Lumendi Learning (lumendilearning.com) is excited to feature a new video presentation by Dr. Kartik Sampath, exploring the novel combination of DiLumen® with EUS scopes for proximal colon procedures. This insightful video illustrates how DiLumen’s colonic balloon overtube facilitates advanced diagnostic and therapeutic interventions with echoendoscopes. Key Takeaways from Dr. Sampath's Presentation: Diagnostic and therapeutic indications for proximal colon EUS Characteristics and limitations of echoendoscopes The utility of a colonic overtube for proximal colon access Cost-effectiveness and clinical accessibility of colonic overtube utilization Opportunities for academic and community adoption of advanced endoluminal interventions Explore how DiLumen expands EUS scope capabilities to enable more accurate lesion assessments and innovative therapeutic procedures, including complex resections, luminal obstruction management, and minimally invasive endosurgery.
Thanks for the opportunity today to speak uh for the Lumani Learning Center. I'm Kartik Sampath and an Assistant Professor of Medicine at Wild Cornell Medical Center. My talk today is entitled Use of a colonic Balloon over tube to facilitate diagnostic and therapeutic endoscopic ultrasound in the proximal colon. Um I have a relevant disclosure and that I'm a consultant to Luandi. Um The outline of this talk is to review diagnostic and therapeutic indications for proximal colon. Endoscopic ultrasound. Identify the characteristics and limitations of echo endoscopes, uh recognize the utility of a colonic over two for facilitating proximal colon E US. Um address the potential cost effectiveness of colon over two utilization for proximal colon disorders and discuss the accessibility adoption of the clonic over two platform for academic community medical centers. So it's important to review the anatomy of the colon, the general audience. So the um average length is about 150 centimeters or 5 ft. Um Some issues with accessibility to parts of the colon can be due to the length of the colon or deport was or twists of the colon. And of course, we need to investigate the colon for various reasons including diagnostic um work up for abdominal pain, polyps, some mucosal lesions, blockages, or stenosis, bleeding, diarrhea, and potentially doing therapeutic interventions such as foreign body removal, uh G I bleeding evaluations, diar uh dilations, obstruction, and uh resection. So as a primer, we have different types of scopes to investigate the colon in including the colonoscope, pediatric and adult based colonoscope, 170 centimeters in length. Most commonly utilized type of scopes. You can also consider a gastroscope. Um They have varying lengths from 103 to 110 centimeters and they can be utilized for different reasons including a blockage or a tight area in part of the colon or in patients who've had prior chic resections. There's also the endoscope which is longer at 200 centimeters. And this can be used in combination with over tubes, for example, a single balloon, double balloon or a spiral based over tube. Um And this can be indicated for failed prior colonoscopies or desired deep aal intubation. So moving on now to echo endoscope or E US based scopes as a primer, there is a mini probe which actually goes through um an endoscope or a colonoscope based channel. It can be used to visualize areas. The resolution is poor compared to other types of echo endoscopes. Um and it's not the ability to um um perform tissue acquisition. There's a radial um echo endoscope 155 centimeters in length. It is a side viewer based exam. So you're looking off to the side, um visually speaking, um it's a 360 degree view from the ultrasound perspective. You can have excellent resolution but you cannot um attain tissue acquisition. There's a linear E US scope which again, 155 centimeters in length, the side of your scope get a 180 degree view. The benefit here is that you can sample tissue with a fine needle aspiration or biopsy. And there's also the potential to do therapeutic based interventions. And lastly, there's the forward viewing um us scope similar 155 centimeter length, it has a 110 degree view. Um but you can look straight ahead. So it aids in the passage of a tortuous Luminal tract, for example, the colon. However, it's not available or present a lot of endoscopic units. So let's move on to the reasons why you'd want to do an E US in the uh lower G I tract um staging of mucosal malignancies most commonly rectal cancers H in the assessment of indeterminate polyps, um submucosal lesion. So G I uh stromal tumors, lipoma, IOM, myomas, Finas, carcinoid renal cell tumors, and also evaluate things like extrinsic compression, vascular abnormalities, et cetera. And there's a potential to do therapeutic interventions from the lower uh G I tract, namely to address things like obstruction, for example, an entero colonic bypass and then we'll hint at this later, but there's the potential to do unique innovation, um evaluations procedures, interventions as it pertains to a metabolic endoscopy. But this is a slide. Just to mention that depending on the location of the G I tract, you can have different distributions of the most common submucosal lesions. For example, in the esophagus may be more prone to uh noting lym myomas in the stomach gir uh stromal tumors in the colon. You may see uh more carcinoid again, just a broad based assessment here and this is one citation. So why use an over two? Well, the echo endoscope is limited by certain properties. For example, the length 155 centimeters and the colon is on average 170 the stiff tip of the um echo endoscope, in particular, the linear um echo endoscope, the side viewer uh portion. So you're not looking straight ahead if you have a stiff tip and you can't look straight ahead in a twisty colon that can cause the potential um to have limited access to the right colon, one part, but also more pressure inadvertently to the lateral walls of the colon. And that can lead to pressure and in areas where you have a weak part of the colon. For example, due to diverticular disease, you can increase your risk for perforation, which is always something that gastroenterologists want to avoid. So the over tube can be utilized as a protective sheet so that the scope does not interfere with those lateral walls and increase that perforation risk. So it allows access to the proximal colon as one benefit, minimize perforation risk. And also depending if based on that US assessment is it thought that more interventions are needed are readily um performed scope exchanges for resection defer closure, for example. So what type of over tubes are there? There's um various types including um single and double balloon over tubes generally does not fit in the US scope um up um or rid over tube, um which again does not generally speaking, fit an E US scope. And then the endoluminal um interventional platform from L Mandi which can be modified to fit an E US scope. Um and other types of devices including a stitching type device or an over the scope uh based mini clinic. So the platform itself, um you have an over tube, you can put a colonoscope within that over tube. You can advance it to the area of interest. Usually you inflate the aft balloon or the more proximal balloon and through um a series of maneuvers of adding the scope, reducing the scope, inflating the balloon, deflating the balloon, advancing the over tube. Um um you can advance to the gear area of interest that's desired. Um Once you're in the area of interest, for example, the proximal colon and the over tube is in the right position, you can remove the colonoscope and then depending on the device of interest. For example, in this case, we're talking about E us, you can make an incision um in the over tube itself, whereby the scope can go into that over tube at a more disappointed approximal point part of the um over tube and then be advanced into the area of interest. And the way we do that is we may get two, about two centimeters, distal to the anal verge, we make an incision that's about two centimeters in longitudinal length that allows us to then insert these various other types of modified scopes. For example, the E US scope, let alone others, for example, over stitch. So um what's the benefit as we've read in different ways is now we can get the E US into the right colon. We can do diagnostic evaluations, for example, coastal staging needle, um aspiration or biopsy. In addition to therapeutic based us guided interventions if necessary, the scope exchange, as I mentioned in terms of complex resection, suturing if necessary. And then ultimately, at the end of the procedure, you can deflate the over tube and then remove both the um scope and the over tube in tandem. So this is a video courtesy of uh um uh Lumani um showing the animation of what I'm discussing. So there's a clo uh Kosco within the over tube. You can then inflate the app for the more proximal balloon and then you can reduce the colon. Subsequently, you can add the scope further into the g into the colon and then deflate the balloon, advance the over tube, then through a series of repetitive uh maneuvers, reinflate the balloon reduce and then re add the scope and then ultimately get the pro the over tobe into the proximal um a colon. And then from there, we can do a series of scope exchanges to get the appropriate scope for the desired interest or outcome. This is cursey of a video gie 23 publication. Um This was actually for a per oral based um advancement of an E US scope um for the purposes of gallbladder drainage, but the same principles apply for lower E US. So here you can imagine you get the over uh tube into the, for example, in this case, potentially the proximal uh colon, you can see that if you just put the E US scope in through the over tube, that it would not be long enough. So what you can do is roughly two centimeters distal to the anal verge, you can make that incision within the over tube itself. And then you can add the scope through this modified incision into the over tube. And ultimately, now you have the length that's long enough to get to the proximal colon to do your assessments of interest. OK. So let's talk about the clinical applicability here. So this was a, a patient of mine who was a 50 year old female who underwent a screening colonoscopy with the general uh G I colleagues at proximal transverse colon two centimeter semi coastal lesion was noted, let's revert to uh myself within our advanced endoscopy group. Um I ordered AC T admin Pelvis to better characterize the reported lesion. And it was noted that there was an indeterminate two centimeter pericolonic um uh tran proximal transverse colon uh lesion cannot rule out a uh gastrointestinal stromal tumor. Um So there was actually some discussions uh from the surgeons about doing an upfront um colonic resection. However, the generalists wanted to ensure that a lower E US was performed first. So this is the CT for that patient and you, you can clearly see in the proximal transverse colon, there is a very well defined uh 2.2 centimeter um um mass and that required further evaluation. OK. And so before we talk about that case further, it's important to remember the guidelines from the various societies for investigating gastrointestinal subepithelial lesions. And um the general consensus is that E US should be utilized for these cases um for the purposes of investigating indeterminant submucosal um or subepithelial epel lesions. Um and particularly in those that potentially arise from the muscular propria that they should be sampled. OK. And so the key here is that um in the E US is indicated in these types of cases when possible, that can ultimately help guide diagnostic evaluations and the potential uh decision to do further interventions. So this is our case and this is like um colonoscopy and you could see a well defined lesion that echoes what was noted on the CT scan. Um But then we were able to ultimately use the endoluminal intervention platform to get the E US scope to this lesion. And then we were able to very safely, very clearly and very granularly um uh uh look at this lesion. and you can see that this is clearly coming from the submucosal or third layer, the MP layer appears intact. And it the other thing that's quite striking is that it's an anechoic lesion more consistent with a cyst. OK. So we very clearly understand what's going on um for this specific patient and you can get certain understanding from just a Luminal assessment, let alone um cross sectional imaging. But the E US does allow us to get a very sensitive, very clear defined evaluation of these subepithelial type lesions. So, what was the aftermath for this case? We were very confident that this was an intramural cyst that was benign. We deferred an FN A to avoid infectious risk. Um surgery ultimately was deferred and an unnecessary resection or health care expenditure was precluded and the consensus was to just do a repeat imaging study in one year. So we'll move on to a second case just to illustrate some of the more innovative um um type of interventions that can be performed in the proximal colon. This is a 48 year old female who was referred um because of super obesity to our Endo Bariatrics Clinic for consideration of weight loss. Um She had a BM I of 68.7 and weighed 472 pounds on initial presentation. Um she had an open ruin y gastric bypass 23 years prior and she had had a post op N of 350 pounds, however, eventually gained that weight back despite intensive lifestyle modification and then upper endoscopy was done which noted dilated gastro jinal stoma. The patient was evaluated bariatric surgery who deemed the patient to be um a non surgical candidate for revision surgery, discussed at a multidisciplinary obesity conference. And the consensus was to attempt a small bowel um partial bypass for colonic diversion, a caloric diversion um for for purposes of further weight loss. So what was the planned procedure? Essentially, we would get a colonoscope with the uh endoluminal interventional platform to the right colon. We would then remove the colonoscope and place the eu scope in the right colon. We would then in tandem do a double ballon enteroscopy, uh pass the jual vaginal NATO mosis into the um um mid distal Judum. And then ultimately, if it was technically feasible, make a connection between the right colon and the JUD room and create what's called a judgmental colostomy for the purposes of partial caloric diversion and weight loss. So, this is a video showing that procedure. And you can see the kaleidoscope with the uh E IP platform um in the right colon. This is actually the view from the double balloon integrate enteroscopy. And you can see here is the E US in the right colon. Here is the double balloon uh endoscope in the um mid to uh distal Judum. And now here you can see the vaginal um um inflation with saline contrast and methylene blue to inflate the Judum. And then here from the right colon, we can see um the, the targeted small bowel, we're able to place a lumen opposing metal stent between the colon into the Judum and deploy that here is the stent, post deployment and you can see a connection between the small bowel to the right colon and we've dilated that stent a very clear fistula or connection has been performed. This is also um confirmed on fluoroscopy. This is the view from the colon. OK. This is a view from the small bowel all gone simultaneously. So, what was the aftermath in this case? Well, there were no acute um perry or post procedural um complications or events in two weeks, the patient no longer required antidiarrheals. Um At four months, they had a 50 pound weight loss. Unfortunately, she didn't have access to um other types of pharmacotherapy. We then layered an endoscopic transoral outlet reduction procedure at the four month mark. And at 11 months, the patient had a 92 pound weight loss or a total body weight loss of 19.2%. And one thing to caution is that whenever you're doing more complex or innovative type procedures, it's important to have established research protocols and surgical backup. So what's the opportunity here? The opportunity is to um use more devices, different types of scopes in the proximal colon? Ok. This allows better um performance of the advanced endoscopic from a diagnostic perspective, able to visualize the lesion more clearly mucosally submucosal pericolonic assessment. Ok. Let alone tissue acquisition, which may not necessarily have been afforded before or safely afforded before. Ok. Now, you also have the ability to do dual capabilities, consolidation of care, do a diagnostic exam and because of the potential to um switch scopes, do other types of interventions, whether it's complex resection, um therapeutic E US. And then ultimately, this broadens the capabilities of endos surgery, whether it's, as I mentioned, complex resection, defect closure, Luminal obstruction and as we hinted about metabolic endoscopy. Ok. Well, what's the opportunity cost? Well, there's of course the over tube or device or different types of scope, purchasing costs, et cetera. There's microscopic in terms of the advanced do being trained to be able to use different types of devices. Um The ability to do complex resection, I feel comfortable with over tubes and that sort of investment in time then macroscopically. Well. Ok. We're able to do certain types of endo surgical based interventions which is deferring from surgery. OK. But it's important to discuss this in multidisciplinary team. Make sure different services are comfortable with these types of plans or interventions to make sure that there's not any um pushback or other types of hesitation or issues. OK. This is just a slide to mention that the endoluminal interventional platform has been utilized in lots of different um methodologies, cases indications. We this uh the first uh reference there is a semi coastal lesion in the pedestal orifice investigated by courtesy of the del balloon and Illumina Interventional platform um to get that us into that right? And to do a better lesion assessment as I referenced before, the ability to use this over to to do U gu inter in al an prior or and then of course, having access with that over two to then do more complicated um complex for sections in a potentially more efficient manner. So what are the reflections here? And this is just a sort of uh a picture slide here just showing that you can be a little bit more risk averse, right? Or you can be a little bit more risk prone or you know, factually mentioned as a cowboy ish type thing, right? And there's different contexts for um the spectrum, right? You can be sort of more risk averse or more averse as a diagnostician or you can be a little bit more aggressive as a diagnostician for example, if you see that subcostal lesion in that colon, you may just send them to surgery and not uh think about doing anything further, be describe it out of sight, out of mind and put it to a different colleague, not unreasonable. However, that's one possibility, the other co um context or consideration would be to be more aggressive as a diagnostician do that. Um uh proximal colon e us really better understand stuff so that you can then counsel your colleagues, your patient, your surgeon. Um exactly what you have found. OK. Um But then you can also have a variant spectrum as an interventionalist, right? You may be very aggressive to understand what the lesion is. But then say I'm not comfortable removing this complex lesion and still sending to your surgeon. But now you've counseled them better or you can be aggressive on both fronts and say, OK, I have the skills to do complex interventions. Let me do that complex intervention. Now, now that I better understand everything from a diagnostic perspective, I can now be more aggressive from an interventional perspective. And this of course, depends on levels of training. Um And the key thing here ultimately is that the clonic over tube affords a safety hedge to now access the proximal colon for novel investigations, therapeutic maneuvers. And ultimately, it's up to the individual endoscopist. Um um a personal preferences about whether how aggressive they want to be procedural. Again, both from the context of diagnostic, diagnostically and from an interventional perspective. Ok. So the take home points here is that the fields of therapeutic endoscopy and end of surgery continue to evolve. In addition to device development, there's more unique and diverse indications for current devices that will continue to be refined. The colonic over tube allows access to the proximal colon to facilitate dedicated us. And then right side of the US um affords more investigation, more accurate assessments from a diagnostician perspective. OK. And then ultimately, we can potentially have access to proximal colon to do more complex interventions and sometimes do it more comfortably from complex resection, defect closure, palliation of obstructions and hinting at potential uh metabolic endoscopy based interventions. And ultimately, the endoluminal intervention platform facilitates opportunities to perform what I already mentioned, which is innovative, organ sparing, minimally invasive um and a surgical based diagnostic and interventional based um um methods. So with that, I'd like to just say thank you for your time and attention.
