Molham Abdulsamad, MD, FACAP, discusses his experience and use of DiLumen® with Overstitch, showcasing procedural examples for ESD cases, and comparing multiple closure devices. His findings show Overstich to produce the most secure, full thickness closure.
Good evening. And I'm going to present to you today. Um and my experience on using Dubin with overstitch uh foreclosure of ESD in the right side with colon. I've given this presentation in, in this most recent DDW in 24. Uh I'm an uh interventional gastroenterologist at Geisinger Medical Center, Geisinger, uh Lewistown Hospital in Pennsylvania. Um These are my disclosures and I basically uh to summarize how the, how this talk will be, we're gonna discuss briefly colorectal ESD. Where do we stand now on ESD uh in the US uh classify the closure methods um and review the efficacy of closure and why do we wanna close post ESD um defects. Uh I will explain um the benefits of using dium and how to prepare dilution uh to be able to get the overstitch all the way into the right sided colon. And I, we gonna show you um few videos uh on a simple closure in the right side colon, how to use even the SX device, how to do a complex closure near circumferential and how to troubleshoot. And finally, we'll talk briefly about the cost effectiveness of using dium as a and, and um overstitch as a closure technique. Uh So, in the scopic submucosal dissection, why do we want to do ESD? And what's the benefit of ESD? It gives you the highest in block resection rate. It has the lowest recurrence rate and the best and the most curative rate uh for a resection of a lesion in the colon. Uh It will also give you the benefit of an accurate histopathological assessment. So you can get an accurate pathology on the staging. Uh And finally, it helps preserves organ. If the patient has a large polyp in the rectum that you are able to resect with an unblock resection, the patient will not eventually need a colostomy, which used to be uh previously as the treatment modality. Uh why not ESD? And why do people still have, you know, hesitance on starting an ESD practice? Uh classically ESD used to take a longer time compared to doing a quick snare polypectomy or an EMR. However, nowadays using traction devices, you can absolutely make the procedure quicker. Uh It used to be an expensive procedure because it was absolutely not inured. But finally, nowadays, we have a Medicare reimbursement code. Um The complication rate. I think this is the most fear factor for most physicians who wanna start ESD is what about complications and what about handling complications? Now, my take on that is um you know, once you become an expert and, and, and know how to do ESD, it will become probably easier than starting a SD. But if you wanna make sure that in the beginning of starting a SD, uh you're safe and you can handle your complications. The best way is to have an adequate, a robust closure and probably the best closure way, even if you have a perforation is to suture it because that will have, will give you a surgical quality of a closure that you're confident your patient probably can go home and will not have a leak or a complication. Later on, it does require extensive training. And I think these days, there is a lot of options for improving training on est uh many of the big companies help offer um ESD courses along with um you know, multiple G I societies. And I think the these days most expert agrees, you probably need a good learning curve of around 2 to 300 cases to achieve competency and the adequate um in block resection rate and the curative rate. Now, if you wanna put ESD on a comparison scale between EMR and surgery, uh putting three things in mind, the cure rate, the difficulty of the procedure and the complication, it probably lands in the middle. EMR has the lowest cure rate. It's the easiest least complication compared to surgery which gives you the best cure rate. Um but it's more difficult and high risk for complications. So ESD lens in the middle, you get the great cure rate. And at the same time, not as complex, not with less complications compared to surgery. But definitely everybody agreed including literature review that ESD is probably has a higher complication compared to EMR. But the goal is to use the adequate techniques and devices to help move your ESD from being complex and has complications into the beginning of this case where EMR lands as a safer procedure with less complications. Uh there is definitely an over utilization of surgical resection in the, in, in, in, in the United States. And this is a nice study looking at Medicare beneficiaries. It was um published um recently in 21 and they looked at cases from 2010 to 2015 and they found 280,000 colectomies and guess what, 34% were for benign polyps, polyps that could have been resected by an expert endoscopist who can do a good quality, er, or ESD. And then you could, you would have probably saved all these uh 80,000 surgical resections and just served all these organs. Um why not ESD? And uh why not surgery um is because surgery and um you know, it, it comes with its risks of complications. Um So in a study published by the Cleveland Group, uh they looked at Colectomy for polyps and they found um that it was associated with a high risk of complications, especially when there was low risk for malignancy in a benign polyp And at that point, they suggested, well, probably it's time to, you know, do endoluminal surgery. And in their review, uh they looked at 67 charts and they found 19% were non malignant polyp. These polyps could probably been resected endoscopically. But this is the interesting part is the morbidity was around 21% mortality, close to 1% hospital stay up to 445 days plus minus. But the morbidity was a ray of a lot of complications including leaks, mis, pneumonias. Um um uh respiratory failure, et cetera. So all these could have probably been avoided by a simple outpatient colonoscopy with ESD. Uh why not EMR as simple as who gives you the best in block resection rate. Uh If you know EMR is a good technique for removing polyps, but that's on the expe on the expense of not having an in block resection. And we know from a, a recent meta analysis in 21 that compared EMR to ESDESD, had a higher rate of resection and more complete resection. Uh You can see the rate was 82,082% for um ESD compared to 56% for EMR. So definitely EMR was not able to achieve a good resection rate. Um The recurrence rate was the lowest in ESD 2% compared to 10% in EMR. And in a study by the Australian group, uh they suggested the larger the lesion, the more chances of recurrence. So you get a lesion four or five centimeters. Your recurrence rate is probably around 35%. Um The bleeding rate was the same. However, the perforation rate was higher than ESD. Uh 5% compared to very low um um perforation rate post EMR. Um So what is the current guidelines from our gas uh A G A society uh on the indications for doing a colorectal ESD. So if you wanna achieve any block resection or lesions, that has a risk for a submucosal invasive cancer, uh this is the time you should embark on doing an ESD. And these are multiple shapes of polyps. However, any polyp that is a KO five is a high risk uh for um for having invasive uh malignancy. And this is an example of a KO five complex polyps, multi uh nodular polypoid kind of looking lesion where these big polyps often could harbor a malignancy in it. Um um The and so that's the complex morphology. If you have a depressed component Paris class two C, for example, that's a high risk like in this example, uh recurrent uh polyps, especially like polyps who has been previously attempted, came back, there is a, a tattoo near the polyp. This polyp is probably best served with an ESD rather than doing an EMR again and having another recurrence uh rectosigmoid locations and then you get those LSD lesions more than 2 to 3 centimeters and there are two types. The LSD granular, you see it's bumpy like in this example, or the flat one smooth surface. And this is LSD non granular uh polyp. Now in, in, in a publication by Stavros where he uh in 2018, when he looked at the um at trying to, you know, put ESD um difficulty by location. So we all know that uh the stomach, especially the distal stomach has a stable scope, good maneuverability. So it's probably the easiest. Uh And so it's a good starting point, probably to start your practice of ESD in the stomach, followed by the rectum and the esophagus. However, uh once you move into the right sided colon, obviously, the difficulty increases and sigmoid and duodenum are probably the toughest. However, starting a practice of ESD in the US, you will get probably very low number of stomach esophagus and rectum uh because we don't have that common um gastric lesions that needs um you know ESD as compared to the Asian uh side of the world. Uh So you probably are gonna be faced with doing a right sided colonic ESD right in the beginning of you trying to establish an ESD practice and in my opinion, if that is gonna be the case and uh and you probably are gonna start implementing your uh learning um um techniques uh from the lab into uh practicing on a patient to do an ESD, you probably need to make sure you have an adequate plan to close your defect in case there is a, a perforation or microperforation to be safe and to have an an a good start of your ESD practice. And so to make a right sided um ESD safe and, and we're highlighting right sided here in this talk because left sided is probably uh easier to get an overstitch and suture it. Uh but the right side it is more difficult to get the overstitch device there and suture it. So for you to have um a safe rights sided colonic ESD, you probably would, you should use the traction to make your procedure safer quicker. Uh Use an overture because once you have looping in the sigmoid, you will not have a one to one maneuverability of your scope and that will make ESD difficult. And we all know in ESD, it's very important to have 1 to 1 maneuverability. Uh So you can get a good resection. And so in the right side with colon, you will probably, you need a stable scope and that's why using um um and a stabilize an over tube to stabilize the scope is important. You could also use that whatever over tube you're gonna use as a conduit uh to do over stitch and take it all the way to the right sided colon. Uh and finally, defect closure. If you have an adequate defect closure, then it probably you will decrease your chances of complication. Uh But you will feel much better that, you know, you have an adequate good closure, the chances of complications will be less. Uh And so the best uh defect closure um unanimously is um uh suturing because you get a surgical type of a quality uh of closure compared to other modalities which we are gonna discuss um uh in details. Now, the goal is to have no delayed bleeding, no perforation and probably send the patient home uh same day. So the cotton closure devices uh we do have multiple closure devices, but I wanna summarize them into two categories. There are mucosal uh closure devices and there are full thickness closure devices. So um the simple one is through the scope clips, these can, you can use them anywhere in the G I tract. Uh You don't need to have anything to access um to get the clips through the channel into the right sided colon. However, the limitations of the through the sco clips, they are um mucosal uh type of a closure of the defects. So they are not very strong and robust. Uh they're not very secure and you will need a lot of clips, the larger the defect, the more clips you're gonna need uh to try and achieve the best closure you can with the clips. Um And the more clips you use, obviously, that's more um uh cause um for the procedure, uh the uh second type of closure is the over the scope clips and these are very good for small perforations uh less than 10 millimeter. However, the problem is, let's say you have an ESD, you get a perforation in the middle, you decide to use an over the scope clip to have a uh a secure closure and you deploy your clip. Now, this will prevent you from completing the closure from on the sides of the clip uh because of the presence of the clip. So that will probably not completely help you uh finish the entire closure and you may have bleeding from around the clip in the blood vessels probably that was not closed. Um Now, there is a new entity of closure devices uh which are um the tissue approximation devices. These simply are uh modified types of eclipse that helps you uh close larger defects by approximating proximal to this. So for example, or light to left from a large lesion. Um and the, you know, the is there are two types available. Currently, the mantis clip and the dual action clip, they are pretty more expensive compared to the through the scope clip. And you will probably require multiple of these to, you know, kind of approximate the lesion or the defect completely. And then after you approximate the defect, you may need to use additional clip to complete the closure. However, they come handy and you can use them um probably in most uh locations uh they through thee suturing device or uh exact, it's good for large uh defects. Again, this is a mucosal closure, although your tacks are buried in the muscle and you are probably trying to approximate the muscle when you close. But it's not a robust closure like a full thickness closure compared to the overstitch. And you will probably require additional clips uh on top of your X tac or probably sometimes two X stacks. If the, if the defect is big enough, could not be approximated with one X stack. Uh Finally, the over stitch is the most secure. It ha you can do a full thickness. So even if you have a complete perforation of the muscle, you can close muscle to muscle, uh including um cirrhosis to cirrhosis when you take your bite. So it gives you the m the most secure closure and it's a full thickness closure. The downside is if you wanna use it in the right side of the colon, you definitely need uh to use an over tube. Um So what is the um the literature now um on, on, on doing closure, you know, um closure for defects after resection uh using clips as simple as that. So in the meta analysis, looking at clip closure after proximal large non predilated colorectal polyps, which were more than uh 20 millimeter. There are four trials. Uh 1200 patients lesions around three centimeter. Uh clip closure. I had the 3% bleeding, no clip closure, 9% bleeding So there is a significant reduction in a clinically significant post EMR bleeding rate. Uh What about the new dual action clip? For example, in a multi center study, like they looked at 100 and 17 patients including EMRS and E SDS around four centimeter uh defect, which is the average defect for ESD. They require two dual action clips plus 3 to 4 regular clips, but they were able to close defects in almost 96% and they got the bleeding rate almost down to 1%. So that tells us that closure is helpful and its efficacy effi um it has a good efficacy uh for decreasing the bleeding rate. Uh after after um resection. Now, uh what about the uh efficacy of closure? Uh after an ESD, there are not a lot of studies looking at the um closure after ESD. However, in, in a meta analysis, they found eight studies and compared closure to no closure and they looked at three parameters, delayed bleeding, delayed perforation and post ESD coagulation syndrome. Uh There was a significant uh pulled odds ratio for uh decreasing bleeding. It was not statistically significant for perforation. However, uh look at this, the rate of um uh post eesd perforation was as low as 0.5% compared to 4% with no closure. So it does, it does decrease the risk of post um ESD perforation. What about suturing? Uh This was published as early as 2014. Um um they, they, they started with 12 patients upper G I tract left sided colon, like I said, because it's easy to get the device there and it was technically feasible. And uh and it was fast uh and the most recent publication on using suturing uh post uh post ESD resection, uh they had 33 patients uh use the SX device again, upper G I tract left sided colon. They were able to close the uh the defects in 94% which is a good closure rate, uh success rate, 91% and they were able to send almost three quarters of the patients home. Uh So we do know that closure is uh is um I I it has a lot of benefits uh post resection. So in summary about defect closure, it is technically and clinically feasible and successful and it decreases the risk of post resection bleeding plus minus the risk of perforation. Uh So what is based on that? And based on how the comparison of the closure device is available. Suturing is the um safest and the uh most secure way of closing defects. And we know that. So if you wanna do ESD in the right side colon, um plus using a Dubin, we'll talk about the benefits of that and then do overs stitch at the end to do closure. This seems to be a very safe approach uh that can get you off even. Um complications as bad as perforations. Uh So there are two types of uh dins available. Now in the market, there is the dium and easy one, which is a single balloon. Uh you see on the left side and there is the dium and easy glide, which is the prior version. Uh and that has two balloons. And the benefit and the difference is when you uh the, the single balloon is good to help you uh shorten the colon, reduce looping, get the shortest distance to the right side and it will help stabilize your colon. So when you do ESD, you have a 1 to 1 maneuverability. And at the same time, now you have a conduit uh to um you know, help get the scope in and out multiple times, clean the lens, et cetera and get over stitch. Uh The um the easy glide has two balloons and you can see between the two balloons if you um open them uh is you get a therapeutic zone. And now you have multiple uses for this therapeutic zone. If you see there is a little thread attached to the front balloon, if you attach that thread to the um mucosal uh flap, you created and push it forward. Now, you can have traction. So the benefit of using that is not just having a therapeutic zone where your uh lesion is in between those two stable balloons. Uh And also you can use it for traction. Now, there are two lengths available that is 100 and three centimeter uh which you can probably use mainly for left sided, but there is 100 and 30 centimeter uh that can get you all the way to the CCM even to the T I if you wish. So the uh benefits of dial loin um again, the benefits of using any of the dial lens is the stabilization of the endoscope. Uh You get an intraoperative conduit for repeated access. Uh get your scope in and out as many times as you want, you shorten loopy and tortuous colons. And you allow for endoscopic suturing in the right side colon. And so that's for easy one. And then the added benefit on using the easy glide is you get a dynamic tissue traction and retraction uh by using the front balloon and it creates a therapeutic zone and the therapeutic zone. Just to give you an example, when do you wanna use a therapeutic zone? Is when you have AAA flexor uh lesion like a hepatic flexor or a splenic flexure. Uh this is very cumbersome and difficult. But if you put the lesion between both balloons and um you know, uh pull the balloons that will flatten the flexure and make it easier for you to do your ESD. So that's one of the benefits of using a therapeutic zone. Uh So what is the uh available data on using um Diallo in as a uh you know, as a uh a double balloon or uh for, for, for helping with ESD uh in a, in a randomized prospective study done by um cancer void, uh looked at 100 and 40 patients and simply compared uh using it to not using it. And the in block resection rate was significantly higher in these cases, that DIN was used up to 97% compared to 87%. Not just that it made his ESD time go down by almost 46%. So it made the procedure quicker because now we have a stable scope and you can use uh traction uh in a study by Stavropoulos where he found also it not just the benefits that uh were reported by other studies, it also helped decrease the length of hospital stay and increase his same day discharge rate uh to uh two times more when they used uh thommen uh in a recent study by the Otman group, they looked at 100 and 10 patients and using Dium gave them less bleeding and more in block uh and less hybrid compared to not using dium. So there is a lot of benefits to dium. Now, talking about overstitch, there are two available over stitch in the market. There is the sx over stitch and that can be mounted on any upper endoscope you have. Um it is uh it comes on the side of the scope. So the gen the complete diameter from side to side depends on what scope you use, whether you use a one T scope or a regular upper scope, but it can go up to 16 millimeter. And that's important because you wanna know what is the measurement of your over stitch. When you use an over tube, you do not wanna use this on an over tube that has a, a small diameter and then it gets stuck and you will not be able to access the right side colon. Uh On the other hand, the um convention of overstitch that goes on a double chin gastroscope, the diameter is 15.8. So if you have a an over um uh uh if you have a, an over two that has, for example, a diameter more than 17 millimeter, then you can get any of these devices through that over tube. Now, the double channel endoscopes available in the market, um we have the Olympus double channel scope which is no longer uh made by Olympus. Uh But alternatively, there is also the Fuji film. Uh what I need you to know here is the length of these double channel scope. So the length of this double channel scope is 100 and 100 and three centimeters. Uh So it is a shorter scope compared to a colonoscope or to even a, a regular upper endoscope, which is um um 1650 compared to this one. So you keep in mind that if you wanna use a shorter scope. How are you gonna get the scope to get all the way out of the um over tube? You have to access the right side colon. So you have to keep that in mind. Uh And we'll talk about how to make dilution uh compatible with using the double channel scope to achieve, reaching the right sided colon. Uh So to prepare uh for a shortcut, uh you need to keep in mind that you know, the there is a difference in lengths and you need to maintain air and sufflation when you use the overstitch through uh and uh through dium and you need to keep a stable scope position. So what I'm gonna show you next is how do I prepare dium men to be compatible with using uh the overstitch through a double channel in the scope? So that the dium easy one, for example, uh what you need to have available is a tourniquet and a AAA clamp, which you can get from uh any previously used Dubin uh or any clamp that looks like like this clamp. And then you need AAA scalpel to make a cut in the over tube to make it shorter. And I'm gonna show you how, but basically, uh you will thread this um tourniquet through the clamp to make a loop. And you can see here uh in, in figure C that I need this loop and I have the clamp and I thread the and I pushed the scope and the Dubin through the loop. And so now I have the loop ready. So if I wanna tighten the loop over the over tube on the scope to make it tight, so it seals air leakage, I just pull the tourniquet and push the uh clamp all the way and, and, and that will make it secure. Uh So in this video, I'll show you how do we prepare. So for example, I got now my over tube all the way in the right sided colon and I'm ready because to get the overstitch through it. So because of the left differences, you're not gonna be able to put the 100 centimeter um short scope um through the regular opening of the over tube, you're not gonna have enough length. So now you shorten your over tube as much as you can, you go two inches away from the anus and you make a cut. So this is um just the uh outer uh sheet of the Dubin between the two rods on the sides of the Dubin. Just make a straight cut. Don't make a big cut and then you stretch this cut with your pinky. And now this cut is enough to be able uh to get the um uh the double channel scope with the overstitch mounted on it uh to go through it. I try to keep my cable on the side. I put enough lubricant and make sure your cable is not wrapping around your scope uh when it goes all the way because if it wraps around the scope, then you'll have difficulties transferring your needle. So now uh this is how it looks when it's ready. Now, I have my tourniquet and clamp and the scope is in. And then if you pull it and tighten the clamp, now you get sealing from the uh cut you made in the over tube and you maintain air and sufflation. And now your over tube is gonna reach and look at this. I'm only 90. So I have enough scope length outside the patient uh to be able to maneuver the scope. Now, what are the avail? What are the common suture patterns we use when we close any defects? So in and the common ones is running pattern and an interrupted pattern. So the running pattern, basically, you use one suture, you start from 0.1 and you keep going proximal distal left to right till you reach 0.8 and then you tighten it. Now, what will happen is you're bringing 0.1 to 0.8. So you're, you're not just approximating from proximal to distal, but also at the same time, you're gonna um move the direction of closure from left to right where you started. So the only downside of a running pattern is if you have a large defect and use one suture, this will narrow the lumen significantly on the other hand, when you do interrupt it, you're using multiple sutures. So the direction is maintained only proximal to distal, you're not gonna approximate right to left. Uh because you're using different sutures, but that unfortunately comes on the expense that if you do not approximate the sutures close to each other and make big gaps, you get a risk of leak in between. So then you have to find your balance on using enough number of sutures. And at the same time, uh you don't narrow the lumen and you don't get leak between the sutures. So you can do left to right, uh or right to left and proximal to distal. Um And in general, I usually like to, you know, divide the colon into zones. So this wall, the anterior wall is one zone and this lateral wall is another zone. If you approximate all the way with one suture, you would bring this point to this point, you're gonna narrow the lumen by at least 50%. Uh And usually my recommendation is start with the difficult location, the location that you don't have a scope of view on compared to the other side where your scope view is much better. So start with the difficult part, then move to the easy part because if you start with the easy part, the suture will be pulling the defect and making it smaller than the most difficult part will be difficult to visualize. So something like this defect, I will start from here, proximal to distal. And I'm gonna go from left all the way to right. I will use one suture for this wall and that's gonna be my first zone. Then I'll finish it, then I will do the second zone and I will use another suture uh from here to here and then I'll send it. So this will not narrow my doin because uh this area here uh is is separate from this area. So you kinda change the direction into two points instead of one point. So in this example, I'm gonna show you the most simple closure in the right side. This is an ascending colon LSD nonla granular lesion. It's a large lesion eight centimeters uh took probably two hours for a resection using the easy one and traction or using a rubber band and eclipse technique. But the suture took probably around um 15 minutes. And so in this video, I'm gonna show you now this, the lesion is on the left side and you can see it's a quite large lesion expanding over multiple folds. I started my uh resection with est I did a rubber band and a clip for traction and we're uh we're doing good with traction. I have easy one to stabilize my scope. And now I'm showing you, for example, I got my scope out with my scope in multiple times and now the lesion is completely resected. But look at this defect. This is almost 50% of the lumen and not just that it, it's crossing over multiple folds in the colon. So this is not a resection bed that you can easily close, neither with X stack nor with clips. I think the best way to close such a defect, it's suturing. And you see here, I got this suture in device using Dubin all the way into the right side colon. I have good visibility and I'm approximating now right to left proximal to this though I have excellent transfer of the needle. I'm not running into any issues and that's how it looks at the end. I mean, you can see the lumen is completely open. I can get the um suturing device through it and it's a secure, complete closure uh that I, I am confident I can send the patient home. Uh And so that is the benefit of a simple closure. Uh In this scenario, I'll show you on the other hand, what if you do not have a double channel scope, you can still use the sx uh to get all the way into the right sided colon uh and do your closure. So um uh in in this example, uh you will see um a large fairly uh eight centimeters um um LST granular uh mixed lesion. Uh there is a surrounding tattoo, obviously, it's crossing over 2.5 folds of the colon. So I started my dissection created the mucosa flap. In this scenario, I'm using the easy glide so I can use the traction. And you can see here there is a, a string thread uh on the uh front balloon, I attached it with the clip and now I have the space open. So now I can use the benefit of traction to do my ESD securely. And when I finish, I can use uh the same um dilution to help assist me get the overstitch all the way to the right side to close this lesion. In this scenario. For example, I get a lot of fogging because of the submucosal fat and I can get my scope out, clean my lens as many times as I want, which you will not have the same privilege uh when you do this without using Blumen because then you're not gonna be able to take all the scope all the way out and go back in and continue with your resection. So now the lesion is completely resected. I'm gonna show you going back in with dium and uh you'll see the defect. Um You will notice now uh in the defect, for example, I had some clips placed because we had a very uh difficult blood vessel that was bleeding and caused a little injury on the muscles. So in order for me to finish the resection, I had to put clips, but these clips will not stand in my way to do the switching. And so that's an important thing because often people think, well, you have clips there. How are you gonna do over stitch? You can still do that and close the cause the to Mucosa over the cliffs and eventually these clips will erode and come out and look at this. I have my sx device all the way in the right sided colon um difficult location, but I can still do my closure and I'm now trying to approximate right to left and proximal distal. And this is how it looks at the end, it's completely closed. And uh the loin is patent and maintained uh this. Uh For example, I'm gonna show you here now a very complex closure. So even with complex closure, we can do it. This is an IBD patient. Uh And you can see he had a polyp which was resected, it was flat. A PC was used uh six months later, the polyp is recurrent. And so, again, an EMR was attempted with a PC. And now um this is a tattoo exactly next to the lesion. And so, in this scenario, uh um in after three years, the patient came back and there is a recurrence of the lesion uh for which uh I decided to do um ESD. So you can see here uh the lesion is very difficult to even visualize it's very flat classic in an IVD patient. Uh there is a tattoo nearby. Uh Luckily, with chromosomes, we were able to identify the lesion, put uh marking dots around the lesion uh to start our ESD. But because of IBD and the sub mucosal fibrosis, these procedures are usually difficult. I even had hard time pushing my needle through the submucosa. That's how hard it was. Um the uh lifting is going away from the lesion because of the Suby casal fibrosis. However, we started our um incision uh on the proximal on the oral side uh to finish that side before we start the um anal side. And you can see here even after I cut them up because that it is not opening. So it's not easy to create a mucosal because of the sub mucosal fibrosis in an IBD patient. However, finally, I was able to get a complete circumferential um incision around the lesion. And I did that because the lesion is on an anti gravity. So the gravity is down at the six o'clock. So I'm not worried even if I don't have uh if I do come it a confer incision, I can still get the gravity to help me pull the uh the lesion down. And in here, uh you can see the extreme submucosal fibrosis. It is not accepting my injection. It is not help lifting and look at those white fiber bands uh crossing above the muscle. These are all fibrosis and scar tissue, which makes such a procedure very difficult. But what I'm trying to show you here is with the use of thin, I know that even if I'm gonna tackle such a very challenging lesion, if I suture it, I will be safe um that I can even send the patient home. So this is almost near circumferential uh defect crossing over a fold and in a very tricky and difficult in an IBD patient with fibrosis and not a really easy colon to maneuver um uh overstitch there. Yet we with the use of DIN, I can get the overstitch and have good maneuverability of the scope to suture, uh such a defect. So now the overstitch device is going through the dium, we're gonna reach all the way um to the lesion and start the closure. And I'm gonna split the closure into, like I said, multiple zones, especially in this one near circumferential. You cannot use just one suture, you're gonna have to use four or five sutures. So I'm gonna start with this side as you can see here, the right side and I'm gonna do this right wall, then I will do the left wall and then I will um suture what's left on the uh superior or the upper border uh of the, of the defect. And so this, you can see excellent maneuverability of the scope. The um lumen uh is insufflated adequately uh to have a simple um and and easy closure despite the difficulties of the uh location. So now we're going um left to right and we're going proximal to distal finish the first suture, almost, I finished 30% of the defect. Uh And you can see because it gets approximated. Don't get f that it's closed. No, if you use the forceps, it helps you spread the uh folds away. And so you can see where your defect is. And in this scenario, now I'm doing the left side. And so now the, um I'm, I'm finishing the left side and in this area here there is only the last part left. And I wanna show you how I'm gonna use that. So even if my scope cannot go all the way to the defect because of the limited space, you can use the forceps to pull the mucosa or the defect to the scope instead of pushing the scope deep into that tight area. So I did the front part. Now I'm gonna do the last suture bite on the uh distal part. And once that bite is taken, we'll sense it and then the defect is completely closed, which is almost near circumferential. I mean, you could imagine this is like a surgical anastomosis uh done by endoscopy. Now, I'm going away, I'm going back to the defect and look at this, this defect is completely closed, the lumen is maintained, my scope is going in it easily and um and, and it's secure I can safely and I did, I sent the patient home after this closure. Um So finally, what are, you know, how are you gonna troubleshoot in case you lose insufflation? And I think that's the most common scenario that can happen after you made a, make a cut in the over to uh to get the um over stitch in there. And so you can tighten your loop, uh You can pull the balloon back a little bit away from the defect. And if you have access to an extra high flow CO2 insufflation, then you can use it. I'm gonna show you in this example, a lesion embedded in a tattoo unfortunately. And uh it's a flat uh lesion um larger than uh three centimeters. So ESD, in my opinion, for such a lesion, uh is gonna have the highest resection um cure rate for this patient. Uh So I start my ESD and right away, you see, I uh there is a deep injury into the muscle, it's not a perforation, but because everything is black, there is severe, some cause of fibrosis, the planes are pretty difficult. So, in such scenario, I do wanna make sure I suture this defect. So I uh know that the closure is secure and this is a after completing the closure, uh I'm going to retroflex and I can do all that retro flexion easily uh by having the um diluent to make a 1 to 1 scope maneuverability. And so you will see here that the defect is almost 50% of the circumference. This is the over two balloon insufflated around the hepatic flexure. And now I wanna do my suturing. However, look at this, despite, you know, um tightening the lobe, et cetera, uh we did multiple maneuvers but I still cannot get good insufflation. So I pro I'm probably having some leak from around the area where uh we made the cut on the over two. But to make that simple look, and now when I um an extra CO2 insufflation, this is gonna give me extra air insufflation, a very high flow rate which will look at this immediately opened the uh lumen and it became now so easy to see where I'm gonna take my bites. Uh I've done that many times and it was very safe. Um The all that is CO2, it will get absorbed. Uh You can suction before you finish, but you're gonna use this probably for less than uh 56 minutes where you're gonna start the suturing and get an adequate closure. So um I usually use it on a very low flow or a medium flow and look at the difference between not using it and using it. It became so easy. So there are many ways uh to troubleshoot. So even that the worst case scenario, nothing worked, use an extra Co2 insufflation and you will get an excellent view of your um uh defect. Uh Co colon lo is completely wide open. So the suturing becomes as easy as if you're suturing uh in the stomach for example, or in the rectum uh uh with no difficulties. Uh Finally comparing cost effectiveness um uh in the in the current era of doing E sds in the rights sided colon. Uh Probably these are the three main modalities uh by experts um to close defects in the right side colon, um X stack plus multiple clips. Um You can use X tac uh simply through uh your pediatric or regular adult colonoscopy. You do not need an over tube, but the downside of X tac, it is still a mucosal closure and unfortunately, it will cause tenting during closure. Um So once you have this tenting, you could risk leakage between these um uh defects when between the XS. Uh And they also might take on using X tac is um when you come back to do surveillance and have retained tax that may create uh problems uh for your adequate surveillance. Um uh In the future. Uh You also may need to use multiple X stacks like the videos I showed you these were large defects, eight centimeters. There's no way you can use one XT, you probably need to use multiple X stack. So you're adding more cost on your closure. Uh The second way is to use Mantis or adapt clip and use maybe four of them to close a six centimeter defect and then use another four regular clips to close in between. Uh This again is a mucosal closure. Uh So I I don't feel comfortable if I have a perforation that I'm, I got an adequate closure. Uh You're limited by the defect size and location and you're limited by clip rotation for the that clip because it does not rotate. So the way it opens for you, you're gonna have to take it that way. On the other hand, if you compare those two modalities to using overstitch and alumen, you would probably, if you use multiple X stacks or multiple mantis and depth, you will get the same price if you're actually using just one overstitch and a dium. And especially if you use the dium in easy uh one which is cheaper than the easy glide. Um you could probably save some cost there. So the benefit though compared to those two modalities is you get a full thickness closure. So even if you have a perforation, you do not worry you can approximate muscle to muscle and have a full thickness closure, any size defect anywhere in the colon. But you will get a free traction and stability of the scope which you could anyways use an over tube in any of those two modalities to get a stable scope for an ESD. So if you're gonna use an over tube, then might as well, you use dial loin and then eventually suture with an overstitch, you may eventually have similar cost compared to the other two techniques, but you get the no headache of no leakage, uh no complications, post adequate closure to the point. You can even send the patient home um safely. And with that, I will finish my talk. Uh So thank you so much uh for listening and allowing me to share my experience with you on using uh diluted.