DiLumen: Expanding the Boundaries of Endoluminal Therapy
Previously Recorded: Thursday, November 6, 7:00 PM - 8:00 PM Eastern
Overview
The DiLumen Platform of products give advanced endoscopists an additional tool like no other. These devices enhance the ability to perform more efficiently during colonic procedures by:
Facilitating the reduction of loops in the colon which result in a straight and shortened path to the cecum
Enable the removal and reinsertion of endoscopes during the procedure without losing position and having to rescope the patient
Providing improved stability and control of both the colon and the endoscope when positioning the balloon at the procedure site and improving visualization when using balloon to flatten areas of the colon
Enabling dynamic retraction of tissue during ESD, exposing dissection planes and enabling a more efficient resection
Presenters:
William Brown, MD
Overlook Medical Center/ Atlantic Health SystemThe role of DiLumen in a busy Advanced GI practice.
Kartik Sampath, MD
Assistant Professor of MedicineThe use of the DiLumen Balloon Overtube to facilitate Diagnostic/Therapeutic EUS in the Proximal Colon
Molham Abdulsamad, MD
Geisinger Medical CenterThe use of the new DiLumen C1 and IgE Grasper to facilitate tissue traction and suturing during ESD.
Good evening. Welcome to Lumenes Dilumen, expanding the boundaries of endoluminal therapy. My name is Eric Coolidge, Lumendi's vice president of sales and marketing. We are fortunate to have three of your esteemed colleagues doctors William Brown, Kartik Sampath, and Moham Abdul Saad with us today. Each of these advanced endoscopists has had several years of experience with some or each of our dilumen devices and have developed new applications or improved the use of these unique devices. Through their own experience, we are hopeful that through today's webinar you will have the opportunity to learn something new and bring that to your own practice. Today we're gonna start with Doctor William Brown. Doctor Brown is a leading gastroenterologist with over 19 years of experience in advanced procedures and patient-centered care, practicing at Overlook Hospital, part of the Atlantic Health System in northern New Jersey. Doctor Brown possesses extensive expertise in therapeutic endoscopy with a focus on advanced procedures aimed at diagnosing and treating gastrointestinal disorders. He is skilled in a wide range of techniques including ERCP, EUS, EMR, and ESD. He has been using the dialing platform for several years in a wide variety of applications. Thank you, Doctor Brown. Hi, good evening. Um, I'd like to discuss complex polyp removal. So, everyone knows. Excuse me. That um the left-sided colon palps are a lot easier. And what makes them easier. Um, this is a pop in the distal sigmoid in a 44 year old female, um, that was too large for our other gastroenteros to remove. So they referred to me, and I looked on retroflexion that the bulk of the polyp was on the back of a fold. But since it was the left side of the colon, I was able to easily retroflex in a stable position. And in a retroflex mode, I could inject, lift it away from the surface. And I was stable enough. To remove. By placing my stiff snare to submikosa. Dissecting through the semicosal layer, cauterizing all the vessels, and doing a zipper close. But most of the referral lesions are on the right side. The right side is much more technically challenging because it's difficult to visualize. The pulp is often on multiple folds, and you don't have a straight shot. It's looped. The scope does not have a 1 to 1 movement. It's very difficult to retroflex. It's also difficult to obtain tissue. I mean, how many people have done this, and you have to take about 10 different specimens out. So that's going to the right colon about 10 times. Also, as I did today, closing the mucosal defect on the right side without an over tube can be difficult. When you put the clip, your scope pulls back, then you have to advance again, you're just not stable. So I was looking for solutions. And I was thinking about over tubes. They stabilize position and they allow a change of equipment. I've used over tubes for close to 20 years, um, especially with surgically altered ERCPs. This is an ERCP um with a ruin Y patient where I use um an enteroscope with a single balloon stabilization to get to the area and cannulate. Once you're in the area with an over tube, you can also change scopes. So you can start out with a forward scope and you can go with a side viewing scope. So I initially sought Lomendi product to do this, and this is a Bill Roth 2 patient where I had a lot of difficulty getting through a stricture. It was difficult because you would have to get through a stricture with colonoscope. With their product, I was able to get to the area, exchange scopes, and use a Duanoscope safely to complete the procedure. But what about the colon? What I like about Excuse me, that the loin over to is that You can Advance Inflate the balloon Reduce Deflate the balloon, advance again. And then go to the lesion. Reduce And then continue. And this allows a straightened path for the endoscope. So you have 1 to 1 motion, a stable platform, and you can also exchange scopes. Let me go through a few cases to show why this works. So I like using the simple, easy 1/2. This is just a simple balloon. Over the over tube, and it's designed for the colon. And it allows for a stabilization and easy scope exchange. Here's a case of, I think it was an 82 year old with a right-sided colon lesion close to the hepatic flexure. This was very difficult to remove because you would try to, to get to the lesion and every time you would try to inject it, your scope would not, it would just slip down. And the bulk of the tumor was on the opposite side, and it was difficult to retroflex in this position. You were very looped. It was difficult to cauterize, it would be difficult to clip and close to. So what I do is I insert the scope to the polyp area. I put the balloon just distal. And then I exchange scopes. I use a very flexible scope. I go from my regular pediatric colonoscope, which I, I used to insert, and I can either use an upper endoscope or the TL uh flexible colonoscopes. And in this case, I was then able to retroflex with ease, and you could see the bulk of the of the growth is on the proximal side. And now you're locked in with a good stable position, and with the stable position, you're able to rotate the scope, have 1 to 1 movements and able to inject with precision. And here I'm able to inject. I first want to debulk that area cause it's blocking the flat area. And after I, I take off the. Semi-pedunculated polyp, I can see the full polyp right here. So, in a stable position, I'm able to inject like 15 to 20 ccs of fluid. Then I slowly work from the periphery. Inject Then remove the edges and a little bit of the healthy tissue. I use a stiff snare, so I can push into the semucosal layer. Then I sometimes pull my scope back in a retroflex retroflex position, push into the tissue and remove the entire mucosal layer. But I give a generous amount of Of saline material. And I work for the periphery. And then I can push the stiff snare into the area. And remove to the blue semicoastal area. This is eluded, which has a little dye, which allows me to see the subbicoastal area. And then I switched to the front view, and with the front view, I also work from the periphery. And I make sure I get a little bit of the healthy tissue so I get good margins. It's important to have all of your bleeding equipment ready because bleeding as usual. So I usually use a coed grasper for the larger vessels, and the first one I vessel did open under resection. So it's very easily to grasp it. And uh cauterize as you go. Work from the periphery. And as I exposed the vessels, I cauterize. And then after it's All lifted and stable. I slowly moved to the center. The anchored scope allows me to push down into the semicosal. And do a cut through the semucosa. When I try to remove the flat part of a polyp without this, it tends to skim the surface. It makes it much more difficult. And after it looks like it's fully resected from the forward view. I then switched to a retroflex view, and often I find there could be a little bit that's a little bit that's still there, so I do a little touch up work. Then I cauterize the edges. And if there's a tack down center or some oozing, I can also give a little touch of work in the center. I find that with a stable position. I, I can do much more 1 to 1 movement, and it makes it very easy to do the therapy. Tissue retrieval, like I told you before, that sometimes it can require about 10 different trips to the area. This makes it quite easy to take the tissue out. Um, you could use it as a conduit to remove all of your tissue at this point. And after I clear out everything. Then it's time to do closure. This lesion I thought would be a little bit better to um close by sutures. So I use the over 2. Which to pass a 2-T therapeutic upper endoscope with an Apolloing suture device. This allows safe passage through. The colon, the loopy sigmoid, which is now straight, it allows you to safely reach the area. I've tried this before without an over tube, and it can be quite um a little frightening because you're going through with a sharp instrument around a lot of curves. So I wouldn't recommend it, uh without the safety of an over tube if you're going to the right colon. But using the over tube, I'm able to do a purse string suture. And close. I have to take care though, not to tighten it up to do too much if it's half the circumference. You don't want to cause a stricture. This is the 2nd case. Of a failed polypectomy. It kept coming back and people didn't know why they wanted me to look at it again. Again, it's the same location. It's the ascending colon near the hepatic flexure. So what I did is I advanced my scope and my balloon just distal to the area, inflate the balloon so I have a stable position, reduced so there's no looping, and now I'm able to put whatever scope I want. So now I can put an upper endoscope or a flexible. Um, colonoscope, and I could retroflex. So this is one that I see the lesion. This is why it keeps coming back. There's some residual on the opposite side of the fold on the proximal side. For me, this is difficult to get at this area, since it's a curved area and unstable. But now with the over tube, with the balloon there, it becomes easy. I can easily inject, and I find that there is a central depressed area. And when you inject, I also see there's a possible a little bit more. Pa up here. So what I wanna do, anytime I see or think there's fibrosis or invasion, I wanna work from the periphery. The periphery lifts easy because it's healthier tissue and it's not tacked down. So, I lift the periphery and then work from the sides. I usually like working from the more challenging retroflex side first. And then slowly, Do a circumferential resection, making sure that you get a little bit of healthy tissue to get good margins. And after it's isolated, this is nearly isolated right here, you could start seeing the uh scar tissue right here. This is the non-lifting section. I can push into the tissue. Using the anchoring of the balloon. If you don't have this, I find that if I'm a loop position, you try this in the scope just pushes back and you skin the tissue. You don't get a good resection. And here you can see I able to go right through the scar tissue. You get pretty good depth. When it's like this, sometimes it could be a tumor. So you have two options. One would be doing a full resection, which may be a little challenging. The other one would be to biopsy the tact down tissue and then cauterize the base just in case there is any tumor that's invading into the subbicosal muscle. I have a few 85 and 90 year olds that have a tumor that are not surgical candidates that I've done this with. This patient though had just benign scar tissue um on the biopsies. And in this case, I wanted to close. With The conventional method. Of clips. And as I said before, in this position, it's very challenging to do clips. Your scope tends to move back and forth, you tend to spin. And when you try to get good. Pressure on the clips to close it. Uh, to close the tissue, your scope moves back. And when it moves back, it just gets kind of jagged and hard to close. So this is what I find another high use of, of this equipment. So I slowly zipper. And then I'm able to close close fully. At the end, I always look at retroflexion, just to make sure everything is clipped on the other side too. Like I saw before, there's a little residual occasionally there could be residual um non-closed area. This is the 3rd failed polypectomy, um, that was tacked down just to show the same technique. Using with narrow band. Injecting it, it doesn't lift as well in the center. So again, work from the periphery. You could also use your water jet. To help Uh inflate the semicosal layer. Work from the edges. Isolate the center. And then once the center is isolated, Use the balloon in stabilization to be able to press down. And complete the closure. And I always check in retroflection to make sure that there's complete resection. This time there was good resection. And then when it's also fibrotic, I also do argon plasma both to the edges and and to the fibrotic area after I biopsied, of course. This one I was a little bit more concerned, so I did a little bit extra, um, barbecue. And then like before I did the uh zipper closing at this point too. But I checked. And then I noted, this is why I like Being able to retroflex easily. I saw an area that was enclosed, and this looks like a blood vessel there. So I cauterize the blood vessel, and then I closed it. It doesn't look as pretty on retroflection, but I was able to close it. And uh that is the end of my brief presentation. Thank you very much, Doctor Brown. Um, so just as a reminder to everyone, there is a box or an area in um your screen where you can ask questions. So our plan is to, if you have a question that you'd like to ask, you can type it in or you want to hold it to the end, we'll hold it to the end. We'll have a brief uh Q&A at the end of this presentation. OK. At this time, I'd like to introduce Doctor Kartik Sampath. Doctor Sampath is an assistant professor of medicine at Weill Cornell Medical Center and an attending physician at the New York Presbyterian Hospital, Wil Cornell Medical Center. He is an advanced fellowship trained interventional gastroenterologist. His clinical practice and research interests relate to the fields of pancreatology, therapeutic, surgical, and bariatric endoscopy, and obesity medicine. For several years, Dr. Sampath has been using the dilumen platform and was one of the first to use it as a protective sheath to deliver an echo endoscope to the right side of the colon to perform EUS. Thank you, Doctor Sampath. Thanks, Eric for the um kind uh introduction and thanks to Lumendi for the opportunity to speak here today. My talk is entitled The Use of a Clonic Balloon Overtube to Facilitate Diagnostic and therapeutic Endoscopic Ultrasound, um, in the proximal colon. Um, these are my disclosures. Most important is a consultancy to Lumendi. Um, the outline of this talk is to review diagnostic therapeutic indications for proximal colon EUS, identify the characteristics and limitations of an echo endoscope, um, recognize the utility of a clonic over tube to facilitate proximal colon. US address the potential cost effectiveness of utilizing an over tube for proximal chronic disorders. Discuss the accessibility and adoption of the clonic overtube platform, both academic, hybrid, and community medical centers. So a primer on the colon, on average, the length is 150 centimeters or about 5 ft. Accessibility to the proximal colon can be limited by the length of the colon, tortuosity. The indication for colonoscopy are widespread, including diagnostic, whether for diarrhea, bleeding, abdominal pain, polyps, early cancers, submucosal lesions, luminal stenosis, and if we identify some of these issues, there can be therapeutic interventions we can do, whether it's foreign body removal, GI bleeding, among other things, dilation, palliating obstruction, and resection. So, as far as your typical scopes that you use for the colon examinations, a pediatric or adult colonoscope, the length is 170 centimeters. It's a gastroscope, which can vary in length from 103 to 110 centimeters on average, so you may not necessarily reach the proximal colon. With that scope by itself, however, may be easier in certain colons or if you've had a prior resection. There's also the enteroscope, which is 200 uh 200 centimeters and be indicated for a prior failed colonoscopy, let alone deep ileal intubation. So let's move on to the EUS, that's the key focus of this talk. There's a mini probe which can go through a scope. However, the resolution can, can be quite poor. You cannot necessarily get tissue acquisition. Uh, the radial EUS um is 155 centimeters. It's a side viewer exam so you're not looking straight ahead. Um, so there's the potential to induce mucosal trauma and other, um, complications. There's excellent resolution, however, we cannot get tissue acquisition. And there's also the linear scope, similar length side viewer, um, but again, because of the length, proximal colon access is limited. You can see a 180 degree view, um, when using that type of scope, um, but you can also do tissue acquisition. and therapeutic interventions. There's also the forward viewing EUS scope, which is a 110 degree view, so you can look straight ahead to an extent for the purposes of passing the scope. However, not all endoscopy units have this type of scope. So in terms of lower EUS indications, why do we investigate? Well, if you have a mucosal-based lesion, cancer, um, can it uh stage that locally? submucosal lesions, identifying exactly what's going on there, whether it's a lipoma, gastrointestinal stromal tumor, highomyoma, carcinoid, cysts, of course, malignancy, extrinsic compression, and vascular abnormalities. And then if you have access to these areas, sometimes if it's necessary, we can do therapeutic interventions, whether it's enterocolonic bypass and we'll hint at other unique indications, for example, metabolic endoscopy. So he has a little primer on the typical submu mucosal lesions throughout the GI tract, and the esophagus more common, could be a lion myoma in the stomach, you can think of a chest, dude and and colon you can consider carcinoids, among other some mucose lesions on the differential. Um, so why use an over tube? Well, the echo endoscope, in particular the linear scope, has a stiff tip. So you can get a lot of pressure there to the mucosal surface, and it is a side viewer exam. You are not looking straight ahead and passing that type of scope. On top of that, it's a shorter length compared to a colonoscope. So you may not necessarily access the right colon. And so in addition to the scope property itself, there's the lumen. You can have a tortuous colon, more twist, more chance for mucosal trauma, or if you have diverticular disease, you can have a weakening in your mucosal or colonic wall that can Increase your risk for a perforation. So an over tube helps us mitigate that risk. It gives you a protective sheet from which we can advance this stiffer tip safely into an area of interest. For example, the right colon. So what kind of over tubes are out there? Well, there's many on the market for different reasons. Single, double balloon over tube, generally speaking, doesn't fit in the US scope. It's a pathfinder, rigidizing over tube, which has a gastroscope and clonic. Um, sizes, and then there's the endoluminal interventional platform from Lumeni, which can fit an EUS scope. It can also fit an over stitched device as you saw from the previous talk, the over the scope clip Mini as well. And so, with this platform, you have, and it was shown in the previous animation on the prior uh excellent talk. You had a colonoscope that was loaded onto the EIP platform and then using Maneuvers including balloon inflation, deflation, scope advancement, reduction, you can get that over to to the proximal colon, and you can modify that tube by making an incision in that tube to then place a shorter type scope, for example, a gastroscope or an EUS scope. And the general rules is to, so, um, once you get that over tube into the area of interest, then 2 centimeters. Distal to the anal verge, you make an incision that's roughly 2 centimeters long to in length, um, for the purposes of the introduction of the scope. So, um, the EUS again, you can advance it with an overtu. What's the benefits. You can mucosely stage, uh, malignancy, US guided interventions, scope exchanges, for example, you can do that diagnostic EUS, then you You can remove that if you feel there's a need for a complex intervention. For example, resection, whether it's submucosal dissection, and it's got the full thickness resection, let alone suturing, which affords you to do more aggressive resection type interventions. Then at the end, you can deflate this over to and remove the scope. So this video was actually played in the previous presentations, so I'm gonna keep it very brief, but just to help remind or reiterate, if you will, you can inflate, generally speaking here the a balloon and you You can reduce the scope when the balloon is still up, you can then advance the scope further into, for example, the transverse colon. You deflate the balloon, then you can advance the um the overtube further, reinflate, and then reduce advanced scope to get to that proximal colon, OK. And this is a, a video from that was published in Video GIE in 2023 from the Stanford Group. This is actually an indication of perorally advanced the over tube to a limb for the purposes of alter anatomy, gallbladder drainage, but it illustrates the key points, which is that you have an over tube, OK? And if you simply put The echo endoscope through this tube, it is too short. So because of that, through the series of maneuvers, you can get that over tube into the ideal location. You can make that incision and then advance that echo endoscope further along the passageway of that over tube and get it into the area of interest for your therapeutic or diagnostic evaluation or intervention. Let's move on to clinical applicability. This is a 50 year old female underwent screening colonoscopy with one of our generalists. Not a 2 centimeter transverse colon submucosal lesion is referred to myself within our advanced endoscopy group. I recommended a CT. Once that CT was done, there was a clear evidence of a 2 centimeter pericolonic lesion cannot rule out a gist. It was discussed with the surgeons. They advised potentially considering a hemicolectomy. The generalists wanted to get a more definitive evaluation referred to me for the EUS and depending on what that showed, resection if necessary. This is the CT scan. You can clearly see a well circumscribed defined lesion in the proximal transverse colon. So what's the guidelines in general for subepithelial lesions? Well, we have multiple GI societies, AGA. ECG and in general, um, in the US is the modality of choice to evaluate a submucosal lesion in the GI tract, and if it's determined to be arising from the muscular propria layer, then sampling is advised. So this was our patient. We see some mucosal lesion. I was able to use the um uh luminity over tube to get the linear US scope into the proximal colon, and you could clearly see a well-defined anechoic. Uh, lesion which is basically a cystic type structure, and you can see actually the layers quite nicely here's the MP layer submucosal so you can see this is an intramural semucosal uh cyst and because of the benign appearance, there was no need to do a surgery and For all intents and purposes, because of the benign nature, we did not need to sample this lesion and we really preclude an infectious risk. Surgery was deferred and unnecessary surgical risk, healthcare expenditure was precluded, and the consensus was to do a repeat imaging study in one year. Clinical case two, very different indications. The 48-year-old female that was uh that had super obesity, for to in a bariatric clinic for consideration of a weight loss procedure. The BMI was 68, patient weighed 472 pounds, and had a ruinide gastric bypass 23 years prior, and the weight later had gone down to 350, but over time, he gained weight despite intensive lifestyle modification. So, this patient had an endoscopy or a dilated pouch, was evaluated by bariatric surgery, was deemed a non-surgical candidate, was discussed at our multidisciplinary conference with the consensus to try something endoscopically to have short and long term weight loss effects and the suggestion was to consider a small bowel partial bypass for caloric diversion. So the planned procedure. was to do an EUS scope into the right colon. We then integrate simultaneously went down with a double balloon scope into the proximal, I should say the mid distal ginum, and from there we were able to make a connection between the small bowel and the right colon for the purpose of a partial, not total, partial caloric. Diversion. Here you can see a video of the procedure, that's the IC valve, that's the EIP platform assisting with getting um um that uh over tube to the right colon, that's a double balloon. Here you can see the EUS scope in the right colon, you can see the antegrade scope in the jaginum, and then ultimately we inflate the ginum using fluoroscopy to match these two lumens together, and we inflate with Methylene blue, saline contrast, we then look from the right colon. And via alumina posing metal stent, we're able to make that connection between the right colon and the small bowel. Again, this is to afford partial caloric diversion for the purpose of weight loss in a difficult to manage super obese patient. Here you can see the stent being placed, can see a balloon, you can see actually the juginum here from the colon side, place an anchoring double pigtail stent. You can see on fluoroscopy that the stents are connected to lumens. This is from the colon side visually the stent simultaneously, this is from the integrated double balloon um perspective. So how did this patient do? She had no acute events and was discharged home same day. There were no diarrhea. Um, anti-diarrheals are required after 2 weeks. Patient had 50 pound weight loss at 4 months. GOP 1 receptor agonists were not available to this patient. An outlet reduction was performed at the 4-month mark, and at 11 months, the patient had 92 pound weight loss, 19.2%. Caution, of course, is that innovative interventions like this should be limited to expert centers with established protocols and surgical backup. And to illustrate that when you have access to the right colon, there are unique things that can be done both diagnostically, let alone from an interventional standpoint. So what's the opportunity here? Well, we have these devices and scopes that can now access the proximal colon. It's gonna allow better lesional assessments, helps the advanced endoscopist be a more accurate or precise, if you will, diagnostician. And then when you're in that area, then depending on your training and skill set, there's a potential to do complex resections, right? And it's not just about being able to dissect, to be able to Uh, to do certain closure type interventions as well. This leads to innovations in endosurgery, whether it's complex resection, defect closure, addressing aluminal obstruction, um, uh, with the therapeutic US, let alone metabolic endoscopy. Well, what's the cost? Well, there's of course, purchase order stuff. uh, from a microscopic perspective, you could think about that. So advanced endoscopists, it's time. But they're increasing their certainty from a diagnostic evaluation. And then macroscopically, there's the potential to defer certain types of surgical interventions. And by doing that, um, there's a reduction in healthcare expenditures. However, I would caution that any of these interventions where a complex, um, type of technique is utilized to discuss this in a multidisciplinary setting and team. This is a couple of publications showing the use of the EIP platform to facilitate a diagnostic evaluation of semucosalle at the appendiceal orific. We referenced prior the ability to do um complex therapeutic EUS like gallbladder drainage with the assistance of the EIP platform, let alone ESD for the purpose of therapeutic removal of complex lesions, but also to aid in the diagnosis of those um complex lesions. So when you reflect, you can think about being either risk averse or risk uh prone, or cowboy, whatever you wanna call it. Um, and there's not a necessarily a right or wrong. However, you know, as a diagnostician, they might see that semucosal lesion, just send it to surgery, out of sight, out of mind. Nothing wrong with that. But you may have someone who has the skills to further investigate that so that they have a better understanding of exactly what that lesion is. They can counsel the um surgeons better, let alone the patients, so they may want to be more aggressive as a diagnostician. OK. And then if you're interventional, you may say, OK, I've done all this work to understand exactly what this is, but I don't really feel comfortable removing this myself. I'll send it to the surgeon. You're aggressively diagnostician and a little bit uh more risk averse and probably appropriately so as an interventionist. However, There's also the potential to understand exactly what it is, and then potentially to do complex interventions like a submucosal dissection, potentially EFTR so that you can truly um spare a surgery and at times, depending on locations in an organ. So the key concept here is that the clonic overtube affords a safety hedge. To enable diagnostic evaluations and therapeutic maneuvers in the proximal colon, and ultimately it's up to the endoscopist to see how aggressive or not to be procedurally. So take home points, the fields of therapeutic endoscopy and then surgery continue to evolve. In addition to device development, creative and diverse indications for the current devices will continue to be defined and refined. Colonic overtube usage allows access to the proximal colon. Right side of the US affords more accurate diagnostic evaluations of set lesions. There are therapeutic inventions which of course can involve um complex resection defect closure, but can also be used to palliate obstructions and metabolic endoscopy, and ultimately the endoluminal interventional platform facilitates the opportunities to perform these innovative organ sparing minimally invasive endosurgical interventions. So that'd like to say thank you for your time and attention. OK. Thank you, Doctor Sampath. Again, this is a fairly recent, uh, new application, and Doctor Sampath was really one of the pioneers in this uh new application, but it seems to be taking off now quite a bit in the, uh, certainly in the US market. Um, OK. Doctor Abdul Samad is a board certified and fellowship trained gastroenterologist practicing at Geisinger Health in Central Pennsylvania. His clinical focus revolves around 3 space endoscopy, complex resections, and advanced therapeutic endoscopy, including endoscopic submucosal. poem, EFTR EUS, and ERCP. He's been using the dilumen platform now for several years, most recently utilizing the dilumen C1 and the IGE grasper for ESD in all areas of the colon. Thank you, Doctor Abdul Samad. Thank you, Eric, for the introduction. All right. So, um, like Eric said, I'm gonna talk to you about dummin C1 and IG grasper, and this is the newest platform uh that has been introduced by Dilumen. Uh, these are my disclosures. I provide consultation for dumin. So endoscopic submucosal dissection in, in my opinion, or I mean, recently, we all know it's been an excellent modality for a section of colorectal lesions. Perhaps it's the best for various reasons. It, it, it guarantees you that it gives you the highest in block resection rate compared to EMR. It has the lowest recurrence rate and the highest curative rate. It has been on the rise worldwide. I mean, back in the days, 10 years ago, probably there was one or, you know, 2 in, in each state that could probably perform ESD nowadays. You could probably find 1 or 2 in each institution. And that performs ESD, um, uh, the, the ES, once, once you get an accurate histopathological assessment, you cure the lesion, you could potentially preserve the organ. Uh, so it is an organ, uh, preserving procedure. However, this comes on some limitations. First is the procedure time. Um, of course, ESD may take longer time compared to conventional methods of, of lesion resection. Um, the complication rate and it requires training. Uh, and in my opinion, recently with the advancements of the techniques and the devices available for this, uh, the procedure time has been faster, our complication rate has been less, and the training has been improved with less learning curve with the availability of these devices, and we know that the ESD has been endorsed by most of the society's guidelines for the resection of complex and invasive polyps. So what are the main ESD steps when you plan for a procedure? So the first and, and most important is the lesion assessment. Uh, you, you have to make sure you know what are you resecting and why are you resecting that lesion. If that lesion has signs of malignancy, do not waste your time because once you hit invasion into the muscle, you're turning a simple ESD into a full thickness resection, which, you know, could have its own, own complications. So if you're not ready to tackle that, then make sure that you assess your lesion, make sure there are no signs of invasion before you embark on, on ESD. And when I do my lesion assessment and I look for dysplasia, look for the pit pattern, etc. how many falls is crossing, I always check for gravity. So just push on the water paddle or flush some methylene blue in the lumen and see where that goes. Once you see where is your gravity in relation to the lesion, then you can have a better plan. If your lesion is pulling under water, then you know, um, you have to do something to improve that because if your lesion is sitting. Uh, on the gravity side, it's gonna be uh difficult for you to access the submucosa. So once you do your assessment and you're ready, you start your injection, you start your incision, and I always stress how important it is to do trimming after your incision. So it's not cutting the, the mucosa. You have to follow that track multiple times with your knife to kind of clear the submucosa fibers. Uh, on the entire circumference because this step will definitely improve, uh, your dissection rate, especially the speed, especially at the end. Now, once you finish your incision, you're trimming, and at this point, you also had in your mind, what technique are you going to use for your ESD. Uh, the next step will be visualizing the submucosa layer and getting into the submucosa. And here is the most important and and key limiting step to finishing the entire ESD. If you cannot visualize the submucosa layer, you're not going to be able to dissect. And in my opinion, this has been the reason why many start an ESD and eventually convert to a hybrid ESD or hybrid EMR and just wrap a snare because he can't get into the submucosa. Uh, or even the reason why many start an ESD, they find it's cumbersome and then they quit doing the ESD. So I think this is where The most important part in an ESD is improving the visualization of the submucosa. So poor visualization of the submucosa, which we call the dissection field, um, has many reasons. And number one is our endoscopes are single channel. So you, this single channel accommodates for your knife only. Uh, so like, like a surgeon, you know, he uses a knife with his right hand, but he uses traction with the left hand. But in the scope, we only have one channel, so you can only use the knife. So you're, you're gonna be limited to what else can you do to improve your dissection field. Uh, number 2 is your direction of plane of dissection is controlled by your scope direction. So if your scope goes to the right, your dissection field is on the right. And, and if your traction is somewhere else, then you, it's not gonna help because everything should be aligned on the same direction where your scope is going to go. Uh, so, so this is what, what we really want to see. When we do an endoscopic submucosal dissection, you want to have a clear identification of the muscle. That's your lesion here, and you have your submucosal, uh, plane, and this is the Dissection plane, you can skeletonize the vessel and you have clear visualization of the blood vessel, so you can cauterize that before you dissect that. And you see how the submucosa is wide open, and this is with the help of traction. So the solution to the difficulty in ESD is to have traction available. Uh, and what traction does, it will improve the visualization of the sub. Coza, you get better exposure of the vessels. Uh, everybody knows who does ESD that once you accidentally cut into blood vessels, you're talking about another 5 minutes. If you're lucky, sometimes more than that, to control that bleeding. Uh, it will stain your submucosa, and now you have a complete red submucosa. You lose your plane after that, and it becomes way more difficult. Uh, if you try to cauterize an act. bleeding blood vessel, you get a lot of charring in that area. You could accidentally injure the muscle. So that's why exposing the vessel by exposing the submucosa will make your procedure safer, quicker, and faster. So that tension on the fibers also, if you see like in this picture, because I have tension, if I just cauterize the submucosa. It will cut. So once you have fibers under tension, it is so easy to cut them compared of fibers that are flaccid and, and they are not stretched. And this will translate into faster procedure, decrease the procedure time, uh, less complications, less bleeding, perforation, and perhaps it will decrease the learning curve. So what traction devices available, I can categorize these into two main categories. So traction techniques without device assistance and traction techniques with device assistance. So the one without device assistance are, you're using just simply the lesion itself to provide your traction. So by using the distal cap attachment and pushing under the lesion, that will stretch the fibers and you can see the submucosa, uh, gravity assisted. So if you change The patient position where your lesion now is against gravity on the opposite side, so the weight of the lesion will pull the lesion down and that will provide traction. Underwater assisted ESD by flooring the lesion and the tunneling techniques and pocket creation techniques where you do not cut the, the, you do not do a circumferential incision and you rely on the tension of the mucosa to keep the submucosal plane open and advancing the scope through that. Uh, so these are just simple techniques that you could utilize to help, you know, make your ESD procedure, um, easier, uh, by, by using this sort of attraction. However, on the other hand, there are plenty of of, of traction devices available to help facil facilitate and expedite your procedure. And these are into two main categories, internal and external. The internal traction are traction devices that you will use inside the colon but you have no control over. Means once you deploy them, you cannot change them, so you have no control externally outside the patient on, on the direction or the, or the, or how the traction has been going on. Um, and the most common and the most simple and cheapest one is just uh double clip and band. So you, you put a clip on the, uh, anal side of the lesion and then, uh, type that with the rubber band, for example, pull on the other side and that will provide traction. Uh, however, there are limitations to these, of course, because once you put it now, you cannot change it. So let's say your lesion is 67 centimeters, and you were able to lift halfway, but now your lesion is again not under traction, so you're going to have to cut it, put a new one and do that and, and keep going um further till you finish your entire lesion. So sometimes the bigger the lesion, you may require multiple times to change the traction. Uh, the comparison to the external traction, these are devices that you could either mount on the scope, use through the scope, outside the scope, but you will control these devices from outside. Simple is clip and line, for example, which is most commonly used in upper GI tract. You clip the lesion, put a line outside. If you pull on the line, you're basically pulling on the lesion. Uh, and there are many, um, advancements in these traction techniques, uh, all the way to, to trying to introduce, you know, similarities to Indo robotics into the colon. And, and, and, and an example of these is the dilumens platforms, uh, including the IG grasper which we will talk about. So what are the characteristics of the best traction? Uh, so you need that traction that has multidirectional, means it can go upward, it can go forward, or it can go backwards. So these are the main traction, um, uh, directions. When you do traction, either you pull the lesion up or you pull the lesion back and then you find the tunnel under or you push the lesion forward and you keep pushing forward till you dissect the entire lesion. However, you, the best traction is the one that can change dynamically during the procedure. Means you, you can start by pulling up and then if you don't like it, you can push forward. If you don't like this direction, you could pull backwards. So if it's a changeable, then it's better. Uh, uh, if it's readjustable, easy to use, and if it's dynamic with real-time triangulation, and these are the new advancements in traction now in colonic ESD. However, what these uh traction um uh techniques that when they are dynamic, it's better if they are not linked to the scope movement because if the traction triangulation is linked to the scope movement, so if you go right, your traction follows you right, but if your scope goes to the other direction, Your traction is gonna follow. So it limits where you're going to dissect, uh, just because the traction is coming out through the scope itself. Uh, and, and the last one is, you know, the, the, how far are you going to dissect? So if your traction comes through the scope, then you're limited because if you advance forward, the traction is gonna move the lesion away from you. Uh, so, you know, working from a distance is different than working close to the lesion. And, and most importantly, working from a distance may limit your visualization of the blood vessels. So you could probably cut through the vessels and not see them compared to people who do dissection very close to the submucosa. So what is the literature review on, on traction, uh, in ESD? There is a recent meta-analysis uh that came last year, uh, and they looked at 6 randomized control studies, 566 patients split into half between conventional ESD and traction ESD and they found that traction ESD has shorter procedure time and faster uh resection. Speed. We're talking about probably at least 30 minutes difference between each one. They did not see a big difference in the R0 resection rate, perforation and bleeding. However, I want to compare this to a previous publication that was in 2020. They had more studies, more patients, and in that um uh meta-analysis, they actually saw a lower complication rate. And lower perforation rate compared to the conventional ESD. So in general, traction will improve your speed, will decrease the procedure time, and potentially decrease your complication and perforation. So the ESGE, uh, for example, they recommend using traction methods in the guidelines for colorectal ESD. So So with that in mind, could we potentially and can endoluminal resections evolve like surgery? You know, surgery started with a big 15 to 20 centimeter incision into the abdomen, which accommodates both surgeon's hand to apply traction and then, you know, dissection. This has evolved in surgery and it became laparoscopy, multiple ports, and recently even single port, which accommodates light and multiple hands for the surgeon. And as simple as the gallbladder resection, you could imagine the big gallbladder as a big polyp, and you see how the surgeons can manipulate the gallbladder, apply traction, lift the gallbladder away from the liver, dissect all that with the help of the advancement of these traction techniques. So could we evolve like surgery did and the work had started with dillumen. In 2017, and the idea came is to provide an endoluminal platform to simulate laparoscopic surgery on colorectal lesions. And so you see from the picture, they had an assistant holding the scope, which visualizes the polyp. And then you have the, um, the surgeon with two hands. One provides the, uh, traction and the other one provides the knife. So they simulated laparoscopic principle in the luminally to, to get the same results. Now this device had its own limitations, you know, it had two balloons, two arms. It was, it was a bigger device, more difficult difficult to reach, right-sided colon, probably longer procedure, etc. So it was not really practical. However, the work with Dilumen did not stop at that point. Then came an improved version of the C2, which is the C1. It's a single balloon that has a single channel which accommodates your traction and now you have your scope and knife to help your ESD. So there are 3 available platforms of dilumen now. The easy one is a single balloon, the C1 and the grasper, and it's the C1 is just like the easy one, but it has a channel in it. And then you have the Easy glide, which is the double balloon. Now all of these 3 platforms can provide stability during ESD. They give you a conduit for repeated access so you can go in and out multiple times, bring your scope out. Clean your lens, go back in, pull the lesion out when you finish, etc. It shortens your colon and allows suturing once you finish. Now the, the easy glide will give you a therapeutic zone between the two balloons, and you could utilize the front balloon for dynamic traction, and the grasper is designed mainly for traction during ESD. Uh, so this is how the traction handle looks, and the, basically, this is the C1 balloon and this is the uh conduit where you can put your uh traction device, which we call the external tool channel. It is actually a 6 millimeter channel. It accommodates a 5 millimeter grasper, uh, but you could use that and there's a lot of potential things you could use with that channel. You could put a forceps, you could put a snare, etc. So it's, it's an accessory working channel that helps during your resection. So I look at the IG grasper as literally the human, the human arm, and it, it literally resembled the human arm. There is an elbow, there is a wrist. The elbow flex and extends, and the wrist will do all 360 maneuvers. So you see here in this video, this is the rotatorary movement, 360 degrees, which simulates the human wrist. Uh, and then this is the bending capability of the elbow of the, of the grasper itself. So you control the elbow with this knob and you control the wrist with this knob, and these knobs just help open and close, and then you can rotate the direction of the forceps. So if you don't like how the, uh, forceps is opening, you can change the direction. Um, so, so ESD with grasper is finally no more doing single hand surgery like we used to do with just the colonoscope with the knife in. Now I can, I can have my second hand to do my grasping. Once I do the grasper, I can lift the tissue. I can have a multidirectional adjustable real-time dynamic traction. It is not linked to the scope movement because the traction is going through the balloon. It is away from the scope. So if your traction is all the way to the right and you're dissecting all the way to the left, you can do that. Uh, it does not require working from a distance, so you can go as close as you need to the lesion, and you can dissect closer to the lesion while the traction is applied from above. Uh, it improves your visualization and better exposure, uh, for controlled dissection, uh, safer procedure, less perforation, and shorter duration time. Uh, so I'm gonna show you an example. This is a lesion that has previously attempted failed EMR, recurrent lesion. So I anticipate scar in it. I'm all the way in the scum, and that's the appendiceal orifice. So I did my, uh, circumferential incision and I'm ready now, uh, to introduce the grasper through the balloon. So here is the grasper coming and I'm gonna try and catch the area I want and then provide the traction. So, again, whatever the direction of where your traction comes, you could control that to finally get where you want to catch. Uh, so here I'm slowly trying to catch the uh inner side because I want to lift this up and then get traction and get access. Into the submucosa and you can see this lesion is on the gravity side, so it's pulled under the gravity. So without traction, it will become a difficult ESD, uh, especially with the fibrosis, the fat, and the location of the lesion. So now I finally Uh, got to the flap that I did and then I started my dissection. And it's, you always start in the beginning with the very minimal direction, uh, traction just to get you enough to dissect and then eventually that traction is going to expand more and more towards the more you go through the procedure. So now I finished the left side. I dissect it as much as I can from the left side. And now I will show you how I can change the direction of the forceps to get access to the right side. So now I'm pushing the forceps forward, and that provides my dynamic forward traction. And I can come close to the fibers. Like I said, you don't have to walk from far away. And now I opened the right side. And this is, this is to show you how dynamic the traction is. It's all the way up and I have a complete exposure of the submucosa. And My traction is completely away from, from my dissection field. So this is one of the biggest advantages of using the IG grasper because you have a free, uh, any direction you want away from your scope and you can dissect close to the some mucosa. So in this, in this, um, video, I'm going to show you the assembly of the device outside the patient. Um, that, I mean, Lumendi can help you and provide you with the stabilization arm to kind of keep the, uh, uh, the traction device on. Uh, so now I'm examining the lesion. This is somewhere in the transverse column. There is a tattoo, as you can see, I anticipate there might be difficulties with that. Um, fairly sized lesion. Uh, with advanced characteristic features on it. So after I did my assessment, did my 300, uh, did my evaluation assessment, now I got my grasper, did my incision, and now I'm trying to catch, uh, the, the, um, flap that I created. And you see, I utilize the elbow. I can rotate and torque the device and then once I catch it. That's enough. Just a little traction in the beginning. Do not over, overdo the traction in the beginning, but just get enough for you to get access to the submucosa. And remember, the more you dissect, the more you get better traction. Um, so now I don't like the direction, so I'm pushing forward. So you see, initially I was pulling backward, and now I'm pushing forward and you see how I rotated the, uh, the device itself. So that rotation makes the grasppa rotate to the other side, and now I have a better exposure of the submucosa. So I'll carry on and continue my dissection. I got into bleeding, but with the help of the traction, there is enough traction on the blood vessel. It will not become that um aggressive bleed compared to if the vessel was not stretched. So stretching of the blood vessel, uh, during, during the ESD and with the help of the traction, uh, will decrease, you know, the chances of having that excessive bleeding. Um, and again, I'm continuing forward with the traction. Uh, so again, uh, incision on the anal side, uh, should be at least 1 to 2 centimeters from the lesion, advance the balloon to the lesion, then retract back. Uh, use the scope inside the balloon to kinda align the grasper. Uh, backward traction is as good as 4. traction, avoid over traction and over insufflation because over insufflation could potentially make your balloon slip back. So in this scenario, I'm showing you that, you know, this is how you get the balloon all the way to the lesion, advance the grasp it, but keep your scope tip inside the balloon. And utilize that scope tip to move your grasper to the direction you want. So now I'm, I'm keeping my scope tip in the balloon and I'm moving the entire balloon to the left to kind of get the grasp or to the direction I want. So, it's not just using the grasper from outside because sometimes your maneuvers may be limited, but you can utilize the balloon itself, the, the scope inside the balloon to move to the lesion. And then once I get into position, I'll catch the lesion, lift up, and now I opened up the submucosa. I start my dissection and carry on. And you see how the stretching of the fibers helps. You just touch a little bit with the coagulation and then, and then you can dissect them, the, uh, these, the fibers. So the dissection becomes way, way more easy. Uh, so to make ESD safe, we know traction helps using an over tube to stabilize and close the defects. Your goal is less bleeding, perforation, and maybe discharge the patient the same day. There are so many closure devices available starting from just simple clips. Uh, these are good for mucosal defects. They are not as secure, uh, over the scope clips, they are great for. operations, but once you put them, it becomes difficult to finish the closure. Uh, the new tissue approximation clips like mantis and that clip, probably more expensive than regular clips, and you would eventually require more clips. Uh, we know through the sur, uh, through the scope suturing like X-tack and over the scope, uh, and over stitch, uh, for, which is good for full thickness resections. Um, we, the effect of prophylactic closure after colonic ESD has been reviewed extensively, and there is a lot of meta-analysis. Uh, this was published in 2020, and they, they were able to find that closure decrease the risk of bleeding, potentially risk of perforation as well. Uh, so suturing in ESD has been reported in the literature. It's technically feasible, fast. Most of the literature is available on the left side of the colon. Um, so the over stitch, um, so, to, to kind of accommodate the over stitch and the double chan double channel scopes, uh, into your, uh, dumin, you have to keep in mind that these scopes are short, so they're only, um, um, 10:30 length. Uh, so you need to make a cut into your dumin to kind of. Accommodate for these to go through. So this is what my colleagues have been saying, uh, 2 centimeters away from the anus, make a small cut, um, uh, you know, minimal cut and then stretch it with your pinky. That is where you're going to advance your scope, and now that becomes a shortened, uh, length for your double channel to reach all the way. Um, so once you get in there, there are two techniques of closing. You can do, uh, um, you can do one stitch running, you can do multiple interrupted. I just want to tell you, interrupted probably has the less chances of, you know, narrowing your lumen because you have to be careful. If you overdo it, you could narrow your lumen, and that becomes a problem. So some big defect like this one, if I want to close it, actually when I closed it. Uh, I, I closed one suture, did probably 8 bites, then did the second suture. So when I, when you put two sutures, the lumen does not uh narrow. Uh, so this is an example of a large lesion, ascending colon, uh, occupying multiple, uh, folds. At that time, I didn't have the grasp but available, so I was using a rubber band traction, uh, and then finished the entire lesion. Uh, with the help of multiple tractions. And this is what I was saying. Once you have a big lesion like this, you'll probably use multiple tractions with the rubber bands, so you have to change multiple times. So you see here how many clips you have 123. I had to change my direction 3 times, so I have to use 3 clips and 3 rubber bands. Uh, now the lesion is completely resected and now I'm going to introduce my over stitch all the way and then suture this. So you see my over stitch, I have stable scope position. Um, I have good insufflation and then I finished the entire, uh, closure. And then it did not narrow the lumen at the end. Uh, so in comparison, XTA and clips, uh, they're good for mucosal closure. They probably decrease the risk of bleeding, but you have to be careful with the tenting between the X tacks. There is a risk of leaks. So if you have a defect in the muscle, I would not use that. Uh, the, uh, mantis and that clips are good. Uh, you probably, if the larger the lesion, you will require more. Uh, but keep in mind when you do ESD, you, you most of the time are gonna use an over tube. So if you're gonna use an over tube, if you look at the cost of these with multiple clips, it's probably the same cost of using an over stitch. So if you're comfort comfortable using an over stitch, it gives you the advantage of a full thickness closure. Uh, you can use it in any location and it, you, you keep the traction and stability. And finally, I asked one of the AI apps to imagine how to do colonic ESD with traction and it gave me a grasping forces. So maybe that's the way to go. We're not even gonna need you because just an AI robot will do all the uh PST. I know we've run over it, but I to spend at least a couple of minutes to answer any questions that you might have. Um, so we'll open it up to uh the group, uh, and please go ahead and ask your questions. OK, I'll start since everybody's a little shy. Um, Doctor Abdul Saad, I just wanted to ask you about the learning curve for using the C1 and the IGE grasper. Um, I mean, certainly there is, there is a, there is a learning curve, but I, I don't, I think if you're comfortable in ESD your learning curve is definitely shorter because, you know, you're good at ESD now you only need to learn the traction. And I think after many, probably 2 or 3 cases, I was comfortable just, you know, um, doing all the maneuvers with the, with the grasper and, and the, the knobs are easy, you know, you, you know, there are only, there are mainly two knobs that you're going to control the big elbow, which you use in the beginning to get close to the lesion, and then the fine movements with the rest, uh, with the wrist, and, and that is not as cumbersome. I think, I think choosing the, the lesion. And where, what traction device wisely is the key. So, you know, it doesn't mean because you have a grasp but you, you want to really use it on all lesions, um, because sometimes if you have a hepatic flexure lesion, a lesion in a difficult spot, you, it might be difficult for your grasper to align and catch that lesion. So then you get into frustration. So I think really choosing a good location and a good spot to utilize the traction, you will realize that, you know what, that actually made it so easy. So the learning curve is not that much. I'll say maybe a couple of cases in the beginning and then you're trying to go by yourself. OK. Thank you very much. Um, Doctor Brown, um, I wanted to ask you uh which size diillumen generally do you use and why? Well, I usually use a shorter one, just because it's a lot easier for me to um put upper scopes in and Um, I find that when I'm reducing the colon, um, it's long enough. So it's um Even the sequel lesions, I can usually get the balloon to the scum and reduce. Um, so I, I find that for the entire colon, unless it's, unless it's a little bit altered and, um, a little bit of unusual colon. Today, I had to get to a sequel lesion. I tried the shorter, uh, shorter one. It wasn't long enough. Uh, but that was the first time I think about 33 weeks that I need to switch. Gotcha, gotcha. OK. And hanging off the edge of the the bed if uh it's a little too long, if it's. OK. Understood the 1:30 sometimes can be too long, uh, especially if, uh, you're in the transverse or the left colon certainly. OK. Um, Doctor Sampath, um, so if you're not able to reach the right side of the colon for a non-polyploid lesion assessment, what would be the standard of care then? Yeah, for a non-polyploid lesion, I mean, I think that you saw those guidelines, right? The guidelines suggest, and again, there's different levels of evidence, um, and different societies may have some slight incongruencies here. However, um, some key society guidelines suggest that Um, it's worth doing that investigation with an endoscopic ultrasound, and it depends on your accessibility, the, um, training of some of those interventionalists in order to evaluate those uh lesions. But if you go by the guidelines and there's a suggestion you have an indeterminate lesion, then you would want to consider doing an EUS and you want to have the best resolution possible and that would really suggest doing um. Um, you know, a linear or a radio-based US exam. And the nice thing about a linear um probe is that you can also do tissue acquisition at the same time, um, and, uh, the safest way, at least in the proximal colon to do that is to uh have a sheet to protect uh the patient from unwanted risks like perforation. Great. OK, we have a couple questions uh on, um, uh, this one is, uh, for Doctor Abdul Samad. um, which lesions do you consider dilumin plus grasper in ESD? Oh, that's number one. Which lesions you say? Which types of lesions do you consider, uh, when are best for using uh diillumen with the grass? You know, honestly. I think the lesion that you know that you will most likely require to change your direction during ESD and these are the larger the lesions that you know, you know, you start dissection here, you have traction this way now, you need to change, you need to advance more traction. So I think the larger the lesion, uh, the better when you use the grasper. Um, you can use it in any location. I've had, I've used the grasper in the rectum without dillumen. I just go side by side, uh, next to the scope, catch the lesion, pull up, and then control everything from outside. Uh, so, in, in, when I use the grasppa, I use it for large lesions. The ones that I know for sure that I need traction and it's gonna be a long traction. Great, thank you. And a follow-up question, how does your institution justify the cost of the dilumen device in setting, uh, in the setting of low overall reimbursement for ESD or any, any ESD device for that matter? I think finally, uh, soon we're going to get reimbursed for ESD better than what we are getting reimbursed now, but honestly, I can hardly think of anybody doing ESD without using an over tube to stabilize the colon. So I think the cost of an over tube is there anyways. Now, if you're going to use a traction device, most of the available commercially available traction devices are not cheap. So I, I think that because you're not, it's, it's probably similar to most of what you're going to use at the end. I think the advantage when I use uh dilumen is I get the stability, I get the ability to uh introduce a grasper, get a better traction. And at the end I suture. Now, nowadays, I think the way you, you justify it is I guarantee my institution there's no perforation, no bleeding, and the patient is going home, and there is no surgery, you know, most of the polyps I do back in the days they were being referred to surgery. So look at the cost difference between doing this endoscopically, save the patient write him a colectomy, or send the patient to surgery. I think eventually at the end, it's a win-win for the institution because you're saving them all this money on surgery, expenses, complications of surgery, etc. Uh, you compare this to an EMR and you have that high risk of bleeding, etc. and then you have recurrence rate. So with this, you don't have the recurrence rate. So I think maybe in the short term, it's not that, um, you know, you don't have the best reimbursement, but I think soon it's gonna get better. OK. Yeah, I think uh January 1st, 2027 is when the reimbursement will begin. Um, OK, this question is for Doctor Sampath. Uh, how do you know how far to create the lamb's anastomosis from the small bowel to the colon so that there is not overt metal absorption? That's a great question. So, you know, unfortunately, there's, it's not like a highway, you could say the exit, you know, the next exit or the next part is, you know, this number of centimeters further down. So these are all estimations. So, um, first you review previous op reports, particularly if the operation wasn't done there. So you know the length of the rule limb, then next you know where the you know ginostomy is. And so from there then you advance slowly. And then you're trying to really match it up. The first goal here is also you're doing this when you're in a unique situation, right? They feel a lot of conventional interventions, whether it's multi-modalities, whether it's medications, surgeries, etc. So they're really in dire straits in a way. So because of that, that allows a latitude with the type of intervention you're going to do. Um, so it's really more of an estimation. One of the key things you want to consider when doing these types of intervention. is safety first, right? So you have to make sure you have the therapeutic window in order to place that type of lumina posing metal stent. So you have to match that up in terms of um on fluoroscopy, assess that window, the typical teaching for um an EU US guided lambs placement, which is a window less than 10 millimeters. If you have a 15 millimeter stent, maybe 12, but generally speaking, a less And 10 millimeters and then you can place that lumina posing metal stent. However, you do need to counsel those patients on some of the things that are alluded to by that excellent question, which was things like malabsorption, diarrhea, etc. And so these patients need to be aware of this, need to be closely monitored. And the nice thing is, if you did, it hasn't happened in our experience, but if you did have a really significant malabsorption component or diarrhea component. There is the potential to reverse the procedure in the 4 weeks or so because you can remove that stent. You have access to that colon. But another key concept to also think about here is you're not doing a pure bypass, right? You're doing a colonic diversion. Think of it as an upside down, uh why, right? So you still have the native lumen. So because of that, that's why we didn't see gross exaggerated uh malabsorption issues. OK, great. Thank you. All right, one final question. Um, uh, Doctor Abdul Saad, do you have any advice about using dumin and the IGE grasper in the hepatic or splenic flexures? Yes, not in the beginning. I will say just be careful. Um, it will make you very frustrated. You will spend a lot of time trying to catch it and you probably won't. The problem with the flexures is, uh, you know, once you have your balloon seated away from the lesion, your grasp or direction is going forward, but your lesion is actually going downward. Uh, so it's very difficult to align both. And even if you get closer to the lesion with the balloon. The moment you try to do traction, your balloon slips back and then you lose it. So the hepatic flexure, splenic flexure, I think should be definitely the last location you would choose to use the IG grasper. Actually, in ESD in general, flexures are the most difficult locations for ESD in the colon, and then this, this is only after duodenum. So after duodenum comes your hepatic splenic flexure. So ESD is to begin difficult. Adding this traction, if you're not aligned and you're not good at using the grasper, it will become very difficult. So I'll say yes, you can use it, but really later, once you use it many times and you feel comfortable, you know, rotating it. I know me and you, we were discussing, uh, probably to adjust for that, you know, loss. Of, of, of your, uh, your, um, your vision of the lesion is maybe, you know, put a, a band on the lesion with the clip and then catch that, uh, band or a loop with the grasper from far away. So there are tweaks to it, we're gonna figure it out, but I think the flexors are tough in the beginning. Great, great. Thank you very very much. And uh I'd like to thank each of you again for spending the time preparing and presenting um these great presentations. Um, you know, every, every few months, every year we learned so much more about this novel device and uh you guys have helped to come up with some really unique ways of using it and also some really nice tips and tricks to uh help the, the, uh, help the new users of this device. So hopefully this, um, presentations, these presentations today have imparted some knowledge to those that attended, and with that, I'd like to say thank you and uh good night. Thank you.
