0:00

So for our second case, I've loaded up a, another case

0:04

with the, uh, the primary three D workflow here.

0:08

And I'm gonna show you how I like to read, uh,

0:10

with a primary three D setup.

0:12

So basically I have the three, uh,

0:14

multiplanar reformat set up here on the left side,

0:16

your axial image, a coronal reformat, and a sagal reformat.

0:20

Again, starting at the anus and flying through to the cecum.

0:24

And then we're gonna turn around and fly back.

0:26

So with the primary three D read, instead

0:28

of looking at the two D images

0:30

and scrolling through the two D images, looking for a uh,

0:33

polyp, we're gonna do the same thing,

0:34

but with a fly through on the three d fly through here.

0:37

Um, there's a colon map here in the corner here,

0:40

which you can, uh, use as your roadmap to try to figure out

0:44

where you are in the colon.

0:45

Uh, we're better able than the gastroenterologists are in

0:49

figuring out where we are

0:50

and in which segment of the colon we are.

0:52

'cause oftentimes when the endoscope is inside the colon,

0:54

they don't know which segment they're exactly in,

0:58

especially, uh, the more torturous the colon is.

1:00

They don't know which flexor is the splenic flexor

1:03

and which flexor is the, the hepatic flexure.

1:06

With our colon map here, we're much better able to tell

1:09

where we are in the colon

1:12

and the colon map, when you make any findings

1:14

and you tag any findings, they show up

1:16

as a nice annotation on this image as well.

1:18

So I like to save these images to packs to show the

1:22

endoscopist where a finding that we make is.

1:26

So that's our map. And then our primary

1:28

three D area is here.

1:29

Some packages will also have another other alternate three D

1:33

views of the colon.

1:34

In this case, this is a, uh, a filet view.

1:37

When we get further up in the colon, I'll show you

1:39

what the typical appearance of the filet view is,

1:41

but there's quite a bit of, um,

1:43

image distortion inherent in this method

1:46

of looking at the colon,

1:47

but it can potentially, um, accelerate your read if you know

1:51

how to read through the, um,

1:52

image distortion inherent in this image.

1:56

So I start here and I fly through from the anus,

2:03

and then initially you fly retrograde through the colon

2:05

and I'm, we're flying along the barrel

2:07

of our rectal catheter here.

2:09

If you wanna see the rectal catheter showing you,

2:12

this is the rectal catheter

2:16

and this is the a**l verge looking back at the back

2:19

of the colon in the a**l verge.

2:21

This is the, the, the tip of the, um, the catheter here.

2:28

And on the fly through, we're looking for any bumps.

2:31

And so here it's,

2:32

I think I find it less fatiguing looking at these images

2:35

than the two D images

2:36

because it's a lot easier to tell what a fold looks like.

2:40

And, uh, it's easier to differentiate a,

2:43

a polyp from these folds.

2:44

But you do have the two D views here to, um,

2:47

correlate a finding that you make on the three D views, just

2:50

to make sure that what you're seeing is not polyps.

2:53

For example, this little dizel here,

2:55

it's small than six millimeters,

2:56

so I wouldn't have even bothered with looking at it,

2:59

but you can tell here on the, on the two D views

3:01

that it's denser than soft tissue.

3:03

It's contrast attenuation.

3:05

So that's just a little tight piece of stool

3:08

and I keep going through in this direction

3:10

until I reach the cecum.

3:12

And then the goal is to flood, to turn around

3:14

and fly back towards the anus.

3:16

So usually we set up 120 degree field of view on the

3:21

endoluminal camera here,

3:23

and you can set that in your options,

3:25

depending on your software package.

3:27

You can set the angle viewing angle here.

3:29

The, the wider the angle, the more of the, um,

3:32

mucosa you're going to be able to see on each fly through.

3:35

And you, you can see on this particular package,

3:37

you can go all the way to 360 degrees

3:39

and have a 360 degree field of view.

3:41

But again, there, there can be quite a bit

3:44

of distortion inherent in that.

3:45

For example, here, this is

3:47

what a 360 degree camera looks like,

3:49

not physically possible, but through the magic of software.

3:53

You can do it and you can see backwards over here,

3:56

but you can see how the image gets, uh,

3:58

very fish eye distorted.

4:00

So our recommended field of view is 120 degrees

4:03

for the most comfort in terms of the fly through,

4:05

but it does require flying through in both directions

4:08

to be able to see both sides of a house drill fold.

4:11

'cause it, for example, if you're flying

4:12

through it may not be seeing the backside

4:14

of each halal fold quite as well, uh, as if you fly forward

4:18

and backwards in both directions.

4:20

So right now we're in the transverse colon.

4:21

You can appreciate also the typical architecture

4:24

of the colon with our three haru folds,

4:27

these three arcades of halal folds.

4:29

And in some cases you can even see the tenia coli

4:31

between the, the sru folds here, for example,

4:33

here's a nice tenia coli between each of the three sets

4:37

of the sru folds

4:40

and the colon map is showing you with

4:43

that purple arrow here, where the camera is

4:46

and where we are in the transverse colon.

4:49

So we're getting towards the ascending colon

4:52

where you can already see

4:53

that I marked a finding in advance.

4:56

So here's our hepatic flexor.

4:58

You can still see our gas fluid level here.

5:01

And then we're seeing something

5:02

that doesn't look like a hostl fold in the ascending colon.

5:07

And I'm gonna delete the measurement here

5:09

because it's obviously an under measurement.

5:11

You see this mass here.

5:13

And then the question I guess is in the ascending colon SQL

5:16

area, is it an ileocecal valve

5:19

or is it not an ileocecal valve?

5:22

And there are multiple of these, um,

5:25

abnormal looking halal folds here.

5:27

So once we've found this area,

5:29

and then here's our, our orifice.

5:31

Again, we know we're in the cecum

5:33

and this is what the appendiceal orifice

5:35

looks like on the two D views.

5:36

So you're confirming that that's the appendix here.

5:39

We're also looking at what the rest

5:40

of the ascending colon looks like here,

5:42

and it's going into soft tissue windows.

5:44

And you can see what these folds look like

5:48

on two D.

5:49

You can see there's definitely some masses

5:51

and hostile full thickening

5:53

and luminal narrowing in the ascending colon here.

5:57

Another plane that appreciate

5:58

that on would be the coronal images here.

6:01

So you can see if this is your appendiceal orifice,

6:06

we can see where the ileocecal valve is.

6:08

It's actually this fold right here.

6:11

And on the three DV you can see the typical appearance.

6:13

This is a, a fairly classic appearance

6:15

of the ileocecal valve, which tells me

6:18

that nobody has more than one iacuc valve.

6:21

So everything else out here is not ileocecal valve.

6:24

It's this anular constricting mass

6:26

in the ascending colon just above the level

6:28

of the ileocecal valve.

6:30

And remi, remember

6:31

that the ileocecal valve divides the cecum

6:34

from the ascending colon.

6:35

So this, if this is located antegrade, uh,

6:39

downstream from the ileocecal valve,

6:41

it's located in the ascending colon.

6:43

So we've got a, an ugly looking mass here

6:47

in the ascending colon.

6:49

Another way to look at this is, um, you can go

6:53

to something called a cube view, which kind of renders the,

6:56

the mass in a cube.

6:59

So on the outside view here, you can see the, what the, um,

7:02

the outside of the colon looks like.

7:03

You can see that anular constriction here in the

7:05

outside wall of the colon.

7:07

So this is the view that the end apic definitely cannot get.

7:10

And then again, the view from

7:13

inside the colonic lumen there.

7:15

So we've got a mass here

7:16

that's clearly measuring more than 10 millimeters.

7:19

In fact, it's probably measuring more than three

7:21

or four centimeters in size even.

7:23

So this would be something that we would, um,

7:25

clearly be very suspicious about a malignancy in.

7:29

And we'd call this AC four finding for a colonic mass.

7:33

This patient ended up go getting sent

7:35

to a colonoscopic biopsy where it was confirmed

7:39

that we were dealing with a cancer.

7:40

And in fact, a management option that that's acceptable

7:43

for AC four is a direct referral to a colorectal surgeon.

7:48

Um, because our confidence is pretty high

7:49

that you are dealing with a neoplasm here, regardless of

7:52

what the histology is.

7:54

More often than not, they want the histology prior

7:56

to planning for a right hemi colectomy.

7:58

But at the time of a hemi colectomy,

8:00

this ended up being AT three and one b uh, adenocarcinoma.

8:06

So this is an example of a, of a colon cancer on three D.

8:09

But just to finish the three D approach,

8:12

basically once we reach the cecum, we turn around

8:15

and we fly back towards the anus.

8:18

And this gives you a chance to look at the backsides

8:20

of all the housel folds, uh, on the way back

8:23

to the, uh, a**l verge.

8:25

Once I do that for the supine views, then I switch

8:28

to the prone images and do the exact same thing from

8:33

a**l verge to cecum starting at the anus flying through.

8:39

And I'll do this in a much faster than I usually would in

8:42

the interest of time to show you the, the primary three D

8:46

method from start to finish.

8:47

And again, you could see that mass in the ascending colon

8:49

there, and then it, you turn

8:51

around in the cecum and you fly back.

8:55

You can control the speed of

8:56

how quickly you're flying back through the colon

9:00

and when you reach the anus.

9:01

Then the one last thing that I do do

9:03

with a primary three D method is since I'm not

9:06

electronically subtracting any fluid that's present,

9:10

I'll look one last time on the two D views,

9:12

just mainly focusing on the, the contrast levels

9:15

to make sure that I'm not missing a polyp

9:18

that's submerged on one view or the other view,

9:21

or rarely it can be submerged on both views.

9:24

If there's an up of a twist of the colon between the supine

9:27

and the prone in, uh, positions

9:29

where the polyp could theoretically still be, um, submerged

9:33

and gravity dependent in both locations,

9:35

especially if it's a polyp on a long stock that tends

9:38

to flop around, uh, where the head of the stock may flop

9:41

around dependently, uh, in, in both positions.

9:45

And then I'm done with the, um, looking at the colon.

9:49

Keep in mind the, the, you have the rest of the, um,

9:52

the abdomen on these images as well.

9:55

So one thing I do like to do, you, you want

9:57

to also make sure that you're not

9:59

finding any clinically relevant extra colonic findings.

10:04

So the other half of the crad s uh, system includes, uh,

10:07

an eCore for extra findings.

10:11

Again, E one would be normal.

10:14

E two is what we call a a finding that's clearly benign

10:19

or not worth working up, for example, like a renal cyst.

10:22

And then the next crad, um, version

10:25

that's coming out imminently, we're combining C one

10:28

and CT together into the same category in effect.

10:31

AC three would be a finding that's incomplete, characterized

10:34

and may require workup.

10:35

For example, a hyperdense renal cyst

10:38

or something that's, uh, not clearly defined, but um,

10:42

but could be further evaluated

10:44

with a contrast enhanced study, for example, CT or MRI.

10:47

And then an E four is a clinically relevant, uh,

10:50

potentially urgent finding like AA

10:53

or, um, liver metastases for example.

10:56

So that's the, the e portion of the, uh, CRAD system.

11:00

So that's the primary three D read.