Indications:

1. To prevent post polypectomy bleeding (particularly with large stalked polyps) or for treatment of post polypectomy bleeding
2. Also used to prevent bleeding in gastric polypectomy

Steps:

1. The endoloop comes preloaded, attached to the end of the sheath
2. The loop will be protected in a plastic casing, from which it needs to be taken out
3. The handle has got a yellow bung, a thumb ring and a body (where index and middle fingers rest) of the handle.

Picture1: The handle of the endoloop

1. Pushing the yellow bung away from the handle (step1) will bring the loop inside the sheath

Picture2: Step1- ensheathing the loop before passing through the channel

1. Next the sheathed loop is fed through the accessory channel
2. Once polyp is located, loop is opened out of the sheath by pulling the yellow bung towards the handle ( Step2-reverse movement of step 1)

Picture3: Step2-Reverse movement of step 1- bringing the loop out of the sheath

1. The loop is then placed over the polyp or the polypectomy stalk
2. The loop is then tightened over the stalk – by closing the handle (i.e. the index and middle finger will close in to the thumb) Step3 – which moves a silicone stopper to close the loop. Don’t close too tightly; otherwise it might snare the polyp off.

Picture4: Step 3- tightening the loop

1. Once tight – check for blanching around the loop as a result of restricted blood flow
2. Lastly to fire/detach/deploy the loop- open the handle fully (Step 4- reverse movement of step 3)

Picture5: Step 4- Reverse of step3- firing/detaching the loop

1. Loop usually stays in for up to 7days and then falls off

Video link of how to use endoloop

1. When to use Adrenaline
2. How to set it up
3. How to actually use it once it is set up

When to use Adrenaline

1. Most commonly it is used as part of dual therapy (submucosal injection) to achieve haemostasis in ulcer bleeding, bleeding AVM, Dieulafoy lesion, MW tear, post polypectomy bleeding and post sphincterotomy bleeding.
2. Sometimes it is used to lift up the polyp base before snare polypectomy
3. It is not used in variceal bleeding.

How to set it up

Picture1: Adrenaline injection

1. Ten ml syringe filled with Adrenaline solution (1:10000 dilution, comes in 10ml ampoules)
2. Injector needle, primed with same solution. In most situations you probably will use a gold probe and use dual treatment with one device.

How to actually use it once it is set up

1. Inject adrenaline in four quadrants at the periphery of the lesion. This should be followed by injection at the centre of the lesion.
2. Assistant pushes the injection hub towards yellow injector stem when you say ‘advance needle’- don’t say ambiguous terms like needle out or needle in.


Picture2: Advance needle: injector hub is pushed towards the yellow stem

3. Inject in the submucosa and inject liberal amount (tamponade effect is probably as important as the vasoconstrictor effect) – 10-15ml should be the total amount. Studies show that at least 13 mls should be injected for optimum haemostasis.
4. After injection is given you say ‘needle back’ (don’t say needle out) and assistant withdraws the needle back in sheath by pulling the hub away from the yellow stem.


Picture3: Needle back: injector hub is pulled away from the yellow stem

5. Although at times when we inject adrenaline subcutaneously at times of giving local anaesthesia, we always aspirate before injecting to make sure we are not injecting in a blood vessel, we have not come across this practice but might not be a bad idea.
6. It should be followed by another modality of achieving haemostasis ( e.g. gold probe, endoclip etc)

Complications:

1. Cardiac tachyarrhythmia can occur particularly in the event of inadvertent intravascular injection
2. Local pressure necrosis (rarely)

Here is the link for Adrenalin injection video

Acknowledgement/Bibliography:

1. Gustavo A et al. Thermal probes alone or with epinephrine for the endoscopic haemostasis of ulcer haemorrhage Best Practice & Research Clinical Gastroenterology June 2000 :14 (3): 443-458
2. Jensen DM et al.CURE multicenter randomized, prospective trial of gold probe vs. Injection & gold probe for hemostasis of bleeding peptic ulcers. Gastrointestinal Endoscopy 1997:Volume 45 (4), Page AB92
3. Arasaradnam RP et al.Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding Postgrad Med J. 2005;81:92-98

1. The basic principle of achalasia dilatation
2. The common devices used
3. How to actually do it
4. Aftercare

Choosing the correct patient

1. If you cannot pass the endoscope beyond the narrowing at GOJ , reconsider your diagnosis and consider pseudo-achalasia
2. A thorough endoscopic examination is important, with particular attention given to the GOJ, where malignancy can simulate achalasia (pseudoachalasia).
3. It is very important that your diagnosis of achalasia is quite firm  ideally with endoscopic, Barium swallow and manometry findings.
4. Quite high risk procedure (5% chance of perforation)- so discussion in the clinic with the patient is important while discussing the alternatives (Laparoscopic cardiomyotomy)
5. These patients are prone to aspirate particularly when regurgitation of old food is the predominant symptom.
6. The patient is advised to fast for at least 12 hours prior to the procedure +/- liquid diet for one or two days preceding the dilation
   

Procedure

Choice of balloon

1. A 30 mm balloon is used for a first dilatation. Subsequent dilatation may involve larger balloon- 35 and 40cm.
   This are quite big sized balloon compared to standard stricture dilatation balloons- the idea being to rupture the muscle fibres.
2. Inflate the  balloon before use to check for any leaks
3. We  describe the  OTW ( over the wire) achalasia balloon from Rigiflex™ II ( Boston Scientific)


Picture1: RigiflexII achalasia dilatation balloon: Courtesy Boston Scientific

4. Another frequently used balloon is Wilson-Cook


Picture2 and 3: Wilson-Cook achalasia dilatation balloon and the inflation and luminal port

5. Another alternative is reusable balloon (shown below)


Picture4 and 5: Reusable achalasia dilatation balloon with the pressure gauge: the endoscope goes through the top end of the yellow tube and comes out below the balloon

Positioning the balloon across the LOS

1. A guidewire is passed through the biopsy channel of the endoscope into the stomach and the scope is withdrawn to the GOJ.
2. Note the distance between the incisors and the GOJ along the length of the scope.
3. The endoscope is then removed (taking care to maintain the position of the guidewire in the stomach- push/pull technique).
4. As an aid in initial placement, a marker (such as a paper tape/ tippex) can be placed on the shaft of the dilating catheter to correspond to the previously noted distance from the incisors to the GOJ.
5. This distance should be measured from the middle of the balloon on the dilating catheter.
6. The balloon and tip of the shaft is lubricated and passed over the previously placed guide wire until the marker is in place at the incisors- that means the midpoint  of the balloon is now at GOJ.
   

Actual dilatation

1. Using fluoroscopy, the balloon is then gradually inflated with air, noting the position of the developing waist.
2. Inflation is achieved with a 50ml syringe attached to the balloon port with a 3 way stopcock ( one end to catheter, second to syringe and third port to the pressure gauge)
3. The balloon is inflated with air
4. Small adjustments usually have to be made in the position (deflating the balloon each time) to ensure that the waist occupies the centre of the balloon- balloon will slip downwards if you are too down and then you will have to exert a pull upwards and vice versa- called the cone effect
5. After a satisfactory position is obtained, the balloon is fully inflated (usually requiring about 120 mL of air).
6. The required pressure will be specified on the moulded junction- average 7-15 PSI
7. The balloon is kept inflated for 60 seconds, during which patients may be very  uncomfortable- give pethidine or fentanyl 2 minutes before the dilatation
8. After the 60 seconds are over, the balloon is rapidly deflated.
9. Sudden disappearance of the waist is very suspicious of rupture
10. Thereafter, perform another full inflation for 60 seconds and again note the pressure required to obliterate the waist. This is usually less than the initial pressure
11. Another alternative is reusable balloon-
    • The scope here is passed through the balloon and then the scope is introduced beyond GOJ- a J manoeuvre confirms part of the balloon beyond the GOJ ( see picture)
    • The side catheter containing the inflation port is attached straight to a inflation device with a pressure gauge ( see picture)
    • Pressure of 200mm kept for 2minutes and then release

Aftercare:

1. The patient is observed for the next five to six hours during which serious complications, such as perforation would be obvious
2. Routine post procedure CXR is advisable
3. Follow up in clinic to assess response

Here is the link for achalasia dilatation video

Acknowledgement/Bibliography:

1. Khan AA et al. Pneumatic balloon dilatation in achalasia: a prospective comparison of balloon distention time. Am J Gastroenterol 1998; 93:1064-1067
2. Kadakia SC et al.Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary achalasia. Am J Gastroenterol 1993; 88:34-38
3. Barkin JS et al.Forceful balloon dilation: an outpatient procedure for achalasia. Gastrointest Endosc 1990; 36: 123-125
4. Product guide of the respective companies- Wilson-Cook and Boston Scientific

1. How to determine the location of the foreign body
2. How urgently the endoscopy needs to be done
3. How to use an overtube
4. How to grab the FB
5. When can you wait and watch
6. Food bolus obstruction

Location of the foreign body:

1. Two important questions-What is it and Where  is it ( Pharynx/Larynx/trachea/oesophagus etc)
2. Take history and get an x-ray of neck/CXR /AXR depending on the history and clinical suspicion
3. Remember -Bones may not show on x-ray
4. Get both coronal and sagittal views- if in doubt
5. Beware of airway compromise

How urgent is the need for an endoscopy?

1. Immediate if
   • Complete obstruction
   • Sharp – up to 35% perforate
   • Battery – burn within 2 hours and can perforate within 6 hours
2. Everything else within 24hours


Picture1: An overtube
How to use and overtube

3. Use overtube- prevents repeated intubation and protect airway and mucosa
4. Thoroughly lubricate the inside and the outside of the overtube
5. Pass the endoscope through the overtube- the thicker and corrugated end remains outside the oral cavity – then intubate and advance the gastroscope
6. Keep the tip of the overtube in the lower oesophagus while you find the foreign body as it immediately deflates the stomach and view will be compromised
7. Once FB is viewed and position located – do a J manoeuvre and advance the overtube – note the tip protruding through the GOJ- both overtube and the scope is black but scope has got white ring marking
8. Next withdraw the overtube just within the GOJ and inflate the stomach again
9. Find the foreign body and grasp it – use Roth net for battery, for razor blade use stent grabber- anything sharp – you need to grab it along its axis and not across
10. Pull the scope very close to GOJ
11. Advance the overtube OVER the scope to cover the sharp object – we find it more convenient than to pull the scope into the overtube
12. Immediately the whole field will look black
13. Withdraw the endoscope and FB together keeping the overtube in place
14. Can go back again if more FB is to be picked
15. Remove the overtube at the end

How to grab the FB

1. Tool kit- snare/triprongs/Roth net/Suction cap/biliary basket/Rat toothed forceps


Picture2: Capuchon hood

2. Capuchon hood is another device which can be used instead of overtube in selected cases- it is fitted at the tip of the endoscope and looks like a rubber skirt which invaginates itself once the scope is withdrawn into the GOJ and then covers the FB
3. Dry run outside the patient with similar objects- ensure the size of the FB is compatible with the holding size of your device
4. Move with pointed end trailing
5. If both ends pointed cover one with forceps
6. For razor blades rat toothed forceps ( stent grabbers) are probably best as with other devices you can catch it across which is problematic
7. If perforation- conservative management only in highly selected cases (endoclips or covered stents)- most require operation

When can you wait and watch

1. If the patient is
   • Asymptomatic
   • Blunt FB
   • Inert FB
   • Not>5cm
   • Healthy gut
2. Warn to report symptoms
3. Check X-Ray

Food bolus obstruction:

1. If complete obstruction with saliva drooling urgent OGD
2. Once visualised one can either
   • Pull- Forceps/snare/net/grasper
   • Push it down in to the stomach by using
     • Air insufflations
     • Gentle pressure
     • Fragment and gentle pressure
3. Success 97%
4. Remember to take oesophageal biopsy particularly if young male to exclude Eosinophilic oesophagitis
5. If narrowing is seen once the bolus is gone- e.g. benign stricture, web, schatzki’s ring or malignant stricture – that needs to be addressed then or later depending on the pathology.

Here is the link for foreign body extraction video:

1. Video 1
2. Video 2

Acknowledgement/Bibliography:

1. Alhaji M et al. Razor blade removal from the stomach utilizing a novel modification of the overtube. Endoscopy. 2009;41 Suppl 2:E166. Epub 2009 Jul 23.
2. Webb WA et al.Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology. 1988 Jan;94(1):204-16.
3. Stack LB et al. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am. 1996 Aug;14(3):493-521.

• Strictures more than 5 cms in length should not be balloon dilated.
• Dilate only fibrotic strictures without ulcer.
• Dilate only if symptomatic.
• Malignant stricture- never dilate

Remember:

• One or more session may be needed. Alternatively, the stricture can be dilated once and if symptoms recur- they can be dilated again.
• The technical success rate, defined as achieving an endoscopically passable residual stricture, is between 70% and 90 %, independent of the balloon’s diameter.
• Complications such as haemorrhages are rare, while perforations are reported mostly in studies in which 25 mm balloons are used.
• It is difficult to define the relapse risk after endoscopic balloon dilatation, as the published studies are heterogenous. In a recent long-term study, stricture relapse rate was 46% after a mean of 32 months. (Stienecker K. Long-term results of endoscopic balloon dilatation of lower gastrointestinal tract strictures in Crohn’s disease: a prospective study. World J Gastroenterol.2009 Jun 7;15(21):2623-7)

Size of balloon
If the stenosis  is > 5mm in diameter- use 18-20 mm balloon
If the stenosis  is < 5mm in diameter- use 15 mm balloon
Pinhole stenosis- 12 mm balloon

Colorectal stent
Indications

• Palliative decompression of advanced disease
• Preoperative decompression- stent insertion avoids an emergency surgery with its benefit on morbidity and mortality

Types of Stent

• Through the scope stents- inserted under direct vision
• Inserted over a guidewire under fluoroscopic guidance

Complications
The major complications are stent migration (11 percent), perforation (4.5 percent), and reobstruction (12 percent).

• Essentially all mucosally based pedunculated polyps can be removed endoscopically.
• Patients with sessile polyps <2 cm in size can be resected in most cases.
• Many sessile polyps >2 cm in size are also resectable endoscopically depending on their location within the colon.
• As a rule of thumb, it has been suggested that sessile polyps occupying more than one-third of the colon circumference, or involving two haustral folds, are too big for safe endoscopic removal.

Diathermy current

• Electrosurgical or diathermy currents cause heat, thus coagulating local blood vessels. This current is very high frequency and thus produces heat but no shock. This is because there is no time for muscle and nerve membrane depolarisation before the current alternates again and therefore no muscle contraction or afferent nerve impulse (contrast low frequency household currents).
• Modern cardiac pacemakers are unaffected by the relatively low power used for endoscopic electrocautery.
• Monopolar diathermy is used in endoscopy.  The principle is the concentration of current at the active electrode (endoscopic accessory) with a small surface area, concentrating the heat at the operative site. The larger return plate (patient plate), which completes the circuit, spreads the current over a wide area so that it is less concentrated and thus produces little heat.
• Types of current- Cutting current have an uninterrupted waveform of relatively low voltage spikes. Coagulation current has intermittent higher voltage spikes with intervening, ‘off periods’, lasting about 80% of the time. Blended current combines both waveforms.
• The principle of polypectomy is to coagulate the core (slow cook) of the polyp stalk, with its vessels, before transection.
• Polypectomy should be performed using coagulation current only at a low power setting (15-25 W). The maximum power setting used should be no more than 30-50W. We use ERBE settings of- coag 30W (forced) and set cut to zero and endocut is turned on. The ‘endo cut’ adjusts output automatically for appropriate heating during snaring.

Snares
The standard large snare is 2.5 cms in diameter and the small snare is 1 cms in diameter. The technique of application is the same irrespective of whether the snare is oval, crescent shaped or hexagonal.

Technique of polypectomy for pedunculated polyps

• Accessories like snare/forceps enter the viewing field at 5’o clock position. So polypectomy will be easier if the polyp is placed in the right lower quadrant of the field of view. A change of patient position may be needed for optimum position of the polyp.
• It is usually best to have the snare fully open, and then to manoeuvre only with the scope controls or shaft, so that the snare is placed over the polyp head almost entirely by manipulation of the scope. It may help to open the snare in the colon beyond the polyp, and then to pull the colonoscope slowly back until the polyp comes into the field of view and into the open loop.
• Ideally the snare should be closed at the mid-portion of the stalk. Initial snare closure should be gentle to ensure it is in the right place (once the wire has cut into polyp tissue it may be difficult to release and reposition it)
• Apply the current continuously for 5-10 seconds at a time, watching for visible whitening. The snare should be closed slowly and simultaneously.
• Piecemeal resection of the head may be performed if the polyp cannot be encircled with the snare, until the residual portion of polyp is small enough to permit encirclement with the snare (piecemeal resection of head is safe as the vessels in the head are much smaller than those in the stalk).

Hot biopsy principles

• Hot biopsy is an effective way of destroying polyps 1-5 mm in size. Polyps over 5mm in diameter are not suitable for hot biopsy removal. Using hot biopsy for larger polyps may cause the current to fan out from the point of contact of the forceps. This will heat tissue at a distance (invisibly) and predispose to the risk of perforation especially in the right colon.
• Principle- The hot biopsy forceps is an electrically insulated forceps through which electrical current flows to direct electrical energy around the tissue held within the jaws. The tissue within the jaw is protected from current flow, so is unheated (unless by thermal conduction resulting from long current application). Hot biopsy thus enables simultaneous cautery of the polyp base while obtaining a biopsy specimen.
• Current- settings are same as for snare polypectomy (usually 15 W coag)
• Technique of hot biopsy:
  • Only the apex of the small polyp is grasped in the jaws of the hot biopsy forceps.
  • Tent up the polyp onto a pseudo pedicle by withdrawing the forceps slightly (this prevents deep thermal injury to the colon wall)
  • Apply coagulation current for a maximum of 2-3 seconds.
  • Pull off the biopsy. Even if some of the head is uncoagulated, the basal blood vessels will have been destroyed and it will slough off.
  • Ensure that the black insulating plastic of the forceps is visible (so that the metal parts of the jaw is not in contact with the scope) before applying current.
• Safety-
  • Right colonic wall is very thin and so hot biopsy is best avoided in the right colon. Polyps 1-5 mm in size may be removed by cold snaring in the right colon. Cold snaring by cheese wiring is safe as small polyps have small nutrient vessels. Minor bleeding occurs, but this always stops in 1-5 minutes. Polyp lifting is not needed when using cold snare.

Sessile polyp

• Endoscopic mucosal resection (EMR) is usually used for removal of sessile polyps particularly in the right colon.
• Injection of fluid into the submucosa beneath the polyp increases the distance between the base of the polyp and the serosa. When current is then applied with a snare, the polyp can be more safely removed because of a large submucosal cushion of fluid. The fluid injected is normal saline or jelofusine with or without adrenaline (1 in 10,000). Some colonoscopists add a few drops of methylene blue to the fluid, the blue showing up the extent of the submucosal bleb. (One commonly used solution- jelofusine 40 ml, 2 ml of 1 in 10000 adrenaline and 0.5 ml of methylene blue). Upto 20-30 mls of the solution may be needed for large sessile polyps.
• Injection technique- Make the first injection proximal to the polyp, so that the raised bleb of tissue does not obscure the view. Subsequent injections are made into the edge of the preceding bleb or directly through the polyp surface (in thin polyps). The plane of separation in the submucosa for successful injection is very superficial. If a bleb is not being raised, withdraw the needle a bit. Failure to lift (non lifting sign) suggests malignancy, the lesion being fixed by invasion into deeper layers.
• Aspiration of air during attempted snare capture of elevated polyp will result in an easier encirclement.
• Complete removal should be attempted at the first endoscopic session because scarring will make subsequent attempts at EMR difficult.
• The basal remnants after most of the polyp has been snared can be safely destroyed by APC.
• The spot should be marked with monospot/India ink because further sessions will be needed to check the site.
• It is permissible to remove a much larger piece with EMR than one would ordinarily resect in the right colon. The pieces should probably be not larger than 2 cms in diameter

Rectal polyps

• Large sessile polyps up to 12 cm from the anal verge are extraperitoneal and may be better removed by local proctological techniques, which produce a single large specimen for optimum histology. A failed endoscopic attempt to remove such rectal polyps makes subsequent removal by the surgeon difficult.
• Sessile polyps more than 12 cms from the anal verge can be removed by transanal microsurgery or TEMS but is more often removed endoscopically

Polypectomy safety principles

• Marking the snare with a pencil or indelible pen at the point that the snare is just closed to the tip of the outer sheath is one of the most important safety factors in polypectomy. It allows the assistant to stop snare closure before the wire closes too far into the tube and there is danger of a smaller stalk being cut off by ‘cheese-wiring’ mechanically without adequate electrocoagulation; it also warns if the stalk is larger than apparent or head tissue or mucosa has become entrapped.
• Large stalks may be injected with adrenaline (1 in 10,000) before snaring to reduce the risk of bleeding. Nylon endoloops or metal clips may also be used for large stalked polyps, particularly in patients on anticoagulants or anti platelet agents. These may be placed before or after polypectomy. However, nylon endoloops are floppy and may be difficult to manoeuvre over a large polyp head. Clips can be applied to smaller stalks before or after polypectomy. However, it is important that the snare does not touch the clip as it may cause a burn to the colon wall.
• Tattooing marks the site of any suspicious or partially removed polyp for follow up or for surgery. 1 ml of India ink injected close to the polypectomy site is sufficient for endoscopic follow up, but four quadrantic injections ensure visibility if surgery is a possibility. The carbon particles of India ink remain in the submucosa for many years (probably for life).
• Only 1:200000 adrenaline is used in the rectum (compared with 1:10000 in colon) because there is a risk of communication to the systemic circulation and danger of cardiac dysrhythmias.

Polyp retrieval

Smaller polyps or fragments up to 6-7mm can aspirated in a polyp trap or more cheaply, onto gauze placed over the suction connector.
Larger specimens may be retrieved using the nylon Roth net or the multi prong grasping forceps or the basket. Roth net is capable of repeated openings and capture of several fragments. Thus, these devices may be able to retrieve up to 3-5 large polyps at a time

Trouble shooting

• Lost polyp after transection- Look for any fluid. The polyp is likely to be there as it is the dependent side of the colon. If no fluid is visible, squirt in some water with a syringe and watch where it flows. If the water refluxes back, the polyp is likely to be distal to the scope and the scope will need to be withdrawn to find the polyp.
• Snare loop is stuck in the wrong position- the snare loop can be released by lifting it up over the polyp head and pushing forcibly inward- with the whole colonoscope if necessary. The alternative is to sacrifice the snare by cutting it with wire cutters, withdrawing the scope and leaving the loop in situ. Either the polyp head will fall off or another attempt can be made with a new snare.
• Difficult sigmoid- Sometimes polypectomy may be difficult in sigmoid colon because of narrowing  either due to diverticular disease or hypertrophied folds. A gastroscope may allow easy snare positioning in the same location where the colonoscope was both cumbersome and difficult.

References

1. Wayne JD. Colonoscopic polypectomy. Diagnostic and therapeutic endoscopy 2000;6:111-124
2. Cotton PB, Williams C. Practical Gastrointestinal Endoscopy. The Fundamentals. 5th Ed

1. When to use APC
2. How to set it up- both the cable connection and the settings
3. How to actually use it once it is set up
4. The principle behind APC

When to use APC

1. Mainly in AVMs (particularly GAVE -gastric antral vascular ectasia) and bleeding tumours.
2. It can also be used in base of polyps after snare polypectomy.
3. Rarely used in bleeding gastric and duodenal ulcers.
4. Unblocking of occluded metal stents

How to set it up- both the cable connection and the settings

1. Turn on both the boxes: Top box is normal diathermy unit ERBE ICC200 and bottom box is APC 300
2. Connection of cables:

• Connect the plug of the nessy plate (patient electrode) to the neutral slot of the top box (top box left most plug)- picture1
  
  Picture1: Top box is normal diathermy unit ERBE ICC200 and bottom box is APC 300
• Three pronged connector from lower box goes to the Cut/Coag slot of the top box – picture2- (remove the single probe connector which we use most of the time i.e. polypectomy or hot biopsy)- operator holding it after taking it off -in the picture above (Picture1).
• If you forget to connect this, APC will not work – a frequent cause of ‘APC not working’


Picture2:The plug holes of the top box from left to right– 1) neutral 2) Cut/Coag- which takes the three pronged plug from the bottom box and 3) Bipolar- not important here

• Third plug socket on the top box called bipolar is not used in APC and we just leave the plug as it is
  
  Picture3:The plug holes of the bottom box from left to right-1) goes to the cut/coag hole of the top box- the three pronged cable 2) Not important for us 3) connects to the blue APC catheter
• The ash coloured cable from the bottom box ( furthest on the right- see picture 3 ) goes to the blue APC catheter
  
  Picture4: The APC blue catheter (coutesy www.erbe.nl)

3. The settings on the boxes:

• Set the current setting on the top box by repeatedly pressing the effect select button (bottom button which looks like a loop with an arrow) and the watt select button (middle up/down button)- See picture 5.
  
  Picture5:Finger on the effect settings- select forced and a second click on same button will make the watt A( A for Argon) and then make it 65 by using up/down button
• The setting for lesion in Stomach/Duodenum/Left colon :Auto Coag (Blue right panel) to Effect Forced and Watt A65
• The setting for lesion in right colon :Auto Coag (Blue right panel) to Effect Forced and Watt A40
• The setting for lesion in jejunum/ileum ( as in enteroscopy) :Auto Coag (Blue right panel) to Effect Forced and Watt A30
• We have checked with ERBE Engineers- the yellow Autocut panel is completely irrelevant and does not matter what you set as we use only blue Autocoag pedal (Some endosocpy nurses may insist on the ‘correct setting’ and set a value on the yellow autocut section. This is totally irrelevant).
  
  Picture6: Bottom box APC 300- programme 3, cylinder 2 is empty and see the Coag/Cut settings
• On the bottom box you don’t normally need to change current setting as mostly we don’t touch the settings –
  • Make sure the programme mode is set to 2-3
  • And the both the argon cylinders are not empty – in the picture cylinder 2 is empty
  • The setting for coagulation is normally 2.0L/min and is shown on the picture as selected option.For use of APC in small bowel/right colon reduce to 1.5L/min

4. Open the Argon tank valve
5. Purge (the button on the bottom box which says PUR- see picture 1) before using it and then test it by putting the catheter tip in jelly and press the blue foot pedal and see the gas bubble

How to actually use it once it is set up

1. The probe is passed through the accessory channel of the endoscope so that the blue tip hovers over the target tissue. A black stripe located a few centimetres proximal to the tip should be visualized to prevent damage to the endoscope.
2. The probe should be as close as possible to the lesion without actually touching the lesion. The best way is to actually touch the lesion with the probe and then withdraw a little and then give a burst
3. Bursts are controlled with the blue foot switch
4. If burst happens when the tip is in contact with the tissue- a submucosal bleb will form. This is a harmless event. But this can be dangerous when you are using deep in small bowel eg Double balloon enteroscopy.
5. For right colon use lower settings of CoagA40 in other areas of colon use Coag A65
6. Depth of burn is a function of time of burst and the power setting
7. Short bursts of 0.5secs to 2secs duration
8. Frequently suction off gas to avoid over-insufflations, particularly in the colon.

Advantage over conventional coagulation methods:

1. Depth of injury is limited – typically 3mm– better protection against perforation of thin-walled anatomy.
2. Can be used over relatively large areas using non contact method

Complications of the procedure:

1. Complications are rare. However, like any coagulation method, serious complications can occur, particularly in the right colon. Rare cases of perforations have been reported.
2. Other complications like subcutaneous emphysema and pneumoperitoneum have also been reported. These are likely caused by over distension within the right colon.

The principle behind Argon Plasma Coagulation

Picture7: The principle of APC (courtesy www.erbe.nl)

APC uses argon gas to deliver plasma of evenly distributed thermal energy to a field of tissue adjacent to the probe. A high voltage spark is delivered at the tip of the probe, which ionizes the argon gas as it is sprayed for a distance of 2-10mm from the probe tip in the direction of the target tissue. Current density upon arrival at the tissue surface causes coagulation. The application of the energy to the tissue is uniform, and contact free.

APC equipment thus combines argon gas with a monopolar power source. The electrode in the argon channel of the probe is connected to an electrosurgical generator.

The plasma beam has a tendency to turn away from already coagulated (high impedance) areas toward bleeding or still inadequately coagulated (low impedance) tissue in the areas receiving treatment. This automatically results in evenly applied, uniform surface coagulation.

Information regarding The Principle of Argon Plasma Coagulation: (courtesy www.erbe.nl)

Here is the link for APC Video:

Acknowledgement/Bibliography:

1. Rolachon A et al.Is argon plasma coagulation an efficient treatment for digestive system vascular malformation and radiation proctitis? Gastroenterol Clin Biol 2000;24(12):1205-10.
2. Grund KE et al. Argon plasma coagulation (APC) in flexible endoscopy Experience with 2193 applications in 1062 patients. Gastroenterolgy 1998; 114: A603
3. Wilson SA et al. Endoscopic treatment of chronic radiation proctopathy. Curr Opin Gastroenterol 2006;22(5):536-40.
4. ERBE: for kindly letting us use the information and pictures

The module covers:

1. What is Sengstaken-Blakemore tube
2. When to use SB tube
3. What do you need before you start
4. How to actually insert it
5. How to maintain traction
6. Aftercare and removal

What is Sengstaken-Blakemore tube

Sengstaken-Blakemore tube is a 3 lumen tube- one lumen to inflate gastric balloon, a second lumen to inflate oesophageal balloon and a third lumen to aspirate gastric contents. There is no oesophageal suction port. This causes saliva to pool in the oesophagus and thus put patients at risk of aspiration.
Commonly Minnesota tube is referred to as Sengstaken-Blakemore tube

Picture1:Minnesota tube or Modified Sengstaken-Blakemore tube

Minnesota tube- or modified Sengstaken-Blakemore tube is a four lumen tube with an additional lumen to aspirate oesophageal lumen to prevent aspiration from swallowed saliva and blood from the oesophageal varix

Linton-Nachlas tube: Single 600ml gastric balloon only

When to use SB tube

It is used in life threatening upper GI bleed from ruptured oesophageal/gastric varices when traditional treatment with band ligation or glue injection has failed or are not available

This is only temporary method to buy time for more definitive procedures to stop the bleeding.

What do you need before you start

1. The SB tube is normally kept in freezer- it helps insertion by improved stiffness
2. Keep ready two bladder wash syringes for suctioning the oesophageal and gastric lumen, another bladder wash syringe for inflating the gastric balloon
3. Stout metal artery forceps for clamping the balloon ports
4. If oesophageal balloon needs to be inflated in addition to the gastric balloon- You will need:

• A 50cc Luer Lock syringe
• An adaptor whose conical end will fit into the oesophageal port and the Luer lock end will fit into the sphygmomanometer ( the adaptor is available in the chest drain kit )
• A three way valve
• A sphygmomanometer with detachable arm cuff–  to remove the BP cuff and fit the Luer lock end of the chest drain adaptor to fit there

How to actually insert it

1. Debate regarding optimal place for the procedure: Resus vs. theatre: anaesthetist prefers theatre
2. Patient in normal endoscopy position
3. Airway protection- in general, patients who require balloon tamponade to control variceal bleeding should also be intubated. However airway protection is particularly important in
   • Encephalopathy
   • If Sao2<90%
   • Aspiration pneumonia


Picture2: Checking for leak

4. Check the balloons by inflating  air and checking for any leak
5. Smear plenty of KY gel and pass the tube through the mouth like an NG tube- It is kept in the freeze in theatres and Endoscopy unit-to increase the stiffness. Sometimes because of the curled position in which it is stored makes it very difficult to insert like NG tube and a laryngoscope and Magill’s forceps may be needed to guide it past crico-pharyngeus.


Picture3: The setting up of Modified Sengstaken-Blakemore tube

6. Once it has gone up to 45cm mark it’s tip is expected to lie in the gastric lumen- confirm by aspirating stomach content and checking pH – position to be checked later by portable CXR.
7. Once you are sure the tip is in the stomach, inflate the gastric balloon by inflating it with 200ml of air (and put two artery forceps as clamp and also insert the pegs supplied with the tube) and gently tugging it. Some  prefer to put contrast mixed water rather than air.
8. It should slide for some length and then halt as it abuts against the  GOJ –then push additional 50-100ml of air and pull the tube out to exert the pressure on the GOJ.
9. For majority of patients this is enough to stop the variceal haemorrhage. However, oesophageal balloon will need to be inflated, if the bleeding continues in spite of the gastric balloon inflation.
10. Clamp the tube in between air refills
11. Finally fix the tube and  keep a record of the distance of the tip from the incisor teeth- normally around 30-35cm mark
12. Initial success to control bleeding depends on
    • Operator experience
    • Concomitant therapy ( Terlipressin and antibiotics )

How to maintain traction

13. To maintain the pressure on GOJ- you will have to fix the tube with continued traction. We have noticed a variety of practices
    • To hang a bag of 500ml of saline by tying it to the loop of the clamp attached to the tube – the advantage of this technique is
      • Bag of saline is universal as opposed to a tennis ball- but units who use tennis ball normally store one ball with the tube
      • No pressure on the cheeks/lips unlike the tennis ball
      • The traction is measured ( 0.5 kg weight ) unlike unquantifiable traction strength which might vary from person to person
      • See the picture of how to do it below.



b. Pull  the tube and fix it on the side of the cheeks with elastoplasts under tension- not very reliable as    elastoplast may become loose and also the traction force will vary among individuals. However this is the most common practice.

c. Another method is to pull the tube and fix it on the side of the cheeks by passing it through a split tennis ball

14. If oesophageal balloon is inflated pressure should be accurately measured with a sphygmomanometer.
15. Inflate it to 25-40mm Hg. Normal portal pressure is <10 mm Hg; maximal pressure in portal hypertensive patients is never >30 mm Hg, therefore a pressure of 40 mm Hg is sufficient and remember the less the better.

Aftercare and removal:

1. Migration of gastric balloon in oesophagus can cause compression of trachea and respiratory distress. Keep a pair of scissors ready at the bedside in case of emergency – to cut the gastric balloon port to let the air escape
2. Instruction to suction both oesophageal and gastric lumen at intervals of 10 minutes increasing to 30 minutes and after stabilization hourly
3. Frequent oropharyngeal suction
4. Don’t forget antibiotic prophylaxis and continued terlipressin for at least 48hrs
5. Pressure in the oesophageal balloon to be relieved for 10minutes every 2hours to prevent pressure necrosis
6. Repeat endoscopy at 24 hours.
7. The Sengstaken tube should be removed in the endoscopy room
8. First deflate the oesophageal balloon, then take off the traction and finally remove the tube
9. Chance of rebleeding when balloon is deflated  is up to 50%
10. On second endoscopy it should be much easier to band or inject glue as bleeding hopefully would be under control, failing which patient should be referred for urgent TIPSS.
11. Serious complication can occur up to 15-20%
    • Oesophageal ulceration
    • Aspiration pneumonia

Here is the link for Sengstaken tube insertion  video:
No video found so far. One good link is http://emedicine.medscape.com/article/81020-media

Acknowledgement/Bibliography:

1. Helmy A et al. Review article: current endoscopic therapeutic options in the management of variceal bleeding. Aliment Pharmacol Ther. 2001 May;15(5):575-94.
2. Seet E et al. The Sengstaken-Blakemore tube: uses and abuses. Singapore Med J. 2008 Aug;49(8):195-7.
3. Han HY et al. Simple method for inflating and measuring oesophageal balloon pressure of Sengstaken-Blakemore tube. Intern Med J. 2006 Oct;36(10):684-5.
4. Kashiwagi H et al. Technque for positioning the Sengstaken-Blakemore tube as comfortably as possible. Surg Gynaecol Obstet 1991; 172

1. When to use Gold probe
2. Different parts of the Gold probe
3. How it is set up and used
4. Other types of thermal devices in use

When to use Gold probe

1. Mainly in peptic ulcer bleeds
2. Bleeding polyp stalks
3. Dieulafoy lesions
4. Mallory-Weiss tears
5. Arterioveous malformations (AVMs)

Different parts of the Gold probe

Injection Gold Probe Catheter can be used to give injection therapy and also for electro haemostasis. It has also got irrigation capabilities.

Picture1: The gold probe

1. The catheter handle is a thick triangular portion- from its apex emerges the cable leading to the gold tip
2. From the base of the catheter handle arises
   1. The injection hub (with the red/green mark) and
   2. The cable which splits into two further cables
      1. One with the thicker, flange shaped end is the bipolar electrical connector- which is connected to the cable coming from the bipolar socket of the ERBE diathermy box (ICC 200)

      
      Picture2: The electrical connector/ irrigation hub

      2. The other cable takes a saline filled syringe to flush the tip after burning but alternatively you can exchange the adrenaline syringe with a saline filled syringe and flush.
3. The device is supplied in 7Fr (2.3mm) and 10Fr (3.2mm)- 7F and 10F probes require a minimum of 2.8mm and 3.7mm working channels respectively. So use 7F Gold probe if your endoscope is not a therapeutic one (yellow colour as opposed to salmon colour which is therapeutic)
4. The length of the gold probe is usually 210cm but 300cm and 350cm is also available to use in particularly deep in small intestine and colon if needed.

How is it set up and used

1. Connect the bipolar electrode end to the bipolar socket of the ERBE box


Picture3: The ERBE diathermy box ( ICC 200)

2. For gold probe:
   1. No patient plate/neutral cable is needed ( in the picture it is left connected from previous use but is not used)
   2. Accessory cable (gold probe in this case) is attached to the bipolar socket in the diathermy box (ICC 200)
   3. Nothing goes in the cut/coag socket (the middle socket in the diathermy box- we just left the plug of the APC in from previous use but it is not needed)
   4. Cutting panel is not needed at all and the setting on the autocut panel is irrelevant and the yellow pedal should not be used.
   5. Chose Autocoag with bipolar effect (as opposed to soft or forced which we used before), power to 15-30W for visible vessels/ Dieulafoy lesion/ Mallory Weiss lesion
   6. Choose power to 10-15W for colonic bleed (AVM/ diverticular bleed)
3. Connect a saline filled syringe to the irrigation hub and inject water until water is visible at the distal tip of the probe
4. Test the probe before passing it through the endoscope by touching the tip to a 1-2ml of saline / KY jelly and depressing the footswitch to activate the probe tip- saline bubbles are to be seen and steam should be emitted
5. Adrenaline filled syringe (1:10000 dilution adrenaline) is attached to the injection hub and pull back on the injection hub until hub locks into position to ensure that the injection needle is completely retracted into the probe tip
6. Turn off the electrosurgical generator during the insertion of the Gold Probe
7. Advance the tip until the gold tip is endoscopically visible through the endoscope
8. For lesions in the duodenum sometime you might find resistance in passing the gold probe when it’s tip reaches tip of the scope- then straighten the scope as much as possible and try again.

To use the gold probe to inject adrenalin

1. After positioning the tip near the lesion – slowly push the injection hub to the catheter handle until full extension of the needle is visible (4-6mm)
   
   Picture4: Pushing the handle in makes the needle to come out of the sheath
2. Under typical endoscopic configurations the green band on the injection hub should be partially visible.
3. Under some very tortuous configurations the green band and/or the red band may be completely hidden. But never push the injection hub past the proximal end of the red band
4. Insert the extended needle into the selected site and inject 1:10000 dilution adrenaline in 2-3ml aliquots and then completely withdraw the needle once finished.
5. Remember the volume of the adrenaline solution is important to exert tamponade effect.

To use the gold probe for electrohaemostasis

1. Identify and position the endoscope proximal to the intended cautery site.
2. Advance the probe until perpendicular or tangential contact is made with the site. Good apposition of the tip to the tissue is important (co-aptive pressure)
3. Using the Blue foot pedal activate the tip to cauterize the site- 2-5secs
4. Irrigate with saline before detaching the tip from the burnt area to avoid sloughing of devitalized tissue.

Other types of thermal devices in use

A) Heater probe ( Unipolar) – Teflon coated hollow aluminium cylinder with inner heating coil- heats tissue directly

B) Bipolar (Multipolar) – generates heat indirectly by passage of electric current. Two electrodes in the tip complete a circuit through non-desiccated tissue.

Types

• HEMArrest- Bard interventional products
• Gold Probe- Microvasive, Boston Scientific
• BICAP- Circon Acmi
• Quick silver- Wilson-Cook Medical Inc.

Here is the link for Gold probe Video:

Acknowledgement/Bibliography:

1. Gustavo A et al. Thermal probes alone or with epinephrine for the endoscopic haemostasis of ulcer haemorrhage Best Practice & Research Clinical Gastroenterology June 2000 :14 (3): 443-458
2. Jensen DM et al.CURE multicenter randomized, prospective trial of gold probe vs. Injection & gold probe for hemostasis of bleeding peptic ulcers. Gastrointestinal Endoscopy 1997:Volume 45 (4), Page AB92
3. Arasaradnam RP et al.Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding Postgrad Med J. 2005;81:92-98
4. Product guide of the respective companies- Boston Scientific

1. When to use Histoacryl glue
2. What is Histoacryl glue
3. How to prepare the glue
4. How to actually use it once it is ready
5. What are the complications

When to use Histoacryl glue

It is used to inject in the gastric varix to achieve haemostasis in case of acute bleeding.

Gastric varix occur in 20% patients of portal hypertension and risk of gastric variceal bleeding varies from 55% to 78% with a bleeding related mortality rate of 45%

It is tissue glue and can be issued to glue cut surface e.g. small incised wound in place of steristrip.

What is Histoacryl glue

Histoacryl® is an acrylic resin (N-butyl-2-cyanoacrylate) which rapidly polymerises in the presence of water joining the bonded surfaces together. It is available in 0.5ml ampoule.

Picture1: Histoacryl® glue

It is diluted in Lipiodol as it does not affect polymerization of cyanoacrylate and allow imaging should it embolize in the rare event.

Picture2:The diluent Lipiodol ultrafluid 100%v/v

How to prepare the glue

1. Wear protective eye goggles and gloves.
2. Draw 1ml  of Lipiodol  in a 2ml Luer lock syringe ( Lipiodol comes in 10ml ampoule)
3. Use of Luer lock syringe is preferable as it is quite hard to push the glue through the injection needle and there is a chance that the syringe can come loose from the injection needle spraying the glue everywhere.
4. Before you snap open the tip of the Histoacryl ampoule hold it vertically and tap the narrowed tip so that the solution settles in the bottom
5. Next draw  the whole ampoule (0.5ml of Histoacryl® ) of glue in the same syringe  and  gently shake
6. The glue has to be freshly made immediately before the injection into the varix.
7. Keep acetone handy as it is only dissolvable in acetone.

How to actually use it once it is ready

1. Use Large channel gastroscope (3.7 or 6mm working channel)
2. Prime the injection needle with 2ml of Lipiodol (some centre uses saline) to prevent injection of air into the varices and also to prevent glue settling in the gastroscope. Some centres use saline only.
3. It is preferable to use bigger bore injection needle (19G) as the glue mixture is very viscous and very hard to inject. Some centre uses injector needle with metal body/sheath rather than plastic body/sheath
4. Keep few 2ml syringes ready loaded with water for injection and 2-3 of 2ml syringes ready loaded with the glue mix.
5. Glue injection is usually done in retroflexed view. Once the needle is in the varix inject the glue mix. Remember once the syringe is empty, all the glue is still sitting in the injector needle (volume of the glue mix is 1.5ml and injector needle volume is 1.5-2ml)
6. Follow immediately with 2ml of water for injection flush to drive the glue mix from the lumen of the injection needle into the varix.
7. Withdraw the needle from the varix and flush another 2ml of water into the gastric lumen before withdrawing the needle back into the sheath- to prevent any glue mix from being left in the needle and occluding the needle or gastroscope.
8. Do not wait for the glue to solidify in the varix and then withdraw the needle for the fear of the hole made by you hosing- that might cause the needle to stick – forceful removal will result in de-roofing of the varix.
9. Withdraw the needle from the varix while assistant keeps flushing saline after the whole glue mix has been injected.
10. In event of the needle getting stuck in the varix- simply withdraw the needle into the sheath- keep the sheath attached to the varix. Cut the needle outside the scope and withdraw the scope. Subsequent management is not clearly defined – but watchful expectancy would not be a bad idea!
11. After the glue is injected prevent any temptation to suction. It is better to remove the suction button to avoid inadvertent suction of glue in the suction channel.
12. Limit each injection to 1ml to prevent embolism but can be repeated to completely obliterate all the tributaries.
13. Obliteration of the varix can be checked by probing with the injection needle when obliterated varix will feel firm whereas normal varix will feel spongy.
14. Because of fear of injection needle sticking to the scope, some centres practice withdrawing the scope with the needle in situ and the cut the tip of the needle outside before withdrawing the needle out of the scope.
15. Reported initial haemostasis rate of 87% to 100% with rebleeding  rate ranging from 24% to 50%.

What are the complications

1. Complication associated with Histoacryl® injection are embolism, sepsis, fistula and adherence of the needle to the glue within the varix
2. Damage to the scope if glue settles down in the biopsy channel fixing the injection needle to it

Here is the link for Intravariceal Cyanoacrylate (Histoacryl ) injection video

Video 1

Video 2

References/ Acknowledgement

1. Seewald S et al: A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos): Volume68,No3:2008 Gastrointestinal Endoscop
2. Sohendra N et al: Endoscopic obliteration of large oesophagogastric varices with bucrylate.Endoscopy 1986: 18:25-6
3. Jalan R et al: UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut; 46 (suppl III)
4. Poole hospital protocol for treatment of gastric varices using Histoacryl® glue