater curvature, which is notorious for being vascular. Okay, coming back to the final 5th of the incision. Mm hmm. Yeah, I used I used dry car to clean the knife, but there was another vessel there. Forceps. Yeah. Another puzzle. That lottery there. Small one. All right. Let's go dr what comorbidities does he have on the Okay. Open. Ah Of course. Well, when you already let me know we have a what? No. All right. I thought that was done. Show him the forces quickly. Come on. Come on. Yeah. A good opportunity. Hello. Open. Alright. We're done with the incision. That was longer than expected. I would say. I don't see there's any other bleeders using all around there. Was that big hidden one there that we ignored. Let's take let's take care of it now. Right. Give me the give me that big clock Glasper. Yeah, difficult. So, which one are you gonna tackle first? The vein of the artery? I'll try for I'll try for both. I really had a choice. The artery. But they're so close together. I think we'll end up getting both. But I'm going to focus my efforts on the artery that the vein normally. How we're touching it. It's gonna shrivel away voluntarily open. Get down to the right a little. Okay. Close. I'm trying to stay on the margin that will not affect my specimen regulation. It's still burning my eggs, which I don't like. So, we get it. I hope we got it like cut. Let's cut. No. All right, okay, You can stand on the family life solely. There's something else bleeding here or all clock. Okay. Now, we need to um um We need to free up the flap a little If we're gonna try the track motion. I'm not sure how I feel about the track motion. We'll see. Let's see what the flop does because I'm afraid the track motion is gonna tear the eggs here. It's very nasty, granular a trophic mucosa. I don't know if it's gonna and there's no you know if you cut some new cause I can get away with here. We will not have a good handle for the track motion. Yeah, we'll see. We'll see. We may get a good margin. We're gonna get a good grab here where the margin is. We'll see. But right now, I don't have healthy mucosa or healthy sub mucosa, which you will need to have a good grass that will not tear off a chunk of my margin. We'll try to create a flap. Maybe we'll get to better some new clothes open. I kind of doubt it though. These elderly patients with gastric atrophy that don't have a very vascular and don't have good sub mucosa. And they're all that way in the west. If you get them trying to bleed already. Unless you're in a community that has asian patients, even the intestinal type lesions you get I am this elderly a trophic gastritis, patients with a lot of vascular charity and not general sub mucosa director region that will have for track motion would be much more pleasant than this. But I wanted to show a gastric lesion also. Uh Western gastric lesion. Give me the four set. Okay. Yeah. I don't know about the track martian on this one. I don't know. Let's go. I don't think we're gonna get to get some new cars so that we can grab. It's a fight millimeter by millimeter. Fight. Nice. I got this. I had another vessel hiding here. Yes, it is, isn't it? It's another actor here open plus. Okay. Alvin give me the knife. Yeah. Not very exciting. Something because of playing. Huh? I Yeah, let's see I have something because I hear on the right let's try to make use of it open. Mhm. Not lifting. I'm injecting here with a hybrid knife. Very limited lifting, wow, look right here, we're getting very little left. I mean, do you feel that the cosa is not substantial. Not picking up or do you feel that it's fi broderick or is it just that it is plastic. I mean this is five brushes and atrophy. It's like classic and elderly. There's a traffic request and patients with lesions. Yeah, it's just not nicely lifting sub mucosa. Okay. So we're gonna make do with what we have. That's why it's important to make a good margin because our margin is of operating because of all these bleeders. Okay. This is wobbly. I don't know why like so both are wobbly and I'm chasing them around. Also using a lot of spray Basically contracts the sub and getting extra heads were here there was a vessel the minute I used I had three of I used spray. It became one millim or something because the whole shrunk. All right. I mean, I could use the food but I don't think we need it for sure. So don't delay. But the is tapered. We might get a better view of this small submit causal plane. Okay. And water pressure right there. This is terrible something because my good left not getting good lift. Let's welcome. This side looks the most promising. I would say it's also the gravity. And so it's not gonna flap over as if we free it up. So I think this is dry right, dry cut. I'm gonna try to lift the edge and inject it like that. Like suck the stomach down, lift the edge. Inject it. We'll get a little bit of lift. That's a good list reasonable. All the water founders. Okay. I want to go into the water. Just sack the sack, check the suction canister and make sure it's not about the film because there's a lot of liquid. I think that does. If we free up one end in the end then we'll apply traction and we'll be saved. We just have to free up whatever end is the easiest. So I think we'll work on that gravity side. Try to get a centimeter or two and then we'll apply traction with what I'm not sure. It depends on how the sub mucosal looks because I look sturdy. I'll do track motion. Don't look so sturdy. I'm gonna just try a clip. Okay, empty the water. How's the canister? Okay, can you change it? Mhm. Okay. I don't have any section now I do. There's a lot of bruising and bleeding here. Mm. Yeah. Pretty vascular. I thought this was I wonder if I can get the clot out too. There we go. Alright, let's see where we are. So we're gonna work on that edge. Work on that edge. There's more stuff. Okay. Okay now we're empty. Okay, let's work on this side. Yeah. Okay now let's do it lifting Jack right there. Okay. And then lift here and you drag. Not super exciting what you'll do. Exactly and that I mean check ah ah I'm great. I sliced them because All right. But you see how how thin the new cause I just the knife slips and it's like I did an E. S. D. There in the mucosa. Okay. There we go now. Maybe try a little landau cut here. Yeah. Because I can see what I'm doing. And we need very precise cutting underwater. I I very thin wall layers. I'm right perpendicular to the muscles. Be careful. We're getting artifact on the scope. I don't know. Something is not grounded and yeah. Okay. That's not a very fruitful approach. Let's try this side now. No upside down. There's that that whatever you want to come in here. How much more? Not much. Yeah maybe a couple of 150. How Much? 215. Based on one. Oh understand. Oh my god. Yeah. Give me um give me a clip. Remember again. The Olympus. Okay so there's a microburst there where we're coagulating that vessel. So the muscle was burned and it fell apart I guess eventually. So you wanted the middle ones or the petition the little Olympus clip. We're gonna do a micro mental part there. Where's the clip? So that's a bit of the momentum peaking out. I use it to plug the. So did you pull it out or did it pick out on its own that flags it up. There's no risk of contamination. Right? And so you're just gonna plug it to the edge. I just can't put the clip over it and plug it there and then continue the dissection. How we doing with a clip? I thought we had the three types of clips here for every case. How we doing? No. Yeah. How we doing. Well, listen, so do you have a reference for a particular kind of clip here has to be something that does not have very long. Strong, super powerful arms because they may turn into the muscle. I'm gonna grab muscle on the left. Also, I can't be too big. It's gonna make the rest of the dissection difficult. We're at the edge of the dissection. Not too big, not too strong. Just something to hold it together because at the end of the year I'm just gonna suit you. So it's just a temporary thing. I just wanted to hold during the dissection. There's something, you know, Not too harsh. Not this big. Um based on the size of this, I just hope the olympus small clip is enough. I mean, the arms are not too short. Remember we overdid it here. Oh, okay. Do it. What am I doing? I have done. Yeah, okay. All right, okay, right there. No, no, no. I want to cut it. Cut it perpendicular to those muscle fibers. So like that like 10 o'clock to whatever four o'clock mm maybe more towards More to the left. Maybe almost 9:00. 9:00, not 12, 9, nine. Okay. Maybe between nine and 10. I don't know, something like that. Okay, okay, hold on, hold on. I don't want to cut towards my dissection because we need to continue to dissect a polyp right? So it has to be away from the dissection plane. See how it's cutting the muscle. That's why you don't want a super strong clip that may cut into the muscle. Okay, how about you do it? They're close deployed again. Open. That's not bad. I would say. Maybe yes, it caught the muscle but didn't tear it. So you need a gentle cliff. That's what you need. This may do for now. I hope so. Let's do traction. I really need traction here and track motion. I'm sorry. It's not gonna cut it here. It's just too the mucus is gonna rip for sure. So give me a the big two millimeter loop that we made. The bigger loop. The micro task. The micro tasks the bigger 1. 5. Okay. Is that the bigger one? Well come again now just give me the five. Can I have a 60 3, 62? I don't think so. And where's the We have the caesars. If we need to cut the loop, this is a bulky lesion. The attraction should be interesting if it does. If this doesn't work we can do it fully with the Overstreet. Thank you. Yes. So this is an island. Look that we made handmade works well. And there's a link grab anything good to catch here too my doesn't look very promising. It made there also also bleeding now. Okay I don't look too promising and I try to dissect this side and this is the sign we want. We may need to dissect a little more on this side and grab this side because I'm just not sure. I'm not sure that this is gonna work. Okay. We need to cut a little more unfortunately. So let's give me back the hybrid knife and keep this keep this ready on the side. We need to free up some more over here. This is impossible when there's no sub mucosa it's cooked. It's near the whole this will try this side but we need to free more dry card. We need to free this side which is the anti gravity side. Ok. Open. Okay. One, wow. Ain't close to the muscle. Uh It was big. You hear me? How much blood do you think he has lost? Uh You think he needs a unit of blood? What's your best estimate of the volume? 100. 150 50 5200. I don't know because anesthesiologist want to get in board. How's that? He thinks it's about you know, 52. I think it's it's so magnified 40 times. Now this is all water. I'm putting liters upon liters of water. Trust me it's his hemoglobin is gonna be the same unless something else happened. Let's do that this. Yeah This is minimal blood loss based on 2000 CSS experience. Okay so let's see you mentioned give me undercut. Sorry, in my mind. Yes. So have you had the need to transfuse blood intra procedure? And what would be the transfusion? Um Inflection points? Want me to transfused? You have to have, you know, a lot of bleeding. I don't know. I can't remember the last time I had enough bleeding on NES D. To require a transfusion but it's not in recent memory. You have to hit a two or three millimeter artery and not be able to control the bleeding for an hour maybe. Uh There has to be something really major like big time bleeding format to two or three millimeter artery at least for you know and then hypertension or Yeah, requirements. I don't know if you want to wake up to that potential, but you know, you have to be substantial bleeding from a big vessel. These are tiny. They look like a lot on the camera, but ah this is very slow. I'm hugging the muscle here. Give me dry cut. Mhm. Okay. Give me undercut. Okay. Okay, this is forget it. Give me try cut. There's there's no way to do and look at. Right. Right. Uh huh. Okay, fine. And cut. Can't win underwater. Dry guide is not doing much. So, do you recognize the vessels between these strands? The fiber strands? Well that tiny. So annoying. But they are very small. So these are not vessels vessels that should be coagulated just by cutting through with dry cat. Unfortunately, dry cat doesn't work underwater. And here we have such pores of mucosa. I need to use water for traction. I have to use and a cat which is not coagulating a lot because I'm underwater or under sailing river. This if I tried to cut the strands with dry cat, they wouldn't cut that. I see a vessel in there now, what to do with it? I could do a little spray there or something and then try to do a cat afterwards. And hopefully we calculated it. I and it was a vessel because you saw a little squirt of blood over there. No, that may be another. There may be a vessel in this truck. I'm not sure. But maybe a tiny vessel. I'm calculating with spray. So you think I'd bend the artery and vein together, the red and the white. So we're working the ads is here under difficult conditions. What doctors have news for you to know that the back if you want any room. Okay. Okay, so I'm a little bit of a plane developing a little bit is very more dangerous for the muscle. The dry cat dissipates and look at even one pulse Kansas buzzer. Half the muscular is away if you touch it. But it's the only kind that cuts reliably underwater. That's another little vessel that what's bleeding now. Yeah. Something is wrong with the pump. Something's wrong with the pump? Yes. Okay. So there's a question about that little perforation. How long do you keep the patient such occasion N. P. O. Um If I shoot you this like overnight I guess like it's gonna do good over disclosure just overnight. I would say my family doesn't good. I don't know why I cannot I cannot get the pedal to work this. This is too many I think too many too many things over it keeping it down or it's the wrong way. Turn around it's turned around it's turned around it should be facing the other way. Can you can you fix the pedal the water pedal? Why don't you take a look at the things that should not be under. That's strange that take this off the tape should be on the on the corner. No again that's we need a good bad though. We spend out is just terrible. Get some tape. Do we have more tape? I think it's not don't do you have any tape? The clock tick? Yeah thank you. The perils there by very very weak. You want to stick this? Don't put it on the bed. No. Now the perils sort of starting to give up its malfunction. I press and I don't get water. Do you have another pedal? Another pedal? Look at that. It's not not not doing it at all. Um What happened? The pedals giving up? So just open it up see if you can pry it apart. Can I get another pet though? Pull it pull it off. Yeah. Put it. Put it right, a part of it and put on some gloves. Mhm. Is it? No. So, Yeah. So, that's I think it's probably given up. It's your heavy foot. Yeah. 1 1 water pump broke one water pedal, broke it. See that switch? Where's the pedal? It's not as Yeah, I think I think I think you're probably the idea of spring or something. Must have slid. It's done. Maybe the contact. I think you have to just You got another one. We need the water pedal that has a very heavy stable base. These small pedals. Mhm. Okay. The question is, can I use traction now? Try it out. It works. Just take don't take the pedal. Take the cable of the pedal. What's happening with the section? Yeah, Yeah. Okay. Is it working this oneness? Okay. Okay, let's see. Is it well, basic more Okay, Nice, my girlfriend. Alright, tough. There's another vessel lurking there waiting for me to cut it right under the edge there dry. Just don't end up. Yeah, dry. Okay, give me another cut. I always hope there are no vessels there. Don't look like that. All right. Let's try some kind of attraction. I think the most robust places this thing here. So, let's do that corner and see if it helps. All right, okay, let's go. Alright, how's it going? No, the traction. The clip with a with a loop. I think this is the only chance that well, is this this fat, this fat heads here, I think. Right, let's try right here, right there. That's that's that's our best bet. Open any everything everywhere else is going up there and here are the important things that just don't cut too much tissue, right, clothes that don't deploy. Right? That that's too much of your casa open a little. Oh, okay. That's better. Right, that's better. That's better. Right. Yeah. See before it wasn't lifting enough, I still have some right, okay deploy open slowly open. Okay, next clip. Mhm. Mhm. But after we left too many to use given all the fibrosis and the lack of And the over there we might have to use a hook knife, have a hook knife ready open close. Okay, so good to see what's the best backstory here. How about not? I think straight on the opposite wall meaning some guy got to suck it down. Be nice. This works open. And so what's your job is just to lift it like this? If you like it before you deploy. See how little some causes its pulling the muscles. But this is a straight shot. I think this will do for us. Okay, deploy open open open, almost start it off. So wow, the muscle is right there. Let me inject with a hybrid first and then see we have to dissect up there and then down there, follow the peak of the muscle then pulled and you're gonna try to get to the area of the perforation last. Or is it on the other side? I don't care about that area. It plugged it. I'm just gonna follow the perimeter of my incision. My perimeter incision. It's gonna be open. So you're not concerned about that. As you dissect in terms of trying to get their last or it is what last? Sure. I mean, that's where the area of the weaknesses. Right? That's where the muscle is the most week. So you don't want to ignore that. That's that's not on my dissection planets out on the periphery of the perimeter incision. So I'm just gonna skirt around it and do my dissection. Let me use this one. Now let's see you have dry avocado. Well, okay, let's look at because I think there are no vessels I think, but I don't know how reliable this is with this guy About nine years ago. Box. Therefore I freed up the muscle right now this is called vascular. Okay, that deal knife here is the hook, but right now we're doing okay. So I'll continue because you have to separate the fibers from the muscle and cut them. There's nothing better than the hook for that. I see this all this looks the magical attraction. All right. Oh, okay. The muscle is being freed. Oh vessels lacking. See this almost tricked us there. His vessel there right back another one there. Okay, wow, wow, That's a huge one. Right? I guess we'll go underneath it. Right. Or would try anyway. All right. There's the there's the the flag governmental black. So I'm just going to ignore it and continue. No. Alright. There we go. Mm. Down here. It is a little drinking now. Like right there. Try to work on this side because this is not so nice. That's a big vessel. That's that's where it enters. That's where that huge art very enters. That's what the problem is. It's not only is it dangerous, it's tethering this end of the specimen down hard. It's still it's still alive I think until announce looks a little better now. Right, okay. There. Look at the size of this. Look at the size of this. Give me the small co a grasshopper. Although I think that's the that's the end. That has no blood. The other may be down here, but that's quite late anyway because sometimes you get a network that. Okay. And that's that may be a two millim another 1.7 certainly. Okay. Open and all the movement Klaus Klaus. Well, did I get it Galvin price. That's okay. See here. Okay, let's go. Yeah, this side. I'm sorry, but I have to use another knife. It's hidden. There are vessels. It's five project hook to free that day. It's kind of torture. I injected already with a hybrid knife and it doesn't lift. And everything is hidden. Yeah, we got uh we got to do something more precise here than the hybrid this side problematic that way, paddle to the mucosa. Okay, parallel to the mucosa lead. So I'll take 11 o'clock more. Start up too much. Okay now more together your cats. And then you check out what your cats. If you don't think it's a vessel, it can't. And then you cut more. When you check what you call it, make sure there's no vessel. Oh I do like a little right there. Car for love. Okay. See the attraction is delivering less uh dividends on this side here. But now. Okay. What do we have? Oh okay. We're getting there. I think we're freeing up the difficult sign here. Oh, gets a second traction here. I'm trying to get away without it. Okay, distraction is not helping for this side much but it was something as away with it. Right attraction was very helpful. Okay now let's work on this side. Yeah. Turn away from the muscle. Not that way. The other way. Okay, so when you see a red structure like that, Is that a together? Oh there's some big vessel somewhere here. This is how the hook, hook, the hook helps on those edges here to clarify what muscle and what can be cut and bluntly isolated and then magic. Okay. How we doing huge. Okay let's go what happened to the knife? Come on, 11 o'clock or 12 or something that will leave it there that actually lock it. Oh, it's kind of lead. I'm not to blame. I gotta grab their I think some infection here might help. So I'm gonna switch to my hybrid. See there's the plug. We're now well beyond it. Okay, how's it going? Hi brady. Absolutely. Uh huh. Okay. Open. Okay. There's some bleeder from the flood. Another big guy day there and on. Right. Uh huh. Right. Lots of more money that doesn't want to do it. Give me give me some force or salt or something. Force. Yeah. Love force you have it. Okay. Yeah, I need spray back. I need spray back. Okay boy, study. Huh? Another vessel coming up pal. So here's the question which is surface and pit patterns failed to anticipate the degree of the fibrosis here. So what other factors or variables might want consider to predict um the extent of the fibrosis that you encountered all the pit pattern? Really? I think, I don't know that this would predict benign fibrosis. The pit pattern would predict something that maybe a T. One cancer that may have uh is involved. Whoa, that's a that's a now, that's a nasty artery right here. You can see the train track, white wall. That's nasty question is, where does it enter here? Let's see, let's avoid this for now. So yes, I don't know that. You can anticipate what I could I anticipate that there will be five brushes because of how atrophied because I looked. it was almost at the Normans color. You could see many vessels underneath, very thin looking. So I said that I think you know again old western patient with a trophic gastritis and multiple parties of intestinal pleasure. I think you can expect a relatively scant sub mucosa. I don't know if we can call it fibrosis. It's really scanned sub mucosa that doesn't lift great. It behaves like fiber optics. And because of it with attraction, we've got some good sub mucosa but you need traction to expose it. So, but that's what you get this thin relatively scans of mucosa that doesn't lift exuberantly right. And um you can predict based on the demographics I think. And there are trophic looking mucosa with multiple patches of intestinal meta pleasure and the greater curvature location where the curvature is bad because the character never lives well. And you have to go over falls, it falls there. Yeah, lesser curvature. It's generally better at least on the greater curvature. I think also because of these reasons that japanese random my study um that looked at traction. And where does it help? Found the most help. I think I believe in the proximal greater curvature. The attraction was the most useful and we see it very well here and without traction. It will be dead in the water. You with such a heavy legion polyp oid legion. And we saw a little sad Mikasa to get used to be able with a cap to lift a flip and get underneath. Looked pretty impossible. So yeah, attraction. So your homegrown traction device or has worked pretty well. You know, Have you used that traction device which is a cap, that bucket handle on the top of the cap with a call, I think end of you. And Olympus have been working also with prototypes that Olympus was looking at, like changing the original one had to a metallic swivel that will be attached to the cap and would bring a four steps forward and then it would grab and then it would swivel back out of you. And it was you have to tape it to the outside of the spring. It's end of you, right? But now that they were also experimenting with a set of metallic swivels because the metallic swivels you lift, but then you have to move sideways with a knife. But the forceps is keeping the attraction in the middle of your cap. So they were experimenting also with, I think, you know, using sutures so you can move sideways despite having grabbed the mucosa. Yeah, I don't know that it's available here, but that would be something to do in situations where it's very hard to get get under the flap like here, here doesn't lift at all. I don't know if there's a vessel in there. Oh come on. Ah This proved a very difficult case to the end. Give me give me another clip quickly. Okay. Okay. So what you're trying to do is just suck out Their limp. Was one. So you're trying to suck out some momentum. Yeah, but not yet. If I suck and there's no momentum which there may not be on this wall, then I'll end up bringing the water from the fund is down here. They don't want to see if you don't see fat there. Maybe you shouldn't suck. But if I suck the water from the funding will come to the defect. Come on things long. Let's go. What am I doing this this world torture. Alright, let's see. I'm only the 2nd 1. I hope you have another one somewhere. There's one out here. Okay, I gotta do it. Yeah. You want a daughter? Okay. Hold it and that's disorientation. Don't change the angle. Oh, all right. Okay. You have to turn to the left I guess left again. This is muscle. You don't want something that will tear the muscle so nice, gentle clip. Okay. See I soft in the job. I got close those. I'm deploying and open now. I need more Or am I good enough? Looks pretty good. Right. You got it right. How's it? Looking at the top? No, it could take another one. Why not? Are we 80% done. Looks like 80% done. So paying for. That's where they said this. You really should use the hook knife where you can grab lift away. Make sure that you're not cutting something. You shouldn't be cutting and then cut the knife, just cutting directly on the muscle. You can get too deep. I think this is good enough, but it doesn't hurt to put another one there. Okay, go. Lotion compute take it. Okay, right there. Okay, come on. Okay. Okay. Uh huh. Well, I'm on tournament. How are you turning it? What are you doing? Look depends the way you like it down there, turn left and sister. I got good. Okay, you hold the metal when you turn the plastic right? You hold the metal, turn the plastic. Okay, that's nice. Not let's go the way it's behaving. It's female. Okay, I'll do the right has a mind of its own. Okay, to the right. A little hold the medal. Turn the plastic. Okay. Uh no attraction. I mean a little section. You could probably use another one. It's a good thing. Beautiful. Do it. Okay, close and deploy. Yeah, let's see what we did open open. I think this will do. I'm gonna switch her at the end. Okay, let's go hybrid in events. Okay, now we got to see what we got to inflate a lot now to get traction because there's so much specimen hanging. Have to inflate the stomach completely. See that's why the the loop doesn't have to be elastic. The stomach is elastic enough by itself. It can be a fixed loop, like a future rotate the Lucas in our face, rotate. Okay. Open injection and cutting. Okay, thank you. Right? And to sabotage me again at the edge some more time hook. We need a hook here cause I'm gonna end up with another whole sooner or later. So you need to separate a specimen from this mussel farmer. They're trying to do it with a straight thick knife is danger. Give me a loop holding it straight. Okay, open. Okay, well that's not how we wanted really Like 1:00 Right there you go. So you check what you got unless you like it, you take it right there, see that, see how much this helps and again and again Vegas before I had this um grab it listed cut it. Yeah, I think you know, you can make a middle contact. Okay, 1 to 12 o'clock 12. Let's stop. Stop now. Uh huh. I think we're cleaner here and and I need the injection now so we should switch after I got this fiber there. Maybe we should try the hybrid again. Alright, let's try the hybrid. I was the final 10% I think. Oh that that's a huge actor. This is where it's getting in somewhere here. It's coming and then authorizing here, like you said, branches off. That's right. You know, some people try to use the I insulate the tip knife and cut blindly under the flat. What if you hit one of these? Um we could spend, you know, and now we're trying to control things. I don't know about this blind under the flap, but isn't the insulated knife like a hook knife essentially without the projection causing any damage. So using but using that to pull and cut this, I mean, you can't cut it, we can't cut because around it without cutting this too. And you won't even be seeing it. You're dragging under the flap. That's my concern with insulated tip, at least in this kind of vascular charity. These ads dangerous with the hybrid. These ads, let's leave it for the hook later. Let's continue in the middle. Oh, it runs the entire specimen. This one right. I have to write the results, this thing beneath it here. Right. I'm trying. I got this okay, we'll continue underneath it. If it doesn't bother us, we're not gonna bother it for now. But if someone wanted to quite grasp it, just, you know, grab it and then burn it off. Would that would that be a problem in any way? I mean, I think it's better if we find the entry where it enters from the muscle and get it done and get done because right now where are you going to coagulate it? It's running sideways along the length of the specimen. So where are you going to grab it? I mean, I think eventually we'll see where it enters. You don't really see where it enters. I see it running across the whole whole specimen there. I don't know where it enters. Okay, the specimen is beginning to swing. Which means it has a very small attachment because I can feel it moving this way and that way as I must say, that's a good that's a good thing. I'm giving it a little bit like a hook here. I'm trying to hook away from the muscle, but it's dangerous because the tip is long where we go, wow this. I don't believe that. Um Okay. What do we have here exact? No, no, I'll do it again. I got all the holes. So something is that right? So something really? No. Pretty good. I don't think. Okay, but now it's creating a situation there again? Oh my God, I'm gonna inject but I think we have to get that. Have to get the hook knife again in the holding up, hold on, attraction. Um mainly the little tightening. I don't know. Can we tighten? It's too late for that. Um I can't tell where the vessel. Anders. Okay, let's try. Let's find more traction. Mm hmm. Okay. How do we do it? Um I don't know. Just give me the hook. Is there, Is that what you were looking at? That's the whole, is that? No. Yes. Yes. Why don't tell me that, Is it? I don't know with nothing in the open. I don't think so. I think it's under just dissection. Under the flap on the phone. So it's probably pulling in that way? Um attraction attraction is problematic now. I think that's okay. Uh We need more traction the other way. I don't know how we can do this final flap here. So can you not use the cap just to push and pry it apart? Well how to deflate? Which means I lose my attraction completely to even get there because I'm retro reflection. Yeah. I don't know. Well, there's another thing we can cut. Right Amen. No, that's mucus. Okay all right now I would need some kind of more traction or you know? Okay. Alright so give me what we can use the same loop. Probably maybe. Okay, give me a forceps. I'll pull that clip off and try to reposition. I think that might help. Not entirely sure. No, I don't think it's gonna help. I don't know it's gonna heal because it's pulling from the wrong side of the specimens. So I think we need to put another attraction here. Give me another loop. Another attraction will look. Yeah, the biggest one you got as you go, let's go. Mhm. I don't think. Why are there two loops on here? Seriously open the two loops open. That isn't the best. Take one. Yeah. Wait, wait, I lost it. It's blue and blue. I can't see it close close close. All right. Why should we pull the tool? We have to pull the left side somehow, right on. Unfurl it? Yeah, I think you have this side pull So you want to pull. Okay, so how do we do this right there on, wow, this is bulky. My husband. Mm I see a net there, but it's hidden right there. So we pull right here maybe. Okay. Open close. All right, deploy open. Okay, next. No, no, no, not to me. You have the overspeed ready? Oh, this guy's gonna get the sleep gas trouble from closing this open. Close. Alright, how would that work opening close. Okay, let's see. I'm glad to work for us. Maybe a bit more, bit more, bit more closer to the previous two. Maybe it doesn't uh, maybe, maybe. Maybe not. Maybe it's not very tight. Let's try to go further down govern. Yeah. Well, let's go there close. Did that cuts? Well, I did. No, no, no, let's see. You would like it. And they were not like this. Can I say? I'm excited completely. It looks kind of maybe we inflate. It goes. I'll go find live alone. Oh, always slow deployment. No snapping. Okay. Hybrid hybrid looks nice. Huh? Really? Are you still inflating? Uh huh. Part of my doing. Oh yeah, that's maximally inflated. It's true. We don't know. Don't know where that vessel is coming from. Right. And I don't even see it now. Open. What do you think about that open? Well, we'll see. So this has to be cut right here and that. Okay. Oh, I also think the hybrid knife was invaluable here because of the ability to very focal e inject and visualize vessels because you have to switch back and forth to inject thing. I don't think something small like the have had trouble, you know, vigorously lifting this kind of sub mucosa. And now I'm getting a lot of emotional because I'm fully inflated and at the end of the turn. So the scope is partially retro flex now and it's a little floppy. No. Alright, okay. I'll exact and switch to the hook. Um I mean, I don't know, we get close to getting done. I don't know a lot of movement because the scope is really semi retro flex. I can't I can't put in with a lot of force. Oh wait really? Alright. So what happened to the vessel? The vessel disappeared. Amazing. The vessel disappears. See, we didn't have to do anything with it. I don't know. I don't know what to tell you. All right. Um They erupt or Yes, now let's take it now. We need I can I can probably rip them now. Yeah, I can probably rip them. Give me the horses. I think I can rip them. Let me let me think. No. Alcott. Alcott. I don't want to clips coming back hooked or dragging along. I'll just cut it scissors. You have a look at her then. Give me the scissors, right? It's draped like a chic. All right. Close close close. Okay. Closed close. Okay, so let's nip that too. I could rip the clips off but that is too much dragging around. I don't want anything caught him his U. Es. And making a rip the meat cut it open. Maybe my favorite, wow. Oh cross was called have fun. Uh huh. Stuck on the cap close. Yeah. Okay well good. Let's take it out. So let's take it out. Close open because oh you have it well which is more sturdy and then gently mm a little bulky. Yeah. All right. Open. Okay. Events this morning. Okay. Now we have to um Yes, we have to unhook the click without without ripping it. So finally a an 18 gauge needle right or something so that we open the clip without ripping it. Unless well actually hold on. Maybe I can do it with my nails. Okay. It's okay. We're good. Give me the cork. Well let's see. That's a nice looking specimen. Um. Alright. Alright. The one edge is close. This is so this is a tricky one to pin this one. Huh, wow. Different needles everyday fancy. I don't know if you want to zoom here. It's a good idea. I don't know some some is the Experts. You know leave the pinning to somebody else. I think you're R0 resection margin depends on properly unfurling the specimen and making sure it's probably pencil. I always do my own pinning until the end of the year. Then the advanced fellow can do it. I don't leave it to chance. We have an excellent margin. I mean the closer we got is five. one x 1. one x 1. Okay, wow. You got a we got a cork size exactly. Right. Maybe. Maybe not. That's because can I thank you? Yeah, we're done with that. So how how much was there at the time? I hope somebody was recording the time. Right. What time did he come? So how long was it? Let's calculate the speed. When was the S. D. Time start? What time today is the start? Mhm. You have the procedure Stardom or the the start? Okay, so it's three hours? three hours. 26. Yeah. Okay. Yeah, but when was when was the start of the injection? Is the question? Okay, so three hours. Okay. So let's calculate the speed. Should look at those things. Where's the ruler? So it's essentially a rectangle. Yeah, I think a quick look. I think it's gonna switch, you know, rectangle. Okay, write down the specimen. So it's seven seven x 5 rectangle. I need one more needle. How much time? 75. So 35 square centimeters. And how much time did you say? Three hours? About 10 10.1 10.2 squares and eight minutes per hour stomach. The benchmark for proficiency is nine. We beat it by 100 m per hour. It's difficult. Okay. Picture. Okay, that's an R. zero resection. Okay. Uh Right. Let's go. Let's go suture. So 10 10.15? About 10 35 square centimeters five by seven For three hours. So 10 point something 11.9 m for stomach is a little on the slow side. Okay. Why? Why not? I don't know. And why? Why looks pretty good? I mean, I think you're just sticking something in there that doesn't belong in there. May be no, but you know, bleeding more rapid healing. You can't do it. But the thing is, let me do it without this at the front. Where is the where is it? It's coming? The gel is coming in a minute, signing myself. Come on. You are the purest art expert. So we are gonna put this self assembling peptide synthetic, self assembling resolvable biocompatible peptide on the creator the I. S. D. Experts like, I don't know Dr Bhandari in England who are finally are big believers. So they they the potential benefits is, you know, cut down on delayed bleeding maybe and or maybe some acceleration of healing based on some a few small animal experiments with autopsy. Um it's I guess right now from my understanding of the literature, it falls in the category that it can't hurt in this scenario. And it's not very expensive. It's three CC's And it's $600 I believe. And can be, I hope we can cover all the defect with three CCs we have to conserve. Right, okay, are you ready? And then we'll shoot you over it and hopefully it's gonna facilitate healing etcetera. Okay, are you ready to go? Okay? It's like a transparent gel substance. Go, go, go, go, no, go, go. Okay, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go, go. Okay. Did we cover it? You have more. Okay, go there. I think we covered the whole thing is transparent, you can see it here um that adhere to the dissected. So let's go that any small vessels will be less likely to bleed under the future and maybe it will accelerate the healing a little bit. I may be protected from stomach acid for the first five or six days that this thing gets resolved during. So that's the idea. So now let's go shoot her. All right. All right. Mm. Are using the fuji double channel scope. What's maybe the only double channel school available soon? These non production of simple double telescopes so it's good to have for fashion. It overstates users like myself. I'm sorry. Do what is this? This is OK, OK, fine. Let's load. So this, this future looks like it's gonna narrow the stomach to some significant degree. So he's gonna get a little bit of a gastro last year with his C. S. D. Alright. Still got oh, all right, where am I doing confusion. Okay, let's go to your and that doesn't appear to clog the channel to which is a blast and very suitable just in case you spill some. Okay so there you go. People control it. Use it to control immediate breeding that has failed other modalities to see look it's keeping some bubbles there, see it's adhering. Okay so now the medial side or the right side here will be the difficult side and it's hidden. Uh Alright then it's it's on a turn. The well seat is distal edge proximal edge right on the turn and hope that it's not too much narrowing. Okay that first bike if I get bleeding sooner or later maybe that job will stop it. I'm gonna go to the this apex there. Uh huh. And then go on this side will be a race against the bleeding that unavoidable bleeding with this his patient. Okay so now I'm gonna try to unfurl the said's I think the edges right here so boom we're gonna go right there. So we did a triangular arrangement in the apex there. We've got distal right proximal to make sure that we don't create a tunnel we closed one. And by going on the apex also so now we're gonna continue the same way. Now it's gonna just be distal proximal distal proximal distal proximal this fell and then let's go for proximal proxima would be here not this way this way is it? This way there's this blue future that gets this confusing things. Right. No, we're good. Right, okay. Yeah. Why is it looking so confusing? Hold on. No. Yeah, a little confusion. And we don't want to catch too much just there. Uh huh. Again, that's not deep enough. Gotta try again. If you don't get the fight that is deep enough, you can't go again. You can't even go the other way. If it's easier grab a bigger piece. Now come here, the approximate land. So this is um this said would be where here? Just that. Okay, and there and the kids I'm gonna live there doesn't really bother anything. Eventually that will extrude in the stomach. Well, difficult leads there. Yeah, we can go again the other way here. We weren't. So no. Again, we'll do a triangle here. All right, we're gonna do this stuff. Apex proximal. I'm giving I'm giving slack on the future because we're running out of future. Okay, little beast out there. Might be just on the other way. And now we're gonna do apex. And then proximal because I was your gang end up creating a tunnel and the apex may open up go to the apex to plug it, plug it up there. Ah No, let's try the other way. Nice. I've got too much dishes and I cannot take the needle off. So let's try again. Oh yeah, okay. Now this side and we're done. Right? I think this side and we're done right there. Okay. All right, We dropped the needle and then see we have done a lot of passes. So we have to be very gentle when we tighten it. So we don't break it. We have to give you time to go through all this tissue. Let me tighten before we even put the sins down a little because tightening with the since in the future can get caught between the metal of the the metal at the end and the metal of the transfer Canada. And then we could have can be ripped. I'm not gonna need another one. Right? What if I break this women need another one? Break this. We have to start from the beginning. See, I'm I'm watching the T tank. You know that the whole shooter tightened up when that gets buried in tissue? Which here was all difficult because I went through so many passes. Plus I made some backhand passes. But now I got buried. So I think we're good on the closure here. Right, Are we Okay? Let's put the scent. Yeah, this this tightening was a bit stressful. Lots of passes. That is the sense. A little more tightening. Are you ready? I can't do it. Fly to fly. Okay, so it looks good. Let's let's go see without the thing on without the overstates. Okay, We're done. Yeah. Yeah. Okay. For every minute they want. Right, okay, let's see. Looks good. Huh? So the guy can be discussed tomorrow. Well, we'll do a lick barium lick test everything good. Then you can go either. Yeah. Okay. Very nice. Alright. Okay, onwards, it was a little difficult. Created by Related Presenters Stavros Stavropoulos, MD, FASGE, AGAF, FJGES, NYSGEF Chief of Endoscopy Director, Program in Advanced GI Endoscopy & Endoscopic Surgery View full profile
