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. 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

1. When to use endoclips
2. Different parts of the endoclip
3. How to set it up and fire the endoclip

When to use endoclips

1. Endoclip is a device commonly used to clip a bleeding vessel particularly in the context of a bleeding ulcer or a Dieulafoy lesion.
2. Other uses are to achieve haemostasis in bleeding from sphincterotomy and to stop bleeding from the base of a polyp after polypectomy.

Different parts of the endoclip

An Olympus QuickClip device has been shown, however the principles are the same for all types of endosclips. It comes both for upper GI and lower GI applications.

1. Starting with the tip/clip which is covered in a plastic sheath.
2. 

Picture1: The red stopper prevent the yellow slider to move so that the clip stays in side the sheath

2. Next is the handle with the yellow slider.

3.In between the two stays the red stopper

3. The thumb-rest ring
4. 
   Picture2: The yellow slider, red stopper and the firing handle
5. How to set it up and fire
6. This is mainly operated by the endoscopy nurse but you need to know the working of the endoclip.
7. Pass the tip of the endoclip which goes through the biopsy channel and make sure the red stopper is intact and the clip is retracted inside the sheath which is normally the case as you take it out of the packaging.
8. The red stopper prevents the clip coming out of the sheath accidentally.
9. When the endoscopist is in right position and ready to deploy the clip he will ask to open the clip. This is when you/assistant should remove the red stopper
10. Pull the yellow tube towards the slider and this would bring the clip out of the sheath.
11. 
    Picture3: The pulling of the yellow slider to the handle makes the clip to come out of sheath but it is not fully open to deploy yet
12. To get the clip in correct position the endoscopist might ask you to rotate the clip. Clip can be rotated by rotating the handle.
13. When everything is ready the endoscopist pushes the clip to the vessels and ask you to fire
14. Now before actually firing you will have to prime the clip
15. If you look carefully there is a waist at the bottom of the clip ( making the clip to look like X rather than V) and the clip in this stage is not completely open and there is less gripping power.
16. 
    Picture4: Olympus Quickclip: Courtesy Olympus
17. Before firing the waist need to vanish so that the clip is completely open and looks like letter V.
18. The same movement which fires the clip will get rid off the bottom waist but you have to be careful not to go all the way which than will fire the clip.
19. 
    Picture 5: Note that the bottom waist has vanished and clip looks like letter V
20. You will hear two distinct sound – the first faint click indicates the waist at the bottom is gone and the clip is ready to fire and the second louder click indicates that the clip has been fired.
21. Lastly fire by pulling the handle towards the thumb rest.

Picture 6: The firing grip and pull the handle towards the thumb-first click means the clip is primed and the second click means the clip is fired- second click is much louder and harder

Here is the link for Endoclip video:

1. Video 1
2. Video 2

Acknowledgement/Bibliography:

1. Tang SJ et al. Endoscopic hemostasis using endoclip in early gastrointestinal hemorrhage after gastric bypass surgery. Obesity surgery 2007; 17: 1261-1267
2. Ohta S et al. Hemostasis with endoscopic hemoclipping for severe gastrointestinal bleeding in critically ill patients. Am J Gastroenterol 1996;91:701-4.
3. Yoshikane H et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gastrointest Endosc 1997; 46:464-6.
4. Product guide of the respective companies- Olympus

1. When to use banding device
2. Grades of varix and stigmata of recent haemorrhage
3. How to actually use it once it is set up
4. How to set it up

When to use banding device

Oesophageal variceal banding is done urgently for haemostasis from a ruptured oesophageal varix and electively as secondary prophylaxis to eradicate the varices.

Sclerotherapy of varices with ethanolamine has fallen in disrepute and should not be attempted.

There is no role for banding for isolated gastric varices

How to actually use it once it is set up

1. The patients need to be optimally resuscitated prior to endoscopy. An actively bleeding patient may also need airway protection with endotracheal intubation prior to endoscopy and banding.
2. Mapping the varices-Get your bearing right on your way in first time  as with the banding device on it will be difficult to see second time
   
   Picture1: Courtesy www.gastrointestionalatlas.com
3. Describe in your report- position and grade of the varix and whether any stigmata of recent haemorrhage were there or not and the Rockall score at the end of the procedure
4. Remember to put the bands on the varices as close to the GOJ as possible but above the Z line to ensure proximal decompression. Don’t put bands on the GOJ or in a hiatal hernia. Don’t put bands higher up as varices fill from below ( bottom 3-5cm)
5. Put plenty of jelly on the tip but avoiding the inside of the banding device.
6. Go just above the  GOJ and suck the varix into the banding device. To do that you will have to make the tip of the scope perpendicular to the wall of the oesophagus. Use big/small wheel to achieve this. You may have to use the wheel lock. Make sure the varix  completely obliterates the field (‘the red out’).
7. To ensure good suction- set the pump pressure to high and make sure the barrel of the banding device is snugly fitted to the tip of the scope avoiding any gap which will diminish the suction.
   
   Picture2:One oesophageal varix banded successfully
8. Fire/release  the band by turning the knob clock wise (you will hear and feel a click of band release) – still keep sucking for another  5 seconds and then let go.
9. Similarly put more bands on other variceal columns
10. Prescribe antibiotics and the terlipressin if not already on
11. If intubed for the procedure, the patient can be extubated if stable and the bleeding is controlled
12. BSG recommends that after the index banding  each varix should be banded with a single band at weekly intervals until variceal eradication.
13. Following eradication follow up endoscopy should be performed at 3 months and 6 months and then yearly.

Grades of varix and stigmata of recent haemorrhage

Grade of varix

1. Grade I: barely noticeable varix (remember after a big bleed varix can collapse to Grade I)
2. Grade II: present but flattens on insufflations
3. Grade III: Varix up to 30% of the lumen ( most varices)
4. Grade IV: Varix up to 60% of the lumen
5. Grade V: Complete obliteration of the lumen by the varix

Stigmata of recent haemorrhage (SRH) :  Red spot/ Red Wale markings- Erythematous raised area on the varix indicating high risk of bleeding

How to set it up

We will describe two commonly used banding devices- Boston’s 7 shooters and Wilson-Cook’s 4/6/10 shooters.

Seven shooters – SpeedBand SuperView Super 7™ ( Boston Scientific)

1. Inside the pack you will find the ligator handle with the metal string attached to it, the barrel with the bands and the irrigation catheter.
   
   Picture3: The ligator handle with the metal string
2. Send the  wire of the handle through the biopsy  channel
   
   Picture4: The ligator handle from another side showing the fastening Velcro and white side port for irrigation
3. Insert the ligator handle into the biopsy channel by pushing the metallic end and fix by tightening the Velcro fasteners
   
   Picture5: The barrel with the bands with the attached thread
4. When the metal string of the ligator handle  comes out of the tip of the endoscope loop the string of the ligating device/barrel through it and then pull it from the top of the biopsy channel by turning the knob on the handle clockwise (it can only turn in one direction)
5. Stop turning when the barrel is close to the tip of the endoscope. Push the ligating barrel snugly (if not snugly fitted the barrel might come loose in the oesophagus once all the bands are fired) into the tip of the endoscope and keep the string taut by pulling the string from top and fixing it by passing it through the extended axle of the spool (white arrow in the picture)
6. When pushing the barrel into the tip of the scope- align the black mark of the barrel along the biopsy channel and remove the plastic covering (it has got a red ring on plastic) the barrel after that.
   
   Picture 6: Showing the attachment of the irrigation catheter
7. If needed irrigation catheter can be fitted to the white irrigation port on the handle
   
   Picture 7: Courtesy Boston Scientific
8. The ‘last but one band’ ( the sixth band in the seven shooters ) is white/yellow colour – rest are blue
9. The super 7 is now ready to be used

Six shooters- Wilson-Cook banding device (Saeed multiband ligator- 4/6/10 shooter)

1. Inside the pack you will find ligator handle, loading catheter, trigger cord with Opti-Vu barrel (with the bands on) and irrigation adaptor
   
   Picture 8: Diagram Courtesy Wilson-Cook Medical GI Endoscopy
2. First insert the ligator handle into the endoscope accessory channel- through the rubber biopsy channel cap. Make sure the handle is on two-way position and not firing position.
3. Introduce either end of the loading catheter through the white seal in the ligator- align the s-end of the loading catheter with the slit in the white seal of the introduction port. If you don’t align it is very difficult to push through.
4. Advance the catheter till it exits the tip of the endosocpe
5. Attach the trigger cord to the hook on the end of the loading catheter, leaving approximately 2 cm of trigger cord between the knot and the hook
6. Withdraw the loading catheter from above making the trigger cord to come out through white seal.
7. Then push the barrel containing the bands to the tip of the endoscope tip- avoid holding the actual bands. If you don’t push well- during sucking the varix into the barrel, suction won’t be optimum.
8. Also remember this barrel does not fit a therapeutic (salmon/red color coded scope) scope tip.
9. Next place the trigger cord in the slot on the spool of the ligator handle and pull down until the knot is seated in the hole of the slot. The knot must be seated into the hole for the handle to function properly.
10. With the handle in the two-way position, rotate the handle clockwise to wind the trigger cord onto the handle spool (do carefully as too much force might deploy a band)
11. With handle in the in the two way position, introduce the endoscope again
12. Then place the handle into firing position by pushing it inwards- it is marked on the handle ( see picture)
13. The 6 shooters is now ready to be used.
14. Irrigation can be done by inserting the irrigation adaptor into the white seal on the handle.

Here is the link for EVL  Video:

Acknowledgement/Bibliography:

1. Sarin SK et al. Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence. Journal of Hepatology 1997;26:4: 826-832
2. Stiegman GV et al. Endoscopic elastic band ligation for active variceal haemorrhage. Am Surg 1989;55(2):124-128
3. Sharara AI et al. Gastroesophageal variceal hemorrhage. N Engl J Med 2001; 345(9): 669-681
4. Product guide of the respective companies- Boston Scientific and Wilson-Cook