Originally Broadcast: September 29, 2022 | 8 AM - 5 PM ET
Case 4 ESD of a cecal polyp originally manipulated with hot forceps on two occasions, and treated with APC. DiLumen device approach originally planned, but proved to be inaccessible.
All right. This is our last case of the day 77 year old female who presented for a surveillance colonoscopy colonoscopy showed a 25 millimeter sequel flat polyp that was scarred down. Review of records showed a in 2019 there was a 15 millimeter polyp in the system that was removed in piecemeal fashion with hot forceps and treated with argon plasma. In 2020 there was a seven millimeter residual polyp in the system that was also removed with hot forceps. So this is a manipulated sickle polyp with hot forceps on two occasions and treated with argon plasma. And the plan is for E. S. D. Of the cervical polyp with the lumen device. All right, alright. So we're trying to use the lumen device which is a double balloon of sheet going over the endoscope. Because number one you can speed dsg on the right column. We did a case control study with 85 Gs. This with the illuminati five regular and there was a 25% gain in the speed and there was also faster discharge in communion. Uh there was like a 30% lower length of stay and looking at patients that were discharged immediately after the procedure. It was 40% versus 20% because the aluminum allowed us to suture anywhere in the right color, which is difficult normally to get the oversteps there. So that the lumen kind of like you to shoot your and that allows rapid discharge. Now we're having trouble because this woman had the hysterectomy. So the signal is fixed. DR Buchanan could not put the development through and so far neither can I. Um and the curtain is how hard to try because the risk of perforation. So when you push hard in this kind of fixed sigma it is not. This is so I'm about to I'm thinking about what alternatives we have. The alternatives. The alternatives are you know, do it without any assistive device. The problem is then if you if you this is a very manipulated listen twice removed with hot forceps and a pc so it's very likely there'll be a micro perforation. You can close it with cliff but suturing is much more secure. So how do we future if how do we get the over stitch there without a device such as a dilemma to this kind of sigma, it would really not be a possibility. Now there's another way to do it that has its problems which has used the pathfinder device, the pathfinder allows you to put a scope through and then it rigid ices and prevents the scope from looping So it can speed up psd in the right colon and then you can leave it there, remove the scope and then put the over steps through it. The problem with this is without the element we use a 135 element device and then we make a slit artificially to it to get the shorter gastric scope of the overstates in. However with the pathfinder you can't do that. So we're gonna have to use an 85 centimeter pathfinder which cannot always get you to the sick. Um That this region is in the sitcom so you might not get us there. You might not get the overstates there. The 85 Centim pathfinder. It may be it may it may at least get the overstate through the sigma To this terrible sigma without risk of perforation. So we could try. Well the overseas is really I mean I'm feeling fixed resistance here. I did go through some of the terms that were fixed but now I'm at 23 cm and there's really fixed resistance. That is impossible. I'm gonna come out with a double lumen. This happens in less than I'd say 5% of cases. Right colon cases where we need to use the dill uman so it's very rare but the pathfinder is very useful there The pathfinder also has another issue. It tends to lose air. So suturing can be problematic because you can't insulate the column to see the defect? Not so let's have a problem with the S. D. But switching can be a problem so we can we can try to use the pathfinder. Okay do you have the pathfinder? You have this action for the pathfinder? Nice. Therefore let's proceed. So the pathfinder let's see how it treats it dies. Is why don't you make it into a loop and switch it here. You on with this action. Leave it on. Is it on Yeah Pathfinder? Okay click to read dies. All right there. It's rigid. So a very interesting device um so flex flexible again and it's a short one. And the short fat one because there's long and short and there's 16 millimeter and 14 millimeter. So in order to be able to put the over sister we need the 16 millimeter right? Yes 16 millimeter. I know it's the short one because I can see is it the 16 millimeter one? I said I needed the short fat one. Yes so it's 85 cm long and 16.5 mm wide. So let's go through. Go find the lesion in the sitcom. Okay get back. Alright um on the side here. Okay I need I need a one of the problems of the pathfinder is unlike the lumen. It doesn't have a tightening ring that tightens around the scope. That's why it has just a membrane. So not not only the risk of losing air, there's also the problem that the scope slides very easily around the pathfinder so which makes scoping with it, hold it there, hold it next to the scope at least until I go to the sigma. We'll probably use it. I use one of those ERCP bins that we use like you know how you use a ERCP been. So we meant this to be a dillaman case but sometimes you don't know what will happen. This sigma is impossible to get the lumen through. So what can I use the pathfinder again. Mostly really not so much. I mean s d being 25% faster is nice but not essential but being able to shoot you in a difficult case where there may be a micro perforation is much more important in terms of length of stay and less risk of a leak. Oh my God that maybe dr Buchanan here trying to get through the sigma. Turn heart could be maybe you know it's further up than where I tried so he gets credit for getting there but we got this so this is the summer because of sloughing here. Okay let's go. Maybe even the the 16 millimeter pathfinder may have problems too. Um Yeah we can try to rigid eyes it here. Well actually I'm outside. No let's not try that. I can go partly into the sigma and try to register to avoid looping while I push the scope further in. Right, okay, Richie does in there. Mm No the working really. Okay, make it flexible. I might have to abandon this device to I think just go freehand but then if something happens we have to use x. Tak clips um as opposed to overstretch, mm difficult so fast and it will not go either so far. We're having trouble here. We'll see where the fund is stuck. Probably on the other turn. I'm gonna come back. See that's that's the how that turned down here. I'm right at the edge Of the fact finder at 85. I'm gonna try to bend the tip of the path and the upward with the scope portion and see if it makes it much. No, it's 60 millimeters pretty even though it's easier to get it in the parliament in this sigma. He doesn't want to do it. Maybe a little water. This is Simon I think because when I came to the lumen had blood in it on this turn. Okay. Make it right. Right tricky. Very tricky. Okay. We made it to the sigma or at least the fixed part of the sigma in the pelvis with a lot a lot of effort. I think that's as high as the pathfinder though. What so the best you can do for us is get the overstates through the through the fixed part of the sigma. But it can't really can't even really clear the left column here. Right, That's what you can do. Right, okay. I think we have to leave it at that. I could rigid eyes and short and rigid eyes and try to push in with a rigid path line about. I don't know about that. Well, let me see I'm shortening the loop is certain. Okay, how about you wretched eyes there. I guess if I try I uh I don't know. No, I don't want to push anymore. I don't know. Just leave it there. It it dies I guess. Okay. Hold it. Is that is that why is he so fast because the gas high. I put the guys as high as you guys three. Floor 3. Okay, that's fine. Her pressure is one 1:44. Because you could take probably even more gas. I don't know. Okay. Because you know the guys having the gas relaxes the colon. This has a spastic looking kahlan. It also looks kind of white. Did you give her anything for the pressure? Did you give her any anything to increase her blood pressure? Not all that educational. It's holding try don't push it in our county. Oh, definitely. All right. I can't hold it. I can't reach there with a defined pathfinder. All right. All right. I don't think we're gonna be able to do it with the pathfinder in the way. It doesn't make the sigma turns. It just stresses her sigma. Which means a pack funded loop in there. That is eating up my scope length. Alright, well, so much for that. Yeah. I don't think we're gonna be able to pass the pathfinder is not making it either. And I hope all the pushing of the backhander didn't create a out of view perforation from an elbow performance. And I'm really worried, you know? Let me let me come back. Pathfinder is not gonna because at that bend you were probably Yeah, I'm a little worried actually. My little Lord. So let me come back. You have the other speech? Just in case we need it for. Alright. An accidental look at this long list for diplomacy so far so good. Here. Here here was the loop of the path right up to here. Oh my God. Alright. We're not gonna use we're not gonna be able to use the pathfinder either. All right. Let's keep the pathfinder at least for now. Maybe we can get it. No, because there's no way the oversteer through this column. There's no way the overseas will ever reach the second. There's just no way the pathfinder doesn't work that the lumen doesn't work. So. All right, well, there's no water here. Okay. Alright, so freehand. Let's try not to make any perforations and then we'll close with the X. Tak or with clips like old fashioned so we don't. Right. Right. Find a job. Okay. What happened? Alright. Freehand, we are using that flexible um short bending portion. Olympus Kelowna scope is good for us. D. Mhm. Very short bending portion. Very flexible. A little loopy. Really. But I think it's very good for us. D Why is it so spastic? We have got I didn't get any narcotics. Right. I'm not sure why it's so wow. Mhm, wow. Is this the cocoa on. Mhm. I'm gonna have to try a PCF. I'm like this is a little too floppy or what? Give it a few more minutes. You need a bit of pressure. Lower quadrant. Okay. Oh, terrible colon. We'll call on. How long did it take you to get to the pole? Because the rest of the corner is not that this either. Did you have trouble getting to the polyps? This? Okay. I think I should use a PCF. This might be able to flop for this for this pasta. Kahlan. Did he have trouble? Did began to have trouble getting in pressure, pressure? I just use a bit of pressure. You need pressure to get there. Yeah. You some pressure. You some um you know, trance versus unbelievable pressure. Yeah. Hold on a 2nd. I'll tell you online, lending. Okay, fine, let's let's try. Mhm. Go for it from And that's a reflexive. Okay, I'm pushing, pushing, pushing, pushing. We're friends. Yeah. Uh It's hard, as hard as I feel the loop. The loop pushing in the loop. Okay. What? Why aren't we? What is this? Is this the polit there's a sky here for sure. What is that that looks like recent. How far are you in the secret? Is that there was a bit of scarred area with the ulceration. What does it do you see? What did it look like? That's where you are. That's not it. Right. If I get there. Yeah. Well, so far so good. I think I made it farther than I did before. Oh God, I hate something out reflection. Wait, that's the valve. So we're here. So what bullet? Wait, that's the bullet? This very article valve. What is there a biopsy proven that there's residual college but I'm at the sick. Um Right this is the valve here. That's the orifice of the vow that's oh here presumably he removed by bob's the forceps also the other one. Right? You did that lost it again. Hm. Where is it from there? Okay well no so that's a dinner norma but then where does it end? Plastic? That's hyper plastic looking. Because this guy clips right? He puts a lot of clips and then he clipped it. Doctor the doctor that did it right? So this may be a clip granuloma and what's left is hyper plastic tissue. So I think I think well that's that's the definitely at the normal and I don't know what happens there on the side. Well let's put some marks guys do it. We'll try. Let's try. Let me. Well I don't know what to tell you. I don't know what to tell you. See I'm retro flexing immediately. I don't know cannot get the deep insertion there. Alright well it's small but the problem is I almost want to do some more hot avulsion right or what's left. It did not work the previous two times. I'm not sure. I think we should try to get it all and get done. Very pleased now I'm beginning to see it? Okay this is a good example why you should not remove others with hot forceps. Wait what what is that injection? Yeah. Oh look fine fine. I can kind of see the area now? I don't know why there's so much contracting ability. I really don't understand. Okay, I have to use some glue gun. And this is very irritating you guys have. I'm gonna try out. Okay. What you have forced. Okay. All right. When does it end? I don't know. Hard to see what? Yeah, Yeah. I'm very close, but I'm not sure. This type of plastic resident at the noma. So, the lesion itself, from a genetic perspective, what do you think it is to a or something? That's a current lesions? I don't know, telling that applies. It's all scarred from the resection. I'm not sure. And still it's a benign legion. There is a normal there. At least at least they're in the middle. But maybe down here, I don't know. Maybe. All right. On the back end. I could go a little closer there, but with the scar tissue that's there, the farther away you go, the better. Of course, the more you have to respect them. But, okay, let's do injection. So, in this case, you're gonna start injecting from the back of the lesion ones, like the back. It's different. And just please. How's things at the back? I'm still on the FBI How fun you can see the vessels at least. And Jack. Okay. Okay, Jack. Okay. I was in the middle of Exactly podcast. Um So, when you're using lift for benign looking lesion. Are you injecting through the lesion or injecting around? Not through the legion around. Always. Yeah, there's always around, no matter. Okay, let's let's uh well, okay, I'll run that as you want more over there and Jack. Okay, let's cut the back. It's got the back and then let's get the front and let's then let's use some traction. And then let's hope that there isn't too much fibrosis is really the question here, is that go around this hyper plastic area? That's probably part of his reception. So probably this is card here. So, I might have to go around that because otherwise, I'm gonna run into five brushes at the edge of the margin of the reception, which kills you. You don't want fibrosis at the resection margin. I'm gonna have to go around because that's gonna make it even more time consuming. Okay, your dry cut. Yes, trying. All right. Did we inject this? two injected? Right, can inject it with a knife hold, have it ready. But I'll tell you when, when she starts contracting again and zack and zack. Okay. Uh huh. Great. I must do an M. B. A. My God. Give me forces. Okay. Yeah, Yeah. All fun. One. Close. Open. Have fun. Was now I'll run. Okay, fine. No. Open corners are not. No long time. Close close. Oh, Oh, come on. Okay. All right, okay. Let's um well, starting again. Where's it coming from? Okay, my God, that's good. So we're gonna go let me and Jack. Okay let's go let's see where it's gonna lift on the front. I'm afraid it's going to be far away. Open and see how far away it's gonna lift. Check out. All right, exactly. So. Okay. Oh God. And that's that doesn't live where the hyper plastic thing is. It doesn't lift c it was the end of his avulsion technique and you can see the bullet better. Right, We have to respect that to them because that's sunken in there. Great. All right, inject. Okay. Um Right here and that. Okay. And then that okay. And that exactly. Okay. On tech, wow, the incision was going to close, They have to divert. Okay, let's go of the knife. Right, give that look at and yes ma'am. That's cool. Yeah. Gas to scope, it's in direction. Open. Open for a legion that lifts sufficiently is the capital snare equivalent but it's work it lives if it lifts. What's the question vision lifts well is a cap and snare as good. What's captains, captains near is the snare within the cap? So you basically put a cap on it. So yeah, but this doesn't lift If it lifts, I mean can you do a piecemeal resection? Yes you have some kind of higher recurrence and if you do an unblock R. Zero resection with the S. D. But yeah if it's a press polyp doing um are you try to get it as one piece even with a snare. If you can inject Um obviously if it's bigger than two cm often you can. I got to divert this because I got close to the fibrosis, yep. Yes, I got close. I got food. I thought that this is hyper plastic. Maybe it's not vibe. Roddick, I stopped going around there, but uh I hope this doesn't see this set is gonna be very close to the fire. Brought the carrier. Uh No. So the reason you never use a T. T. Or a triangular knife is what? Well, if you want to pull on fish and carrot, I find a hook better. And for other indications I find these sort nights that are like the dual also better. Oh come on. Mhm. All right, come on. Okay. Oh great. Okay let's see if you can inject their inject. I was not doing anything. Try hunger, Jack. I. Okay so All right, family here inject up and Jack. All right, okay. Mhm. Mhm. So I'm carrying nothing. Is the incision on the back and check remember? Nobody baby actually, definitely incision in the back. Um I did. Okay. Were there a bit of a pocket technique here? Right, the gel works well here, you know, you want to try want to try and say if it's gonna be okay if you let go go back it's okay. And exact. I think I don't have to be able to feel your hands in a little while? Yeah. Okay, we are progressing and Jack. Okay, There's a muscle fold in the middle of the specimen. This white thing that we don't want to cut. Right, you see this white thing here. That's a muscle making a fold this white. So we have to dissect up and down up and down. Not through this white here. That's a fold. Muscle fold. We're getting to the hot avulsion area here. All right now we're gone right on the muscle. Hold you see that's that's the sky right there. Okay. This is this is the problem right there. What bleeding inject? And that's where the issue is. It's all huge to the muscle. Oh God, exactly that. And Jack like that. Okay, now we need to go to hook here because look at this. It's all fused in there. Inject. No, I just thought, exactly. Okay, give me there's this thick vessel that is killing as a Give me the small car and get rid of this tether over there. But then we have to start scraping the scar from the muscle, trying not to make a perforation like right there. So it's so the way you hook is what with the knife? Yeah. Small car grasp. Right? I'm gonna coagulate and cut that brown tether there, which is a multiple coagulated vessel. But they're still trying to blame. Small plastic. The only mistake is that I brought the incision too close to the scar tissue here. So I'm returning to the specimen. That was a mistake. As I've gone very high out very far away from the scar. You need to get to the scar with a nice established flap which is pointing you to wear to dissect. Don't want the edge of your specimen to be close to those five brochures because then you have no flap to guide you. That makes sense. Okay, let's like, let's grab this little gathering vessel there. Open buzz. Get out of it. Okay, so we cleaned out the brown feather. I can dissect this. Maybe not. Okay, now try to dissect a little bit more withdrawn knife. I thought we switched to hook. Oh, come on. So trying to complain here. What is this? That scar tissue? Okay, well. Okay. And check. Okay, what we're doing here, inject. Okay. Okay. Let's do the Okay mark. Where is the sky? What is the muscle there? Okay, injector. Okay, give me and because this is really scarred, that cause bleeding. But why am I? What am I gonna do? Do you like a fracture or disability? Exactly. What was that? Oh, can you comment on your plane on this section of the plane is not good because you see that? That's inject. Just give me the hook knife. There's no there's no plane. I thought I was cutting between muscle and your cousin the fibrosis. But see that little hole as a whole the specimen because this is not playing. We have to create a plane. Well, you know, you have to calculate where you think the muscle is that muscle, the white there and then that's folded specimen right there underneath the blue underneath doesn't exist there because it's sky. There's a little bit of blue there. So we got to you got to cut the blue down to the muscle and then follow the muscle without perforating open water. How I want it is at 11:00. Okay. Right. It's hard to tell what's muscle and what's five browses here. Right. The question is, can I sell But now that there's a little tear in the specimen and it's the salvage by going under like finding the plane under the polish. Very difficult. Look at this. Now, I'm taking muscle basically. I'm erring on the side of the muscle. I'm taking a very superficial layer of muscle. Hope it's not deep. Okay. You see. And you gotta know this is this is muscle here. Right? And this is the specimen there. And there's all this all this yellow stuff here, scar tissue. All this. And then if you come and what is this? Right, just and then there is muscle below that. Right? Yeah. And so that bit of a triangular defect. See here, away from his. It's you get some sub mucosa right here and vessels. So this is this is this is because of their Then there's five brushes here in the middle and we have to hug the muscle. Right, hug the muscle. I'm really cutting muscle. I just don't cutting, trying not to cut down to the to the peritoneal cavity. So this is the wall over here to about between six and maybe 87. And so is there a defect here in the muscle dissecting the muscle? Not yet. Oh, maybe. I don't know. I hope not. I'm just peeling it off, scraping it off. I'm trying to do it on blocks. So this woman will finally be told that he's free of this pollen. Amen. Hot biopsy forces removal. Really? Twice people that do that should be made to watch this. I'm just estimating where the muscles and try to do partial thickness resection of the muscle. Really? Ah There's a bit of a slit right now. My God! Now I'm cutting into muscle. There's no way to avoid it. That's why I wanted to have access to over speech just in case we go too deep. Okay. See on either side of this, on the other side of the incision, there is of mucosa. On either side of his avulsion. There is of mucosa. So we're peeling, we're peeling and peeling. Try not to pay for it, underwater technique. Yeah. one Life. I have the knife. I want here, wow, look at this. That's the epicenter of the distraction. Look at this. It's fused. Surely you need to be precise now. I want it. And I wanted. I don't know. I'm carving. I'm carving scar from carving. I'm doing some carbon here. Okay. What's happening here? What's this? Well, let's free this specimen here. Right. Mhm. Okay. Maybe. Why 1/3 done? I mean I mean with the sky. Okay. Okay. How how are we doing here? Right. Oh my God. Like this a technique to remove this card, legions, double tunnels tunnel on either side of the scar. And then when they expose exactly where the muscle and mucosa is on right and left. Then they know where to cut through in the middle uh in the sick. Um It's a little tricky but that's what I'm doing. I'm basically dissecting this side of the sky, that side of the sky. And then when I know I can I can estimate where where it's muscle and where it's not. Then I bluntly cut through the scar tissue, but not bluntly. Certainly what I mean. Very delicate technique. Okay, I will go come around. Okay. Okay. The great of course. Why don't you have your first? Well here, it turns out that the scope is not Lupe. Um Right. So that the element basically the ability to accept the overstates and future this and not worry about it. Okay, Okay. Sky. That. Oh, that was a go that way with. Okay. Yeah, I messed. Amazing. Right? I'm estimating that I need to cut here. Right about here. My commission is wrong. Oh, okay. Right, verify brother. Huh. Uh The only thing that I've seen that's more my brother is somebody who used multiple times the end or rot or to remove a polyp that was more fire broader than this. But this is pretty much done with the hydraulic area. It seems that would be nice. What do you think? Looks good. I just don't want to say let's hope the fibrosis ins there. I don't know I think but you made it looks like you're right. Got rid of the fiber optic area. Yeah. And this but this is why the hook knife is an essential knife for the armamentarium. And she's a girl. So you basically spliced the hydraulic area. You just do a straight line from Basically it sounds simple when you say this one without really without perforating. So you did go fiber by fiber. Right fiber by fiber. Oh contraction please give the other .5 of Google .5. Yeah. The other .5. Okay. Alright, we've done this. Yes, he kicked me out now I'm gonna need pressure again. I don't know. I'm feeling trouble getting on that. Well hold on, let me see I'll try without I can't get to the back of the bullet without pressure. I think I'm on. We got good control. We also have contractions that let me try to go. Let me try to give me a little pressure to go in just a little pressure. Okay. Okay. Can you hold it there for a little while. Okay. Like yeah I'm pushing in. I'm looping now. I'm looping. I'm looping. Uh Oh another good deal. Okay. There we go. There we go. Hold on. No any problems with the vitals. Doing something good. Whatever. He's fine now. What? Okay, how can I close this? I do X. Tack. Yeah, that's what you're alluding to. Right. And we could do X tax just to cover up this muscle that we kind of coagulated a little bit there. Some purest art. And so I can try to put clips, clips would be district. What can you post the walls with the clips? I mean it would be double if we have the double action. This might be a good one for a double action here. One that grabs right left from, what is it? Microbes like double action clip. But I'm not sure if we have it. We got we'll get it. But I don't think I got the double action. I don't think we got it. It's okay. No, I don't think we have it. Okay, good enough press out. Okay, what do we have? What do we have a look at the muscle falls now? You can see it very well. Right with all the scar tissue on top of it. Oh well we have a little penetration there. Uh Everybody's on the other hand. Or did we just do a full technology section here? Give me that liberals clip. I was just a bit tonight. Tonight. What's left of the pole? If I don't know, but it's almost done. So that wait till I till I get it. I don't want any more fluid with the move bigger than America. Okay. Let's see. What do we have? What we have right here, Whatever it is is you flip it. Let's flip it. Right. Let's clip it and let's continue on. Is preserved or not, but let's clip it. Right. And that's not. That's the fold. Almost done. Okay. Go closing. Okay. Okay, fine. Do it. Okay. All right. Now let's go grab this. I gotta turn it. Sorry. Okay. Oh no, we wanted across right. Turning 12 o'clock. Flowers. Okay. No, no. Okay. 11 o'clock. Okay. That's it. Close. Close. Close. Close. Okay. Open. Alright, correct my How close are you going? I don't want to make another hold. All right. It's a man. Okay. Because men are bad. Okay. Alright. Okay. Okay. Did we do that back? Well, I hope we did. So let's finish. Let's finish. Hmm. It's hanging nicely. Yeah, I love it when it does that, right. Yeah. All exposed. Open. Okay. Let me see how that looks here. Nice. All right. Now the question is, I mean, I said the injects didn't I well, forget it. Really? I think in, Jack. What do you think the way it is away from the muscle depression. Right, Okay, good, wow. Yeah. Right. Right. Okay. Mhm. Okay. We're doing it, we're done. Okay. What do I cut? I'm all confused here. Yeah. All right. Mhm. We're gonna use for sure. Not for sure. Just like that. Yeah. Uh Okay. Okay. Okay, wow. Over here and a little bit there. And how is that that How's that or that? Where's the incision going here? Oh God. It's coming out back to there. Where is it going? Where's my shooting? Oh yeah, I see the incision. Very well, you can see them there. Is there no for what? You can use it again? And I don't know. Maybe I might remember where where is the see the incision is too superficial. Right? So, I can't really I can't see where it is. Maybe the hole deeper. And I'm looping when I tried to go in. I'm looping. Uh huh. It's retro flexing. It's looping. It's doing all kinds of things. I don't know how to do it. Uh I don't know under we do it. I can't go to the back the scope. See the scope is too redundant here. Let's recall on. Let's see if I can see the backside there. This is the back side, Right, where does it go here here? Right, back there? Just behind that red behind the red, nothing here. We're fine. Right. Yeah. This is James chilly in here. Just contracted again. Yeah. Is she okay. I should let go, go go. Okay. The generation that what? It's okay. Uh humidity. When we lose the title to? What's the reason it's humidity in the in the line? Right? What do you do? Go fix it? Let me think. Okay. Ah All right. Okay. That's what that lumen does. You don't flop around like a face like that. That's that's what I can do. Alright. There you go. What's left? Nothing near nothing. I don't know. Right? I can't get that good deal. Okay. Alright. Final strand. Right. Is that that's it? I did this. Um Oh yeah. This is the final stand. There. Just doesn't want to show it. No, that's it. You're done. All right, okay. It looks good. So now clips or extract is the question. It's not showing up. Question. You're not changed more. They're not here anymore. It's too bad. We cannot use the overseas. It would have been perfect. It could go on the same day. This is just too bad. Let's try the X. Let's try to at least start with the X. Tack on the left side, which is difficult to see. How do you clip it, clip? It was very hard. I mean you'd have to probably clip millimeter by millimeter. Okay, let's do the X tag. It's that colonic one, right, colonic. Alright, so the ecstatic little question, but the most relevant of the day is what people still watching People. He thinks caught. Yeah. Really die hards. So when does get to meet the Fockers? When this This cannot be on there? It's not beep beep censored? So we use pure a start. What do you think your stat favor and Yeah. No, only with overstates they should give. Yeah, because there was a little uh micro but it doesn't doesn't have to worry about this polyp ever again because it can be not zero reception. Really? Yeah, I just changed the watercraft working all of you. Okay, let's go. We'll do a little pura stat and then we'll shoot your and that's it. Yeah, two minutes ago. How long, how long was the sp for this? No, but when we start injecting are cutting. Okay. The S. D. The S. D. Not a procedure. The S. D. Yeah. One hour. 12 minutes. Okay. He called the camera man is on top of the time scott from the amazing broadcast. Maybe even keeps track of the procedure and writes on E. S. D. Times. Why he did 112 minutes from the from the start of the S. D. Alright, let's let's inject the gel. Let me let me think I will do it like this. Help to proximal. Right. Yeah. That sounds that sounds like the way to do it. Okay, start yes start going. Start going, going, going, going, go where is it? Where is it? No, it's not. Go go go nice going 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 go, go go, go, go go. Ok, let's do a double layer. Go, go, go, go, go, go go nice. Go go go go go go. Okay, I think we're good. Okay. Okay. Okay. Okay. Okay. Well no, I think we are very good. Right here it looks nice. So covered. Okay. We may have to use two kids for the X Tak like half the left half and on the right half. Right, but it's only 6 50 I think 6 50 plus 6 50 1300. Very similar to one over Speech. Two of them are one Overstreet. Right? I don't know how to work this. Hmm. How much is a pathfinder? The past 7 50 800 I think. Wait a minute. Why is this same color? What do you start? Uh huh. Well why don't you take this out first of all? Okay, well, I don't understand this. This is supposed to come down here. What did you get? What size except for the part. How long is this scope? I don't understand. No miss a good box. Those are the five. This is ridiculous. Show me the other one on the short one. Alright, so this is the set up. What happened? Oh good. It's not the right tech stack that sadly Use it. You take this and push it out here. You have it go push out the X back, push out the attack so keep going 1662 short. I don't think so. maybe it's the right one. Okay. Open go out. What? No no no what are you doing? Push it out from here close it close it okay go I gotta do it do it we just we use that stop that, stop that. What are you doing? I'm gonna shut it off, I have enough yeah okay deploy. Okay no take this out go go I just don't know. Okay right now Okay hold it straight hold the switcher there hold the suture suture there hold it there hold the suture there. Mhm. Okay you push it out take it and push it down. Was about no right push push stand up we use the entire asse copy extract. Great go go wait a minute hold hold tension on this tension tension tension. Okay now push it out holy holy holy holy okay give me a little tension on the seat. Okay hold we're gonna put the other X. Tak maybe here right right there it's called. I gotta go go go go do it I'm gonna deploy. Okay so we put the two tax there we're gonna put another two there. Okay fine let's do it for the next one let's use the shorter X. Tag please. Okay let's go you see what it says there you see 1 35 you're supposed to put it out I'm supposed to put it out put it out look at this court. Okay nice. Alright so we're gonna put the third X back here. Hold hold hold hold this. Okay. Yeah, That proves. So these are 1:35 colonoscopy which is what the problem is. 1 35 Kelowna scope. This retro electric scope number 1 35 which is why you have to push so much also. Yeah, the european could almost go modern american one. Okay, so what are we doing? So how far should we go? Let's let's inflate where we're going to end up using a third extra. Right, so we can go there maybe there. Yeah. Okay. Go. That's right. Did you get did you go deep Did you okay deploy? Yes and that was over there. Right. And then since it I gotta go go go, we still have one more. You have one more. You know the problem or the problem is not true due to the problem. Okay. Yeah. Okay. So let's do the final attack. The 4th 1. Right, Okay. Uh a little tension. Hold on the wire on the hold on the future. Hold on the future. Hold on the suits Or hold don't make it loop. Hold it fast on that. All right. Let's see where where I'm gonna put it looks like it wants to go over there. Yeah. Uh when does he want to go? Let's get something there I think down here. What do you what do you say down here? Down here? Right, maybe just a min immature above. Right here. Right, okay. Go did you do it? I didn't fly yet. That's what I'm saying when you do deploy, hold on. I'm exact Did you get it? Well, I think the only one more time. Okay, I think it's okay. Good boy. Alright, let's sense it. So we pull everything out correct and pull everything out. All right, I'm stuck. Oh, you know, I pulled first a metal pull the metal first. Careful, yeah, bullet, bullet, bullet. Okay, another sense. Okay, let's do it since, well, I think maybe with one more extract will be okay there. So, the sense is the same exact sense as the Apollo. This is long enough, right? That since you gave me, okay, don't pull too much on the future. Don't pull too much on the future Because that's 15, but there's more. Okay, there we go. That sense. Nice. Huh? Okay, so we put less than with the Apollo 1 to rip the things off. Okay there. Do it go all the way. All the way go, keep going. The okay, the one this this side behind the valve was a difficult one. So, it's good that we did it first. Now, not the easy side. Now, what's left is the easy part from here to there. That's the way we got to get the out of the way. Give me the politician the closure. But look how the gel the gel really literally attach is the and covers it. Well, it's like a scotch? Look at the jail. What what the forces the box. Of course I want to move the specimen out of the way and then we close the other half of the incision and the gel is gonna count. Keep it happen. Okay open. Okay we're done with that. Hey can you raise your leg? Okay let's see if it's gonna stay there. Okay. Is it open? Okay it's staying. Let's go. Okay let's close let's close got a little poorly shiny look on it. You can see the polymer or whatever that is. If we only want to use one we have to put it here. Well maybe on this take here here, one here and then between one and 212 and three. Maybe you can cinch this. Let's see if this is the right line. That's what you said. There's more one. I don't think so. See I told you this is for the afternoon. This is what this is what size Is 1 65. Well one just just well we made the other one work. It's 1 30. It's a column a scope. That is 1 35. Okay put it there. More on that when you say isn't that's gonna work. I got my work and uh I'm hoping to do work. And this extract is what upper E. G. D. X. Tech or corona scope E. G. D. Bye. I get that. I think that's a polymer. Yeah I gotta do it good. I can deploy. Let's hope this works. I want to use the four to close now. I have to go all the way to nearly the apex and then you don't want to do this side and then the apex and then this to this, this this this this okay. After the apex down here. Okay, fine. Let's go Get the next one. So that the client is gonna be, which one? The one for this talk will trust one or the long one. No one To close the long one. Okay, so we're gonna go, whoa. This is all tight. We're gonna go right down there. Now. I say, I'm not, not a specimen. I gotta go go. Did you get it? Oh, what happened? What happened? Okay. Okay. I got deeper. Like just like, yeah, why not? Put it. All right, put it there. Is it Okay. What happened? We've got a piece of something there. Okay, now we're gonna go there and there and just do it, do it right like there and there or something. Okay. Okay. This, right. Let's see. Yeah, I gotta go. Nice. Yeah. Okay. Final one right down here. Right. Open open what I call the whole, the shooter. No, I won't go over another one. Let's see how I work. Maybe the final, We can use a clip or two. What? Maybe you can use a clip or two If they're small. I think we'll be fine. It is. They spray some purists that over it because it's impure stat remaining. You have this side, you know better to the other side appears to be a woman. I think this side right here. No, not because look where we are. You want to do the Yeah. What happened to my original one too? So that it seems so that God seems okay. Fine. I gotta go deploy. I got that sense. It so looks nice. Right? Yeah. Okay. Ah The jew. What happened? The recorder is not here. Then record this to the I. M. H. The Olympus recorder, attention to cordon tension. So we have it right? It's a nice case. Okay. And then I'll try to remove it to the box before so it's just like he's a rapper. Okay, tension. Not too much though. Okay, goodbye. Mm Nice and slow. Go, go, go, go, go, go, go keep going, go, go, go go. Okay. Alright, closure. Let's see, we're done. You have put time for the closure. Okay biopsy forces. No, he's about all right. Close. Yeah, ruler. We need ruler open open closed because you grab it. Um Alright, I think the gastric was hard. The one from yesterday was tough too. Right. Oops, oops. Don't lose it. Don't drop it. Oh that's the damage from the from trying to put the element and then the pathfinder. You're right. Yeah, I tried. Fantastic. All of our gimmick. You can see your All right. That's it open. Let's let's calculate this speed. So, the storm the gas. It was 10 and changed. Right? Let's see what this one was. That's alright. That's a wrap. Right. That's a wrap. That's a wrap. Okay, let's take let's show the final space. And then it's a wrap for the diehards and stuck it out all day to the last breath. Yeah. Can you hit the lights? Okay, needles, pins, pins, pins. Can you open it there? Yeah, he's done now. No more. No more colonoscopies. So, how often was she getting a colonoscopy? Really has been working hard on it. So you create a problem and then you keep Kelowna scoping to fix it. Right? See how this was rolling. And we didn't even know it was doing that. And we almost Pinned it rolled there. Look at this size. I called it 25 mm. There's a nice margin to it. We did some things here when I put it together for the pathologist. So they don't, you know, because that's cosmetic, pinning my Yes. Yeah. You got the hyper plastic area around the store. Yes, I did. I got it all because I'm like, you don't want that. She's done. She's done no more. Yes, it was Jeff. Okay, melissa. The pathologist like this specimens. Right. He hasn't seen any of this specimen before. That's his first. You know, they went from last yesterday. He saw first years. These specimens attachable mark. We had a series. That's the R. B. So one of the we're having problems with one of the. Alright. There is there is you want to focus? It's not very impressive but the scar tissue was impressive there. Or I can show it with a scope. Maybe the scope maybe better. All right. You got it. Uh huh. Okay. Picture with the scope. Where's the ruler? We didn't calculate the speed. Where's the ruler? So it's also kind of a rectangle. So it's five five 5.5 By 3.5. 5.5 x 3.5. What's this? What's multiply? What's the surface area? But how about the policy? The polyp is about 2.5 by 2.5 five. x 3.5. Where is the West length appreciate the length of uh what do you want? So this is the this is the sky right here. One hour and 12 minutes. Let's say 1 15. So that's 1.25 hours. 15.4. So the speed was 15.4 faster than the gas tax. Go figure. Alright, we're done. Okay so time to say goodbye to whoever is left. Thank you for joining. I'm sorry that he s these were a bit uh rocky. But I think that's a good learning S. D. So um Please join again. I think we're the big course will be in a year. The with Asian colleagues that will come here. But we could be doing another mini course with myself, maybe 2-3 months when the staff here recovers and forget the pain. Okay. Thank you very much for joining by.
