Stavros Stavropoulos, MD, performs an Endoscopic Submucosal Dissection (ESD) procedure with the assistance of the DiLumen for enhanced optical visualization, diagnosis, and endoscopic treatment.
Hey, guys. So now we're presenting the fourth case. Um, it's a 61 year old male with past medical history of hypertension and prostate cancer status. Post radiation therapy. He was referred to us for a 30 millimeter. A sending colon polyp. Um, the polyp was biopsied on. The biopsy showed tabulated. Noah. Complicating factors include tattooing of the site that was in close proximity on multiple forceps biopsies. So today we will do in this topics of mucosal dissection. We will show you the diluted platform or rise jail traction devices and sue Wittering on. Now we're going to the room with Dr Civil Office. Okay, so here we are. So let me show you the dilemma in which is what we're using on this case. So it consists off soft Ah, sheath that goes over the scope has ah inflation device that with this clicker can inflate and deflate separately. The forward balloon are the backward balloon. The forward balloon can be extended like that on inflate a little. So then the idea is you operating a therapeutic zone with this balloon stabilizing the scope and this balloon keeping the Lumen nicely stretched and stable In reality, most off I do with a backward balloon, the forward ball attraction. It has a shooter attached to it. I was a later edition that you can grab the end of a religion and then by operating those stretch that extend the balloon, you can dial as much traction as you need during the case back and forth like this from here. Is this this towards me Because nobody's manning them Now turn the viewfinder towards May? No. Okay, there. Well, not very focused, but Okay, so that's that's I find it very useful to stabilize the endoscope, which makes CSD easier because you have 1 to 1 movement on the scope. I mean, one of the most difficult factors to solve on a Kalanick ia's They is, um, poor and the scope operability because of a twisty sigmoid or trans verse, or if lecture or what not. So it's very useful. It also useful to shoot her, and I'll show you how that works. So now it's easy to insert. So I don't think that in the last three or four years I've put in a deluge on myself because Dr Tarek, we just started can put it in on Dr Maas. But last year on Doctor does the previous year. Dr Condor Ski the previous year. I think that's when we started using the development. Yeah, so it's very, um, convenient. So here I am. Uh, there's a dilemma. Oh, God. So now what? The problem with this polyp is again. It's not a big ball lip. I think the finals best. It's gonna be something like 34 centimeters. But for some reason, um, Trump is on. Ah, that, too, was placed right in tow. Fallen. There is the full lips. It's smaller. We thought, I think, um oh, yeah, The report from the referring doctor really said three centimeters. I don't think this is three. It's more like, ah, who knows, too. But again, you know this this able to be removed in one piece and definitely not with negative margins. If we do. Yes, dear, it's gonna be short and sweet except for the tattoo year, and with that again will come with a guarantee of non recurrence. And she can go to her surveillance in three years if we get a non zero section. So that's the advantage, particularly if it can be done efficiently. Now then I'll searcher this because another Norma that I'm pretty sure you can get a non zero resection on. So I'm gonna situated with Missy. Can go Hey, with a guarantee off non delayed bleeding or or delayed performance, which is anyway. So the doctor is actually only close to this area. You're perfect. Well Oh, the scope guy, I I think you can probably see the scope guy there. You can see how the Dill Uman I see. It's a very short scope that can be moved in and out in one toe. One movement. All I have to say, I don't know how. Well, look, this is there's a lot of resistance. Don't know why. Why the scope You put enough lubricant If the Lumen or what? Yeah, there's something. Ah, some things. What is this area here? Yeah, that's a tattoo. Our guy. So, yeah, I have to say this is not a word religion. So we have thio about Another hand is good toe finish early on a Friday. You can still see the whole product. All great picturing goodbye. No need to do any surveillance ever for this open. So for years, they had to start with a distal side in general. And Jack? No. And that no mhm dog got go. Good. Okay. Well, okay. And Jack, Uh, good. Now? Yeah. Okay. This is, um, by the scope like that. Okay. We did the back and there. Yeah. Ah, I'm good. Mhm. Okay. And Jack? Yeah? Direct. What's happening with the questions and that Our guy What? Great. Ah. Okay. Think. And Jack? Yeah. On Jack. Yeah, a question. A question off the wealth. Mhm. Most of my mars off my ears. These were built Zia Mars. Um, on a lot of them. I do it in the US on Do do us a depth. So you get a near mari us. We can't get to 67 eight are we use, um, now that we merged with N Y u um, some of them, if the insurance approved way, I think we build with an unlisted code on, try to find an equivalent surgical code which are building department. Um, does it might be a, um, but it's equivalent codes different for the column. Stomach, um, that are resemble Ah, Golden legion resection or a stomach resection or what? Not for the rectum. It's easier because there is, ah, transitional resection code that is not specific to surgery. Eso they you can use that one. Got to look it up. I don't know. I don't remember what it is because, frankly, I don't write my own reports on the directors, but there is. Ah, there is a the code for transcendent resection for the other ones. You've got Teoh, be a little more creative question about if you use diluted for all your colony. I used the Lumen I'd say for I don't know what, 90% your thing, maybe. Well, it's a more like That's at least 80%. All right, Black. It could be close to 19. Well, they were not looking for earlier place. I didn't have time, Thio. So our data on the Lumen in our retrospective start it showed that it, uh, it cut the procedure time by a third. When we did a case control study, it cut the procedure time by a quarter on with the dye aluminum were able to close with featuring and over 85% with that adult. Lumen, we're able to situate 15% and that is in a significant. I'm more people discharged the same day, then, um, than in the conventional group. So maybe 10 10%. 15%. This started same day in the non development group versus, uh, versus 40. 44 5%. Uh, this has the same day with Dillaman. So big difference in the length of stay What? Well, the the scope mechanics are not good. Which means that would have been a lot worse without the Lumen. Why the movement is so jerky going out around here. Now, I'm gonna put some marks here because the way that legion is sprawling like a cross, I'm gonna get close to it and lose my zero resection without realizing it. That looks like a tattoo here. So? So that may be a bit of an issue. Okay, get closed. Got a leased out out here. Right At least out there. Yeah, outside. Maybe I should go outside the marks there because if you that would be okay. You think? Ah, think that the effect looks too big that the defect? Very I've been a previous question. I think they missed part of this and there's they're worried about losing that SD sites because says anyway, no. Yeah, I answered that way. Have to inject the because I'm getting close to it. Eso after completing the back incision. I'm not. I'm not. You know, there's this pocket technique where you go from the front to the back, Onda. Then you progress the incision backwards as you go. But here it wouldn't help. And I don't need it to stabilize my endoscope because pocket technique and tunnel technique are great at stabilizing the endoscope. But here, I don't need to. I can do the incision on, then maybe use a little traction and quickly dissect open inject. Okay, that's in the tattoo. Exactly That and that. Ah, on that. Okay. And Jack Mhm. Okay, Exactly. Direct. I cannot do this side. So this is the This is the gravity side, which is always the most difficult one. So we're gonna complete the incision on the gravity side first, and then moved thio to the other side. So that's Ah, let's go here. Breath forever. Uh huh. From I had the first. Yeah. All right. Oh, all right. How about this? I think so. The solution. Where is the right job? Which is basically a solution that includes food blue dye on some kind of viscous agent from Dell on gum that is also used in food. Hey, it's a nice jail that lasts a very long time, much more than Casper involvement. Um, the solution, um, is has an interesting property. It's real static property where what you injected it shows very little resistance while being injected. In fact, when they measured, the resistant is actually less than has been. But once it gets injected, it becomes a true jail with much more viscosity than than the husband. So it's very ideal properties, um, cost similar to the I love you cost of about $80 for 10 CC's. It is more expensive than than respond, which is something like $2013 per bag, the bag being 500 cc's. And that was my go to solution for many years until until arise. This has much better properties it than than than husband. Initially, I was using it on the difficulty is days, but just so, um, so helpful. I really use it on mostly of these days. Okay, so you see that what the problem is here, This is gonna be a northern easy area to enter anywhere where I will complete now. Ah, it z jerky Because for some reason, the way the colon is even with the aluminum you see the scope guide. How straight a nice scope we have to the ascending colon. But it's not very easy movement. Okay, so this is the This is the situation. Now, the question is this This this is caused by the here very difficult to enter. Um, very difficult, Brenda, and looks like a high risk of perforating as we tried to enter that a difficult situation. It's stuck because of the tattoo here. Um, yeah, we should the exact more. Maybe Let's start the exact more. And then I think my heart to try some traction. Anything else? Direct. Okay, so I'm gonna think in this case, I may use the micro tech traction device because here, Nice small Lumen, and that the question about the underwater SD with without yeah underwater the original video of the dilemma and somehow creates a therapeutic space. And in some of the videos that fill it with water And also, um, Milson publish something on the Lumen and what the country is is not really specific to the aluminum inject underwater is this. Help on in some situations is very helpful. Like in the duodenum. It can open the incision and allow you to enter the sub Nicholas Little space. It also decreases this kind of shiny correlation effect. Exactly. So it's a very well accepted technique. I've been using it for years, but recently, interestingly, since 2017, the Japanese have published a number of things. But I think it's ah, well known common secret years. Uh huh. In Jack, then, well, in the color Gordon very use from the Jordanian because of many reasons, including the consistency of the duodenal mucosa, which is very thick and fluff. So water It's called water pressure technique There underwater in the collar. Uh, the way What? The pressure on the water. The very useful technique. Yeah, mhm. We're essentially using water to float them, um, and and to live well than to live toe the mucosal flapped and to enter similar toe trying to get into upon tunnel with the water pressure that the useful technique? Absolutely. If if the need arises here, I'll use it. Usually the need arises on legions. Look at it on the gravity side. But now, in these days of the two traction devices, I'm using more and more traction devices. The problem with underwater is, um, hypothermia. In Jack, if you do a longest day very difficult. With a lot of underwater, you can drop the temperature. The other problem is any slight blade, dirtiest, entire water pool. And then you have to sit for a few minutes, sacking toe, empty that water, control the bleed and then put fresh water. Basically not idea. But it's very beautiful Now, denying that and selected situation. Yeah, is this Ah, the recite can help the same cook on what you were saying. Events. Yeah, this is Ah, this is a difficult situation here as a difficult situation. Uh, yeah. I mean, I lifted and lifted and lifted. Let's do hook. So when the going gets tough, we pull out the hook knife, the hook knife, Um, very delicately and precise. Can pull tissue away from the muscle on. Give us a foothold in this terrible something across a here. Okay, Now open. Perfect. Oh, God. We're slowly getting a foothold trying to put traction right now under such severe angle mend up tearing the edge of the specimen with a clip falling off on destroying our negative margin. I think it's better to try and get a flap going before we attempt traction. I don't have the Yeah, Person is paralyzed, right? Uh huh. Why did I do that? Um, there's a lot of respiratory movement. I Okay, so now I don't know what I'm fighting so hard. Yeah, yes, I've got this. No. Or did somebody Is this a recurrent? Somebody snored something here on this has been lost in the history. But this is not ah, not unnecessary. Cars are to go under. Wow, this is not so bad. So Oh, what happened there? This is terrible. Okay, let's work on the other side. This is this'll front side. Very difficult. Wow, that's got to hear. Now, can you go up? Okay, that's all. Tattoo here. Um, yeah. On this constant respiratory movement, it was probably the event because he spiral light. Uh huh. So yeah. For what? Yeah, not the last vision at all. Small, but nasty. Mhm. So direct. Any questions on what to say? We're fighting of flap going easy. And here centering might be really important because from after day second here the muscle and then you see, I do use a little underwater on again, right? Somebody the layers magnify. There's just too much movement. Still a movement say I have the development pulled back straight on, pushing the scope forward. Still very, very much Very low stability, very low stability. We fight for every millimeter fight for every millimeter. Now we're making a little progress here. There's a question. Yeah. Do you part of have correct? Well, a lot. The So I don't know. So asking. This is a recent question, because that was basically the subject of my entire talk is. So there's a question, or when you start GSD, where should you start? Well, clearly, stomach and rectum, distal stomach and rectum are fair game, no matter what the religion looks. Also, it's very unlikely to prepare for it on those areas. And even if you pay for it, it's easier to do. Was so wrecked. My stomach absolutely now said you may have thio, even earth after your thirties. 40 30 kids. So you include a lot, not something like this in the call on all they can fool you right all. Thank you. Don't realize how much start to this guy put in there. I mean, it's so it's a sea of black. Doesn't live, can create a flap. Um, you know, obviously, if you start and it's like this, you can you see the board on? Do piss me, Liam, are, uh that will keep your completion rate love for foreign bloc resection. But it's a reasonable See here. I'm getting close to the poulet issue. Uh, so, Kahlan, the easier areas of the column. Well, let's put it this way. The difficult areas of the collar are the fleck Shire's definitely the Sigma, the splenic and hepatic, but also the most of the sigmoid on the fleck, Shires to the rectum and on the descending columns. All these flexors are bad. The sigmoid itself is bad because has very thick, muscular wall that is very undulating with big troughs. It's not fixed. It's fixed, very angle ated by surrounding disease or previous pelvic surgeries of the Sigma. It can be thankless. Try to do is Dion. So, um, the sudden column mhm better. The second depends on which wall, but the system is not a great area either. So I would say mid ascending colon record. Big stomach. A software ghoulish, small nice of epithelial tumors, like a gastric carcinoid or a small I on my own. Particularly ones that arise from the muscular is new. Causey. It's all good legions. Start with. That's where I started. But as I had to Really? I diet off Colon lesion. Wow, This is torture. Yeah. Okay, See that? Try traction, maybe. Haven't exposed enough love. Yeah, maybe I should try here again. But here, the more I dissect the closer I get to the poulet, I'm now a three millimeters from the bullet. Unfortunately, have to be very careful. Give me the door. See the hook knife while I'm dissecting down to some because of the side of the hook knife is burning the EDS. That's not gonna do because it's eroding my margin. So I need a knife that has an insulated catheter. That's that. I will end up cooking it all the way after the poulet. We just have to use the dual knife as using its hook faction with a little ball at the end. Yeah, often. Okay, Okay. We have to delicately try to go through here without performing. All right? Yeah. Mhm. I don't know if they go there a lot. Right. Okay, we're making slow progress here, and hopefully I'm not burning closer to the polyp with a duel. Is this a contraction? Uh, I'm running out of School of Rapid Layer is pushing. The ball learns down. Yeah, you know, I'm going to give, right. I want to know what I want. Mhm. All right. Yeah. I don't know how how we're going to avoid the perforation here. Really nasty, right? Yeah. To question what you there are three. Let's used you saw what a nice configuration of the scope that'd Illumina allows. Um, it's ah, it just shows you the But it's a nice straight scope. I don't do I mean, you know, more direct. Do you use the Do you use the scope guide when you're inserting that the alumina? Does it help to reduce the loops or something? Use it initially like I don't use it with hope. I use it with the dark room in just to see where I am and where we're looking. Yeah, I think Sergei Katzen was a big believer on non scope guide. Um, I use it on enough. Yeah, we use it because of the life. Course wanted to show that the Lumen reduces the call on. Well, yeah, uh, there's another device, the Pathfinder that is a nover tube. But when placed under section, it becomes rigid and locks into the shape that it's at the time that you will turn on the section can reduce look too. Ah, well, I've used that to you can't yet insert the overstates through it. However, as you come with the Lumen so But in certain patients, especially male patients that are big and have Big Colon's, that the Lumen balloons could slide and they don't perch, they don't get purchase on the column because of the caliber of the column. This is terrible toe doing. Uh, I don't know where the muscle. That's muscle there. Yeah, I mean, here it's almost like perforation is enough of a This is terrible. He injected that doing them so too. I can see. I can actually see damage to the muscle. Here. Something is moving in the back. Uh, okay, so now what? Well, let's think we could at this point use the traction off the Dillaman. We can try anyway. Yeah, um, so you can try. So that's the forward balloon here. And that's the Sioux chur. Uh, you like Well, why? Why is there only one shooter here? When did a long suitor? That's Ah, it's Ah, Read it. This on all the price. This is the long. So basically, there's a sort of a long loop at that doll. Oh, my. Here, it looks like we need to use the long lube. And the longest black sort is blue on the longest blood, right? Ah, I think it's on the opposite side. Right? I don't Ah, yeah. Well replies, longer black here, But it's not on the side. I want. So that's not good. Um wow. Farther blue Reaches? Yeah. I don't want to use a resolution to try and see if I can exert traction open. Uh, okay. Yeah. First one that doesn't reach well here, I guess. Damn. Okay. What about the other one? The other one is killed them. Mhm. I was gonna try. Oh, now the other one is not gonna be good. I don't think close. Okay. Uh, that's the total bucker. So where should I put it. Why should I? Let's see which way it pulls. Was older the left. So put it to the right. Tough one. Teflon. Look at this muscle there. Okay, Open. Close. What? Can I do your thing? Okay. Uh huh. Okay. Um, Deploy. All right, Open. Okay. Nice. You know the whole story. That's how the hook. What difference? Traction makes the Sure. So, Dr. Tarek Al Unser is gonna read some questions. So there's a question in your experience does a circumferential incision. We'd use the left time by causing leakage off the inject eight as opposed to their pocket method. I have I didn't catch, say, a little louder mhm technique of like doing a different vision apart. Oh, yeah. Okay. Yeah. What's what's the question? Do you have any pressure? Sometimes I do wonder. Sometimes I'll do the other e Don't believe that. Like the circumferential incision with, like, reduce your left in time, right? The second the I used the pocket on the tunnel. When in certain cases where this will increase cope stability because once you get under the pocket of the tunnel, the scope gets very stable. So I use it there. Um, if I don't see that this will help. I do What? I did. Hear the standard. So confidential incision. Um and then traction. You can get into trouble with not completing the incision, right? I say now. Okay. See, the case progresses could become more difficult. Todo complete the incision on so that downsides to everything. But I I use tunnel and pocket when they will stabilize the scope. Let's say the religion isn't very difficult. Let's say the middle, the middle and the interior wall of the duodenum, the scope can barely reach. The only way you can stay paddle to that wall and do it. The ordinary SD is by using tunnel technique. Same thing. For example, this is called director Leah's. These Athens, the only way the interior world is to have a tunnel technique. The posterior could not be done so but yeah, zits dependent. Generally, when you have a difficult where the scope has to operate and generally to the wall opposite where the scope lies by gravity, the only way to continuously operate and essential to that world is toe create a tunnel as a hammock that holds the scope onto that wall. Because gravity wants it to stay on the opposite world. So anyway, so that's so, Yeah, it's certain times it's needed. Other times we dio complete circumferential incision. Uh huh. There's another question about polyps on the icy valve and like the concern for strictures on how to prevent it. Objection. Yeah, we found this. It's in the article. The first two we did. We brought that patients back for pre emptive dilation, and then we realized that they didn't need it. You go back and it's a fairly spatulas opening off their leaders off the ice evolve. I don't know if it's because we excised it's fat or for any other reason, but we found it very fairly. Patchouli. So we basically stopped doing preemptive dilation for the next five, and nobody needed a dilation. So I don't think you get strictures for with the confidential re sections of the ice involved. And there's a question about, like here that you're having some difficulties. When would you consider using that? If the f D R D device, not in a three or 400 middle specimen that doesn't lift with tattoo underneath inject? I don't think I think he exactly tattoo through the muscle to understand that this is not gonna busy to bring in. But, uh, you know, anything bigger than two centimeters, you risk getting a positive margins. So then I'm gonna end up with a Nova Scotia clip with a little piece of fall. If somewhere in there uh, you know, I'm not they acceptable situation if for somebody who obsesses about our zero resection rates inject, if I want to do that, I may even try your mind. What the hell? Um, the The thing is to just get it all and tell the patient goodbye and that and prove pathologically that you can tell them goodbye as the whole cost savings there. See you in three years in Jack. Go home today and see you in three years. Can't be touched. If you look at the Invesco Siri's inject anything bigger than 15 millimeters, there are zero resection follows at 50% or lower. And jack Okay, so we do yourself Vasko, the four appendices polyps. It's fantastic. No amount of VSD is gonna get a negative margin for a public that is sucked into the pond. This er Lumen. But you put it These are usually small 10 millimeters, 15 millimeters so that the perfect size and usually the obviously it's off. The appendix is very mobile, so you can pull it right into the invesco and get 20 millimeters of appendix clamped in there and resected so and you get a negative margin on the up in the sea outside, which would be impossible by tomorrow. Or even he is D. Even with using a rubber band or other attraction toe pull to invert the appendix, you can do as good a job as you can do with the idea. The tough thing is getting it there, of course, but it needs some skill. But then you just pull the appendix, do a nice The FBI are of a third of the appendix, with fall of the second, and then the person is not looking at subject on may. Maybe him a collector may risk of leaks to respect a benign smaller than normal just because it happens to be in this inconvenient location. So there's I mean, there are indications for every to really, I think, but that's I use the differ because I'm pretty good at the SD and the FBI are if necessary, we can resect. Sometimes we need to take a piece of muscle. We just take it. And with future it and then you still get a non zero section even for a scar down at the noma that this stuck to the wall with 100% certainty based on an R zero resection complete curative resection. Um, I'm just requires a little more patience and work. Okay? Attraction works, huh? Well, so far and then, uh, regarding attraction. Right. Okay. Uh huh. Let's stay. Let's stay. Do you think about leaving? No. Yes. Okay, because someone has to do the future. I can't even get a drink around No water. All right. Okay. Well, we'll get you some whiskey. Okay? We're making progress dissecting backwards, all right. Every every port in a storm, this is working. There is a question about the risk of have been decided after FDR D and the initial order first. Okay, so the question is appendicitis After putting FDR joins up with the C l orifice. Well, I think that Germans got maybe one or two out of 20 or something. So let's say maybe it's 10%. I may be approaching 17 or 29 myself. I think we've got to people that had a touch of it a little bit off a little bit of white count, but it went away with antibiotics. So without requiring any appendectomy, may require some extra days in the hostel some antibiotics to make it quiet down. But that happens probably in 10%. The other ones just with a prophylactic antibiotics. They they don't they don't require anything else. So it is. It's something would discuss with the patients with down there that's probably not more than 10% chance they may need surgery for a pond decided. Mind you, if you have a confirmed negative margin resection, the surgeon can just do completely appendectomy only and not need to do a subject on They are something Ah, worrisome for leak like that. So that's OK. And Dmitry is asking again about using FDR device for this follow e thought I answered that. Uh huh, Yeah. I mean, if you use the f d r d, I based on the weight sprawls, there will be no 50% chance of an R zero resection that I don't think that's acceptable for somebody that came here for this kind of He is d R zero t section and there's a question about respecting polyps and determine Allay. Liam, how far have you gone into the alley intersect? Problems less than 10 millimeters. Um, could it be possible if it would say more than 10 millimeters I or the question was for those donut re sections of the classical valve? How deep can be managed this way? I mean, the ones who have done, I believe are 10 millimeters or less. Um, I think more is doable, but extremely difficult because the incision in the eh Liam is okay. The incision in the second is okay. But when you try to dissect from the second up, the ilium all around, that gets very difficult. If it's more than 10 millimeters, it becomes very difficult. I think it will become more difficult. Fortunately, all the ones we tried were within 10 millimeters off the They only had 10 millimeters of William involved or less. Yeah, So this is a This is a muscle fall there that is trying to get cut. It is a prepared ing massive fall here that we need to avoid scrape the sudden, of course, are awful. Now, the reason the lenses like that is because unfortunately, on the standing column, you get fat in the subject, cause a like that, that's all it took to stay in the lands. Um, wait a minute. I did not complete the incision here. Really? Where is it? I don't think I completed the incision on this side. Right. I got to complete it. Uh, let's inject and complete the incision. It's looking. It's looking. Okay, so we're pulling it off this muscle fall there when everything stay, But there's a strict off fat here on that. Uh, that's one of the other advantages on the on this article in Surgical and Dusko. But we discuss all the tricks off dissecting the donut reception. Now, obviously, the that's up because I filled with fat from nearly a sickle valve. So doing that? Yes. The helps to not have fat stick to the lands on would discuss that in the article. So, as I said, under what is because it's purposes and uses. Okay, Now, let's complete the incision right here. Yeah. Jack, where is this guy and Jack? Hey, Want somewhere now? A guy exact okay. Do I want what? The dual or the hook that do electorally. Let's do this. The duel and the other question questions about the use of the hybrid sdm r technique. Okay, that's a good question. So there's this s o. There's this technique, obviously, where you do Ah circumferential incision using is D technique. And then you use ah, close as a vessel that Then you use a snare to sit in the group of the confidential incision, then resected the doctor is still there. I get it. I'm not so sure it's Oh, it's still there. So that's a small artery. It looks deceptively benign. But if that gets got, it's kind of bleed terribly. Give me the the small koa grasp. Er, that's very deceptive. Those pay a little flat and arteries, but you you cut this. The dirty the water put blood everywhere is gonna cost 20 minutes of time. So the hybrid hybrid EMR hybrid Es de So Yes, So you do an incision, then this nurse, it's there and you can't now the problem with that is the minute you get above 2025 millimeters. Um, what happens is the snare skips in some fashion on false the legion in and skims the top, and you live a little peace in the middle for lesions that are difficult. About 50% of the time, you have a really nice fluffy one. You can even go up to three centimeters and get it all. Cut that way, all of stretching it generally, once you go toe above 20 unless it's really vertically raised with plus sub mucosal lesion, you can have the snare skip and cut it and turn it into a piecemeal but and somebody on the ASD learning curve. If they do the circumferential incision like we did here and they run into this wall of fibrosis and I cannot continue, it may help get the legion in fewer pieces and be sure that you got it all because you get everything within the incision. But this legion would know it wouldn't work, for example, here because the major close the sub because I such poor quality that has the snare closes, its gonna ride higher and higher until it it cuts into end or burns over the central portion of the polyps. So it's ah, sometimes it works. Sometimes it doesn't. And it only works in very nice legions. But for those with a little bit of effort, you can finish the ASD. The studies that show the best results for that technique is about people that are good at PSD who don't don't just do an incision. They also undermine the edge of the whole poulet by quite a few. I think what they live is the central 10 15 millimeters that can make a technical of good and also save you a few minutes. But these people know how to do USD. They undermine the edges. I mean, here undermining the edges is the whole game for this least difficult legion once you have a place to go under a good day as the person can finish it. Okay, Open close. Yeah, uh, as a dead really helpful. Okay about so now that's the problem with regulation playing there. This up. He told God shriveled and cooked just to get rid of that vessel. But it was the lesser of the two evils. But try to cut it with a knife, no matter what current I used as a high likelihood of all kinds of bleeding. But now I lost my window there. Ah, yeah, Yeah, that would only work. Yeah, that would only work with the doctor. Is that okay? Yeah, right. Yeah. Scott Hajto, Let's just finish the incision. Sure. So we'll finish this. A conference. An incision. Now, over here and then go back to the attraction on Finish it. How far is the polling from here? Where is it? There is the end, so I can easily cut here and be fine. There's no need to go crazy. There's a question about the surveillance after easy like this is it? Six months, 12 months, three years R zero resection. You can easily go toe one year. And frankly, the reason I do it, he's because I need the data. Um, but if even rz reception like a religion this there's no reason not to go to regular surveillance. The risk of recurrence is minuscule. Well, I mean, near zero. Uh, anything going on? Yeah. Uh, paralysis within paralysis. Okay. Okay. Yeah, yeah, yeah. All right. Find our little bridge. Have to get away from that muscle there. Away from the muscle. Oh, how cares of complete? Uh, yeah, yeah. Uh, mhm. Okay, especially no incidents. Uh huh. Okay, Which way? Today. Second now, Uh, you have to continue in the coming away. I'm there because it's like the water. What now? Let's inject Mhm. Okay. Yeah, There's a lot of fucking this avenue plaza often. Exactly. Stop! And Jack, I just stopped and check. Help! Exact Stop, Jack. So Okay, Jack, stop Derek of that. One of our attendees is very impressed with your technique. And they're asking how many hours of PSD have you have? Ah, lot of ours. Well, how many hours of is the well? I should say so. We were at 750 cases in 2018. That's another 1 81 90 at least per year for the last two years. 303. 80 plus. So at 1100 years, this now plus 7 800 poems, which is also something cause of dissection plus 200 a FDR's so and then there's deep ponds. EAP on etcetera. What's that? 1018 100? 2000 on something like 104,000 to hundreds of Mikasa Linda Skopje's because of the sections, but the average duration of I don't know 2 to 3 hours each. That would make it something like $6 and B 6000 hours. Still less than the 10,000 hours. You need to be a now outlier. I better keep working on it like another 34 years. We should get to 10,000 myself for you. Okay, Let's Okay. I'm skimming the muscle here. I have to get it. I don't want to get the special many. There it is. Getting a little difficult here. Is it that task? Little layers here? Can I have a question? He's asking if you have different settings for the different knives you're using. Not really. Right. A sina? Yeah. Depends on the legion. Not so much on the knife. Dual hooks said things and hybrid, right? No, I don't really. I might worry the certain things if I use something like this be a class knife because they coagulate. Ah, lot. So you may need to move more towards. And a cat onda Karen's that do less calculation because the whole metal conducts are going to grab something to cut it. It conducts all around the arms. So you may need something. My candle cat. Maybe, but I don't really use those knives a lot. I mean, I don't I hardly use them. Make it one o'clock. One o'clock, girl. Oh, right. Uh oh. What is when is that from? This is a completely different vessel. Look at this. Uh, want that? What happened there? Spurred. Right on the on the on the Okay. This is crazy, I think just squeezing it with a cap did that. The forceps. Hard horses. That's interesting. Got literally are filled. Six years. Uh, no, no, no, no, no. So now I have to cycle the water out. Uh, he is contracting the Koran. Can he give Luke a gun? Thanks for nothing. 1 mg. Yeah. Yeah, they drew in my water. Her after cycle. The water. I take this out. Well, okay. This is bleeding a lot. Yeah. Where is this guy from? Uh, I think that the cab just scrape the vessel. When I when I was moving the skull, but I wasn't cutting anywhere near that place. Uh oh. Okay. Um, how's the idea? Uh, the death. Uh, outfront old? Uh, yeah. Hurry. Have you know? Oh, yeah. Close. Interesting. Yeah, it's that cat Carter right there. Such a small little stupid artery. But so much damage. Nothing is. But how can I get the forceps there? Uh, we'll have to rotate. Uh, stay. They they? Uh huh. Uh oh, yeah. But there. Oh, yeah. After? Yeah, full of fat. I'm okay that we stop it. Uh huh. Yeah, yeah. Uhh For your help. Yeah, Yeah. You Yeah. Okay. Mm. Okay. Okay. Okay. I'm sitting. That thanks for Okay. What do we have, uh, have a bunch of muscles? What we are? I think this is getting increasingly difficult from here. We have to change the Lector. Maybe not yet. Let's cut here has gone rejected already. I don't think I can get any more. Miliband's It's just the tattoo here. It's all disgusting. So let's solace cut. Ah! Ah! Why is it turning this way? I don't know, but he's contracting. Is the synod paralysis? The sim need some? This pressure is up. Hardware desire. Um, the special in somehow twisted around I Oh, come on Open. Right. Uh, prejudice. Okay, The problem. The fat doesn't cut well, and it smokes because it's an insulator. Five years of problems. The position. Okay. Yeah, yeah. Other question about yes, The effect of legions involving the didn't take line. Yeah, lesions involving the dentist line. Um, we actually did one recently that was outside the den. Deadline. A square, aimless square, aimless, high graded to El Nino. Pleasure from HPV. It's definitely doable. Some people think studies that look at factors that predict difficulty of VSD found proximity to the dentist line as one of the difficulty predictor. Similarly toe location in the fleck. Cher's location in the sick, um, or the ice evolved, Um, if the circumference is more than two thirds. So it's one of the predictors of difficulty. Some people believe in exacting things like Mark Ain or lighter cane. I didn't found that there's any need for that. If it's truly erectile at the nanometers lesion, it's from the from the epithelium of the director of not the anus. If you cut right at the dent I lined with with a dual knife, sometimes underwater. There is no really much pain now, but why not? We did not was outsider. Then they light in the in the anal canal. We did give marketing, Um, what's there to say? I mean, they usually helps to use a food the cap so you can hone in on a dual knife to be very precise and very superficial. Yeah. I mean, often you Let's inject often. You are, well, the Kalanick dual, which is tiny. It's 1.5 millimeters with a little bit of injection it above the hemorrhoid. All vessels. So then you can see them. Uh, yeah. In the end, all can now. No need for light again if you stay at the dented line and don't get any skin. But as I said, skin is an option if you have us can. Our religion has been reported. There has been reported in another 10, 10, 16 patients, mainly from Japan. So yes, so then that line. Okay, it's a predictor of difficulty, but it's definitely very doable often. You know, e thought he gave me the hook. Now my guys and it cutting All right? She was like, No, we right. Injecting now. Uh huh. I'm trying to capture the middle. Like, why is it it's Cathy? Uh huh. Ah, Inject that stuff. It looked like the hook knife. It's all black. Right? And silvery. Uh huh. Ah, this is necessary. This fat and Jack. Yeah, yeah, Okay, Now, let's do here. And Jack. Okay. Nice. Now, can we cut here? Exactly. Good. Okay, lets since my subconscious wanted to use the hook knife already, I think it z it knows best. So what are the question direct follow up question about? Yeah, Again, I haven't found this to be an issue with through rectal lesion because usually they're not circumferential at the dented lines. Uh, haven't found this to be a problem. I remember 23 years ago. I was at the dinner talking to Yamamoto. His theory is that the stool itself is a dilator for the rectum. So that's why he thought there was less pictures than one would expect. So I don't think there is a problem that now for this squamous anal canal nearly circumferential religion that we did. I think stricture could be a problem. In fact, what? Um, one off? There was a recent Afghanis study that looked at predictors off stricture in the colorectal in the Colorectal Master s Day. The data it life was actually or actually the anal canal was a risk factor. And some of these lesions were not squamous that were rectal adenomas. So I think there may be some risk that the one we just did recently we had her. We had the patient self dilate with one finger than two fingers. Um, try some day as a preventive measure, I think she's gonna be OK. Know what? Just just loosed on it. Bluestem right to get the back. That's what I mean. This Lesia was deceptive, more difficult than I was expecting it to be. And mainly it's the location. And the stability of the scope is just terrible here, I believe. Yes, but it didn't because she knew she was like this one will be the problematic one. Even when she knew it was like, this one will give us a headache. That that's expertise. Ah, yeah. Give me spray. Okay. Yeah. There's another question that I asked about after a long day like this. Do you do any shoulder exercises for massage to deal with the stress and the muscle fatigue? Well, as you know, this is not a particularly in law. Yeah. Now regular practice makes you resistant to problems. Yeah, I mean, once we once we free up this back end, I think we will be well on the path to finish in here this final. This is the final bastion off the Paulie back here. It's trying to hide from us. If we get this, we should be okay. Come on. Yeah. And there's a question about we adjusting the MND balloons to change your position and get in a better angle. Uh, well, the fact that I'm not in a terrible language is the position of the balloons. The in the perfect position, about 10 15 centimeters from the lesions improve on that. The scope is rather was straight. And the front balloon is giving me good traction. So this is what you want real. This is as good as it gets because often the often the balloons are in a position where you can't really utilize the attraction of the dilemma. But here it's working perfectly well, It was working before now. I'm at the back of the legion, so I released Attraction. So that's the other good thing about the adjustable. So now I have listen completely attraction in order to get the back the back part here. Uh huh. So here I'm using a little water pressure. Uh huh. Okay. What happened? What happened? worse. Worse? Oh, most of gone. But uh huh don't give yes. Flopping around in all kinds of weird views. Uh, what? Yeah, yeah, yeah. Oh, Dr Pillars Asking How great are you? On a sociologist? Uh huh. Yeah. Uh huh. This is geologists are the greatest. Our question of I keep cutting, but it doesn't release. Start there. That's safe. Ban. I've got such this right? Yeah, this one. Much more difficult than expected. Curry? Uh, yeah. Mark. Mark. There, There, there. Oh, that's good. That's good. Was good. It's capitulating. Okay. Mhm. Yeah. There's a question about if you use PCF or CF scope for your PSD regions in the colon. That's a good question. I use I use PCF, but I've heard sums up on his experts that, like, the stiffness, often adults cope or the Olympus Culp. So I'm a PC Afghan all guy. I like flexibility, but there are There are some experts that, like the adults for the better control, because the stiffness allows them to have more of a control of the tape. More. Yeah, the heart, you know. Okay. What do we have left? You know? Well is done. All right. Now, some quick suffering. I wish you'd be good. Yeah. So how long does that? He s? Day 4. 53. Deal. 14. 53. The military for it. 4. 53 to 6. Right. 4. 50. Okay, who's good God? One hour, one hour and 40 minutes. Okay, Not bad. Sorry. Memory. We're gonna take it out later. The peace we can take later. Do you think is going to interfere with the structuring or should be taken? Yeah, but now we can, Uh, no. Let's take it later. I'm just gonna pull the balloon bag, right? Yeah. And then we can shoot you. Hopefully. Okay. You got the Lumen. I mean, you got the overstates you need to, right? Um, that's an excellent question. So now we need to put over states to the development, which is much shorter. So the question is, do we need to reposition the balance deeper so we can be sure that overstates will make it to the Legion? So that's the question. Let's see how far the after balloon is as the forward balloon. Um, yeah. What do you think? That's quite far. So we should try to reposition the Yeah, so I'm gonna pull this ball on back? Uh, not yet. Let me go. Some try toe. Put the scope through the forward balloon again. Get to the usual. Uh uh, Absolutely annoying. So we're trying toe put it, inflate a little the forward balloon because the streets are crossing. It's just really don't The column was redundant. Yes. So we should get the balance back in position as close to the polyp as possible. Well, what? Don't say and fled. What consensus? Which one? The front, right? Doesn't look inflated. Jamaica, But okay, it's hard to Ah, hard to do it. Look at this. Okay, Deflator little. You have to keep it in the middle. Somewhat inflated, but not completely to keep it rigid so I can put on the scope through it. Ah. Uh huh. Okay. Okay. Success obvious. Okay, walking. What? Uh, okay. Now we need to reposition the balloon. Yeah, What? It follow one stay. It's a great stuff in the world. Yeah. No. Okay, so let's let Z try to go deeper with both balloon. So I'm gonna pull the scope right at the edge of the forward balloon and not try to go deeper. Uh, if I can. Okay, let's go back. And Stephen. Okay. The scope is let's stiff on the scope. Uh huh. Okay. I might need pressure or not. Uh, this is not There's a nasty column. Did you need pressure to go it? Yes. So the Lumen So you don't see it works in the shadows there, but or yes. D for something like this in a column that needs pressure. Go in. Not another idea. I cannot give me a presser. Pressure pressure. Wait. Did you deflate? Yeah, that's what I'm like. Both the rooms are inflated. So what am I doing? I don't know. That's why it's so difficult. I got Let's go. Okay. Okay. No, I trying to go. I'm probably dragging the polyp with me too. Karen. Hard. Ah, well. Oh, my God. God do that. Um, where is the defect? Not evolved friends right across on the vaal as it here I got here it is. Okay, So the balloon now is Basically I live it right? Almost in the sick. Um right. Wait. The forward balloon is right here, so I can leave it right here on. They inflate both. Oh, no, no. He fled the back. Now I'm going to go back on going with the overstates like I'm coming out. Yes. Yeah, yeah, you have it right. Mhm. So now we're going to remove the Kelowna scope, Then put the over states and future. This is, like another 20 minutes or so, Or advise what do you and then we'll be done. So the advantage of structuring is that this extra 20 minutes, even 30 minutes and these extra $1000 means we can send him home immediately. And as I said, you, as I told you on the 120 dilute Mints, uh, that we have done after the 1st 50 learning curve ones, the same distance rate is all the same. Day district is almost 50%. So again, the assumptions on the cost effectiveness analysis that every colony is these days for today's maybe Japanese level assumptions here the Lumen. So you can situate e 5% of the developments on most of them go home. So the 45% Maybe because initially we were shooting less, we might go upto two thirds go home the same day as ah, the initial cases get diluted. You can explain this for? No. So basically, we're doing a hole on the side of the development to put the shorter over stood through on putting some lube through. Uh, okay, we're ready to insert the for over stitching in the call. And you should always load this later on. When you put some lube, put some lube, put some Logan on the deliver. What about? Yeah, and I need another glove. Okay, so let's let's do it. Getting a little age? Yeah. We should be done by seven for sure. 10. Minister seven. So we shouldn't be too much over? No, actually, seven more like it. I can't. Another gloves? Yeah, his hands. Uh, just Yeah, that's it. Okay. Don't touch it with any liquid on it. Ah, that. No, I just Why? It's the glove you Is it? Yeah. Well, I get it. Thank you. I think it hands. It was so sweaty. Come on. What? Where's the book, please? I feel very thin. Maybe. Yeah, maybe a short movie. This is very thin. There's something wrong. Yeah, I think. Or they changed it. Suddenly there's something wrong. This doesn't feel right. I'm gonna let you. Yeah, I push it back yourself just like this, Okay. What? Spitzer on. Quickly. Okay, so let's load the searcher. Go in. Right, But, uh okay, so I'm gonna go right in there and look how quickly I can get there. Boom, boom, boom. Quickly. You're holding? Sure. Oh, just just the only problem is getting rid of the lubricant. Why did you get there? I think your album. What is your house? Yes, I am. So we have to try to suck the lube. Odd. And we are there on the express leg. What's going on here? All right. How are you? He hurt. Hold it, Hold it, That's for sure. Yeah. Ah, come on. I put a lot of lubricants because it was sticking before, so I might have overdone it a little bit yet Hard to suck. Okay, where is the defect? And Oh, there it is. Come here. So how long was the insertion? When you too many. 22nd inception. Can't be that. Okay. I can't be without the Lumen with aluminum have done 45 seconds, but without the aluminum, it's more like 20 minutes if you're lucky. Okay, so here we are. Mhm. Deflect on. Let's quickly close it. Ah. Oh, I with or not a case control study. The end are first. They without versus God of that was the Lumen with not quite the same. So now direct. Any more questions? Actually, Uh huh. Guys still outside, You know, many, many participants. Pau. So how about yeah? Oh, and no questions. People are thanking you, and they're saying they learned a lot from this course, as they always do. Thank you. Now we don't know. Second artery on the second. We might have to search her this and continue because this is a matter and this field Is this our field of view? Very annoying. There's some sudden because the artery that happens to be in their own place. About time. Yeah, uh, the artery we have to act. Yeah. Have to manage to see to take another bite. And then since it in Southern use future. Very. So that's what you do when there's a lot of bleeding. Got to deploy sense. Can't see anything. I can't see anything. Uh, down marker. Yeah. Uh, okay, I got it. Just sent it. That's just yeah, Mhm. I am knowing. So the sensing, the bleeding and then we're gonna do our job. Okay. Come on. Uh, come on. On the roof. No, you're not seeing it, man. Come on. Okay, go build attention. Attention. That's too much tension. And to see a little bit of the future. No. Okay, There you go. 12345 Do it. Okay, so that sense on now we're going to see again. Let's tackle the blood out. Now. Hopefully, we're not gonna hit any other artery. This fighting us really every step of the way. Yeah. Okay. Wow, for, like, 12 minutes ago. Okay. I can pull him back. Yeah, Yeah. Have too much more to close here. A scoop. Is the configuration here? All right. Get out of here earlier. Yeah, sure. No, I didn't assault perforation. So this do it Because But it they can. Sure. Same dairy, same day. Discharged with no concern at all. After year marred. Reported rates for right. The Michael Berk study is like 5 to 10%. But with this protocol, Um, all right. Guaranteed zero rate because we do complete. Sit. Sit closer. Sure. Yeah, not a muscle. What? What? What? You. How's your mom doing for? Does you know, some problem? No member. Just saw a little longer. Okay, Okay. And good books. Well, don't let it go, Eric. Wow. Question. Uh huh. So there it is. Do both friends here, maybe. Have you? Yes. Remembered. Three more. I wish had been good. All right. Should be the last lap. I cried here. Right? Mhm. Okay, done. Tension, tension, tension. Okay, stop. So seize all since died. Ready for discharge. Good. Let's go. Uh, okay. We're done with the situation. Any more questions? Yeah, I guess. So. Let's bring the specimen out and see what the sides. And then we can calculate the speed and see if it's more than the nine square centimeters per hour band. Smart. After asking the final question Apollo has finished there. Have changed their needle size or shape. And are you still notice? Multi. Yeah. For spring device. This one started. I don't know if they change the needle. Not that anybody told May, but I'm not sure if it's more bleeding a little this for I guess I I was okay. I'm coming out. Um, now we have to bring We have to bring the Oh, my God. Is this What is this? Not something that I was at school from the injection every anyway, it's all since. All right? Yes. Okay. Yeah. Okay. Okay. We're coming out now is the specimen. So, what have it with? Well, here. It's a touch I wish and grab it with something. I could try to put the needle through it, Paul. Okay. Have it all. Double court now. The balloons down. Okay. Cool. Deflated. Right? How they fight. But it Alright, I got Okay. Let's see the specimen. Mhm. Yeah. Uh, have some Caesar's to cut. Where? The seizures that was here. Okay, Cut. Okay, cut. Good. All right. Let's see the size. Mhm. Yeah. Okay. Okay. Yeah, yeah, yeah, sure. Right. Yeah. Okay. It would go your emotions. I'm good. Uh huh. And there's a specimen. Okay. Uh huh. Uhh! As his to sleep. Pretty. Okay. You see who it is? The body important. Okay, there we go. The words the full of almost invisible now. Uh, so glad is he right here. Oh, there it is. 40 ID. Uh, so this was That's where we got close. Or to three millimeters. Very fairly sufficient. Okay, so this is it again, the size is so this is basically a parish to a lesion. I think it's a good all three s a day net today with previous manipulation, including pai Religion All tattoo on by upstairs. Multiple biopsies. Yes, One fibrosis, I would say, was Earth one not really Have to five brushes off one. Um, Why the specimen size? He's 4.5 on long dimension. Andi three On short dimension Ellipse Elliptical, you can calculate. Correct Yeah. 4.5 by three. So that means 2.25 times 1.5 I'm 3.14 Corporate fired 4.5 times. Three. That means 2.25 from 1.5 times 3.14 which is the area of the Ellipse. Important five. 1.5 nights a 10.6 and how long you take to remove 1940. So one hour and two thirds oven hours. 1.69 right 1.7 divided by 1.7 10.6 Divided by 1.7 hours Yeah, 6.2 square centimeters per hour. This is below nine, but this is very difficult. F 15 brushes difficult position. Redundant Collins. Um, but that's it. But that's also gonna be. Are zero un completely structured. You're gonna do it. Religion side. It's a 22 by two. Because it was like a star or a triangle. Okay, So for whoever is still out there, that concludes the course. We did our four cases first. I hope it was enjoyable. On that will be the Long Island Live. Unfortunately for this year, maybe next year you can have your hugging you. Your job back on Sergei and Ghost out on. Have I even more fun on more education? So thank you all for coming. It has been a good day. Thanks.