Since the beginning of the 1970s, flexible endoscopy of the gastrointestinal tract has been the dominant modality for the diagnosis of gastrointestinal disease. Over the same period, developments in technology and methodology have made possible the use of endoscopy to treat a host of conditions that once were considered to be manageable only by means of open surgical procedures. The integration of flexible endoscopic techniques into the armamentarium of the GI surgeon permits a more multidimensional approach to the treatment of digestive disease. The modern GI surgeon should be conversant in and adept at many of these procedures.

Diagnostic esophagogastroduodenoscopy (EGD) is indicated when a patient has abnormal findings on traditional GI x-ray series, dysphagia, odynophagia, epigastric pain that does not respond to medical therapy, persistent heartburn, or upper GI bleeding; it is also indicated for surveillance of patients at high risk for malignancy and for sampling of GI tissue or fluid. One prepares for the examination by ensuring the patient's hemodynamic stability, having the patient fast for 6 to 8 hours beforehand, and performing conscious sedation, which generally involves applying a topical anesthetic to the posterior pharynx and administering a narcotic and a benzodiazepine intravenously. Monitoring of arterial blood pressure and oxygen saturation throughout the procedure is now standard practice.

Technique

With the patient in the left lateral decubitus position, a topical anesthetic is applied to the posterior pharynx and an intravenous sedative administered. The forward-viewing panendoscope—a small-caliber instrument that is long enough to permit examination of the foregut from the mouth to the third portion of the duodenum—is employed.

Figure 1 - Diagnostic esophagogastroduodenoscopy

Complications

EGD is an extremely safe procedure. Perhaps the most common problems associated with the technique arise from the preparatory sedation and analgesia. Respiratory depression and aspiration may occur during the procedure. Careful attention must be paid to the patient's state of consciousness and airway during the endoscopic procedure, appropriate drugs must be available to reverse sedative effects, and a suction apparatus must be ready for use at all times. Blind advancement of the endoscope by force may lead to perforation of the esophagus; this problem may be avoided by taking care never to advance the instrument against resistance.

Control of Variceal Hemorrhage

In patients with massive upper GI hemorrhage, the first priorities are to establish a secure airway and to ensure hemodynamic stability. These priorities must be addressed before endoscopy is attempted. If the bleeding is thought to be coming from esophageal varices, it is frequently useful to perform endotracheal intubation for control of the airway before the endoscopic intervention.

Technique

A rapid but complete diagnostic upper GI endoscopic procedure is performed to determine whether varices are present and to identify the exact site of hemorrhage. Endoscopic therapy for variceal disease is then delivered by means of either sclerotherapy or rubber band ligation.

Sclerotherapy is commenced in the distal esophagus at the site of active or suspected bleeding: 2 to 3 ml of a sclerosant solution (e.g., sodium tetradecyl sulfate) is injected directly into the lumen of the varix. Additional varices can be treated in the same fashion. After the bleeding has stopped, further therapy is usually delivered at weekly intervals until total variceal obliteration is achieved.

Figure 2 - Therapeutic esophagogastroduodenoscopy: control of variceal hemorrhage

Control of Nonvariceal Hemorrhage

Bleeding from peptic ulcer disease, gastritis, or vascular malformations is a common indication for EGD. Once the patient has been adequately resuscitated, endoscopy should be performed, and the entire esophagus, stomach, and duodenum should be examined thoroughly. Before the procedure is begun, the stomach should be vigorously irrigated through a large-bore tube so that as much clotted blood as possible can be evacuated. If a pool of blood is noted in the stomach, the position of the patient should be changed so as to move the pool and permit complete examination of the stomach.

The therapeutic modalities available for control of nonvariceal bleeding include (1) the injection of hypertonic saline, epinephrine (in a 1:10,000 solution), or 98% alcohol, (2) bipolar electrocoagulation, (3) the use of heater probes, (4) argon beam coagulation, (5) the application of acrylic glue, (6) the application of hemostatic clips, and (7) the use of the neodynium:yttrium-aluminum-garnet (Nd:YAG) laser.

Technique

The most popular therapeutic modalities are injection therapy, bipolar coagulation, and the use of the heater probe. Injection therapy is performed around the bleeding lesion to create edema and vasospasm in the area. The bipolar coagulator or the heater probe is applied directly to the bleeding lesion in an attempt to coapt the bleeding vessel as heat is delivered. Frequently, injection therapy is employed in conjunction with coagulation; this combination is very effective.

If there is a clot covering the ulcer base, it must be removed with suction or a snare before coagulation is attempted. If a rapidly bleeding lesion is present, the best approach often is injection therapy in adjacent areas to slow or stop the bleeding, followed by coagulation by direct coaptation. Vascular lesions are often multiple or diffuse, as in so-called watermelon stomach. Such lesions are most effectively treated by means of modalities that can be applied in a spraying fashion, such as the Nd:YAG laser or the argon beam coagulator.

Complications

Nonvariceal hemorrhage is successfully controlled by endoscopic means in more than 90% of cases. At times, however, attempts at endoscopic control may exacerbate the bleeding. Several therapeutic modalities should always be available: one may succeed when another fails. Excessive injection therapy or persistent attempts at coagulation may lead to tissue necrosis and subsequent perforation. Although the argon beam coagulator can injure tissue only to a depth of several millimeters, excessive application may result in massive distention of the bowel if care is not taken to aspirate the constantly infused argon gas frequently. The Nd:YAG laser has the potential to cause full-thickness injury to the gastric wall.

Dilation of Esophageal Strictures

When patients complain of dysphagia or odynophagia, prompt endoscopic investigation is warranted. Strictures may be secondary to reflux disease, secondary to caustic burns, or of neoplastic origin.

Technique

Endoscopy is performed in the usual fashion. It is imperative that the endoscope be advanced only under direct vision. When a stricture is encountered, its location, morphology, and length should be determined. Biopsy and cytology specimens should be gathered from the circumference of the stricture. When a stricture is present at the esophagogastric junction and the scope can easily be passed by the stricture, it is helpful to view the area from below with the tip of the scope retroflexed.

Figure 3a - Therapeutic esophagogastroduodenoscopy: balloon inflation

Figure 3b - Therapeutic esophagogastroduodenoscopy: complete dilation

Stenting of Esophageal Tumors

Under optimal circumstances, esophageal tumors should be treated by means of extirpative surgery. When surgical cure or palliation seems to have little to offer, placement of an esophageal prosthesis by endoscopic means is a reasonable approach.

Technique

Figure 4a - Therapeutic esophagogastroduodenoscopy: stenting of esophageal tumors

Figure 4b - After stent insertion

Retrieval of Foreign Bodies

Many ingested foreign bodies pass through the GI tract uneventfully, but a good number must be removed by endoscopic means—in particular, foreign bodies in the esophagus, sharp objects that are likely to perforate the bowel, and objects that do not progress from the stomach.

If the ingested object is of an unfamiliar type, it is an extremely good idea to practice with a similar object outside the patient before attempting endoscopic retrieval. This preparatory step allows one to select the most appropriate accessory and technique for removing the object.

Technique

Objects with sharp edges should be removed with the sharp end trailing to prevent perforation. In some cases, this means that the object must be pushed into the stomach and turned around before being removed. If multiple foreign bodies are present or if it is highly likely that the foreign body will injure the esophagus if removed in the standard manner, an overtube should be placed over the scope before insertion. The overtube enables one to pass the instrument several times and retrieve any sharp objects without injuring the esophagus; it also helps ensure that the object is not aspirated into the airway. If the patient is a child, general anesthesia may be advisable.

Perhaps the best method of removing foreign bodies is to surround them with a simple polypectomy snare and secure them in the endoscope's grasp. Meat boluses that form in the esophagus or proximal to a gastric band may be extremely difficult to dislodge; the use of a variceal ligator cap to produce a suction chamber can be helpful in such situations.

Complications

Endoscopic removal of foreign bodies is extremely safe and effective. Care must be taken to ensure that the esophagus is not injured during removal of the object. If the object is deeply embedded or refractory to removal, a surgical approach is preferred.

Percutaneous Endoscopic Gastrostomy

Since 1980, endoscopically guided placement of a tube gastrostomy has been widely employed to provide access to the GI tract for feeding or decompression. Indications for percutaneous endoscopic gastrostomy (PEG) include various disease processes that interfere with swallowing, such as severe neurologic impairment, oropharyngeal tumors, and facial trauma. PEG has also been employed to establish a route for recycling bile in patients with malignant biliary obstruction, to provide supplemental feeding in selected patients with inflammatory bowel disease, and to accomplish gastric decompression in patients with conditions such as carcinomatosis, radiation enteritis, and diabetic gastropathy.

Technique

The patient fasts for 8 hours beforehand, and a single prophylactic dose of an antibiotic is administered just before the procedure is begun. The patient is placed in the supine position, a topical anesthetic is applied to the posterior pharynx, and intravenous sedation is begun. A forward-viewing endoscope is passed into the esophagus and advanced into the stomach. The abdomen is prepared in a sterile fashion and draped. The stomach and the duodenum are then inspected.

Figure 5 - Therapeutic esophagogastroduodenoscopy: percutaneous endoscopic gastrostomy

Figure 6 - Percutaneous endoscopic gastrostomy, Part 2

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced procedure that is technically more challenging than standard upper GI endoscopy; however, it can be mastered by most endoscopists who are willing to dedicate sufficient time to learning the method. ERCP yields a radiologic image of the pancreatic and biliary trees, and in many cases, it provides access for therapy. Indications for ERCP include suspected benign or malignant maladies of the common bile duct (CBD), the ampulla of Vater, or the pancreas. Cholelithiasis per se is not an indication for ERCP unless choledocholithiasis is suspected.

Technique

As with standard upper GI endoscopy, the patient fasts for 6 to 8 hours beforehand. Intravenous sedation is administered, and prophylactic antibiotics are given when biliary obstruction is suspected. The patient is initially placed in the left lateral decubitus position but is later rotated to the prone position after the scope is in place in the second portion of the duodenum. A side-viewing endoscope is employed because it allows the best visualization of the ampulla of Vater. The instrument is passed into the esophagus and maneuvered through the stomach, across the pylorus, and into the duodenum. Manipulation of a side-viewing instrument is a bit awkward for the novice but is easily learned.

Figure 7a - Diagnostic endoscopic retrograde cholangiopancreatography: short scope position

Figure 7b - Diagnostic endoscopic retrograde cholangiopancreatography: long scope position

Complications

When contrast material is being injected into the pancreatic ductal system, care must be taken to avoid overfilling, which can lead to acinarization, or rupture of the small ductules, with extravasation of contrast material into the pancreatic parenchyma; pancreatitis is a frequent consequence of acinarization. Cholangitis may result when contrast is injected proximal to an obstruction of the biliary tree. When obstruction is demonstrated, drainage of the system by means of stone extraction, stenting, or nasobiliary intubation is important to prevent cholangitis.

Technique

Figure 9 - Therapeutic endoscopic retrograde cholangiopancreatography

Complications

Perforation can occur during endoscopic sphincterotomy as a result of extension or tearing of the papilla beyond the junction of the CBD with the duodenal wall. Retroperitoneal or free intraperitoneal air may be seen. In many cases, intravenous antibiotics, hydration, and avoidance of oral intake are sufficient to manage such complications. If the patient's condition deteriorates, surgical exploration is indicated.

Bleeding may also occur with sphincterotomy. It is usually controllable with injection of epinephrine solution (1:10,000), electrocoagulation, or balloon tamponade. Arteriographic embolization of the gastroduodenal artery may be helpful in some cases. As with diagnostic ERCP, pancreatitis may occur; it usually responds to conservative measures.

Colonoscopy has become one of the most frequently performed endoscopic examinations. It has revolutionized the diagnosis and treatment of colonic disease and offers the promise of reducing the occurrence of colon cancer. Indications for colonoscopy include iron deficiency anemia, frank or occult rectal bleeding, a history of colonic cancer in the patient or in first-degree family members, a history or suspicion of colonic polyps, inflammatory bowel disease, and a persistent change in bowel habits. Preparation involves purging the bowel mechanically by placing the patient on a clear liquid diet for several days, then giving cathartics and enemas; alternatively, one may use osmotic lavage, in which 1 gal of lavage fluid is administered orally over a period of 4 hours. It is often helpful to administer 10 mg of metoclopramide to enhance gastric motility as preparation begins.

Technique

Sedation is accomplished as for upper GI endoscopy, and the patient fasts for 6 to 8 hours before the procedure. With the patient in the left lateral decubitus position, a rectal examination is performed. This step helps relax the anal sphincter in preparation for insertion of the scope and ensures that low-lying rectal lesions are not overlooked.

The colonoscope is introduced into the rectal vault, and insufflation of air is commenced. The instrument is advanced only when the lumen is clearly apparent. At times, only a portion of the lumen may be visible, but this is usually enough to guide advancement of the scope. Frequently, when the lumen itself is not visible, light reflected onto the colonic folds can guide one to the lumen, with the concavity of the fold indicating the direction of the lumen. In contrast with upper GI endoscopy, in which torsion on the shaft of the endoscope is rarely necessary, such torsion is the rule in colonoscopy. The shaft of the instrument is rotated with the right hand to facilitate straightening and intubation of the colon. By applying torsion to the shaft frequently and pulling back the scope as necessary, one can pleat the colon on the instrument as it is advanced. Pulling back is one of the most useful techniques for advancing the colonoscope through the colon.

The colon exhibits a number of characteristic anatomic features that are readily observed during colonoscopy. The sigmoid colon, because of its frequent turns, yields elliptical views of the lumen. The descending colon appears as a long, round tunnel with little haustration. The transverse colon has well-defined triangular folds, and the hepatic flexure may exhibit a blue hue resulting from the proximity of the liver. The cecum is recognized on the basis of the appearance of the ileocecal valve on the lateral wall, the convergence of the colonic taenia to form the cecal strap (the so-called Mercedes sign), and the presence of the appendiceal orifice.

Insertion of the colonoscope as far as the hepatic flexure is rarely difficult. Occasionally, the sigmoid colon presents a challenge, in which case placement of the patient on the back or the abdomen to change the orientation may be helpful. Once again, pulling back and straightening the scope is a highly useful maneuver. Once the scope is in the hepatic flexure looking down the right colon, pulling back, counterclockwise torsion, and the application of suction may all assist in advancing the instrument into the cecum. Changing the patient's position or applying pressure to various points in the abdomen may also be helpful. Once the cecum is reached, the instrument is slowly withdrawn while the colonic parietes are carefully examined. Biopsy and cytologic brushing may be done as appropriate, and colonic contents may be aspirated into a suction trap for examination.

Complications

Perforation is the most common complication of diagnostic colonoscopy. It may result from direct tip pressure, bowing of the shaft of the scope while a large loop is being formed, blowout of a diverticulum secondary to air insufflation, or tearing of an adhesion of the colon to an adjacent structure. The risk of perforation can be minimized by observing the lumen directly as the scope is advanced, avoiding excessive insufflation, and minimizing loop formation. Close attention to patient discomfort is important. If the patient feels poorly after the procedure, an upright chest x-ray, an upright abdominal x-ray, or a lateral decubitus abdominal x-ray should be obtained to determine whether there is any free air, which would indicate a perforation. Such situations have been successfully managed by nonoperative means in some cases, but in most cases, prompt operative intervention with primary repair of the perforation is the best approach.

By far the most common use of therapeutic colonoscopy is for the excision of polyps. Other applications include control of bleeding, dilation of strictures, and placement of enteral stents.

Technique

Figure 12 - Therapeutic colonoscopy: removal of pedunculated polyp

Figure 13 - Therapeutic colonoscopy: excision of sessile polyp

Complications

Perforation may occur as a result of transmural thermal injury during polypectomy. Some perforations are immediately apparent, but others may not be noticed for several days. When perforation is documented, surgical exploration is indicated. Occasionally, a patient may present with fever and abdominal tenderness several days after polypectomy but show no free air on abdominal films. Such a patient may have a thermal injury to the bowel wall or so-called postpolypectomy syndrome and can usually be treated with intravenous fluids, antibiotics, and observation. Bleeding from the stalk of a pedunculated polyp may occur after excision; it may present immediately or may be delayed until the coagulum on the stalk separates 3 to 5 days after polypectomy. Such bleeding is a rare occurrence. When it does occur, it can be treated by injecting epinephrine solution (1:10,000) into the stalk.

The development of extirpative endoscopy has allowed physicians to treat several conditions that previously required open or laparoscopic surgical procedures. However, it is not always possible to see the difference between diseased and healthy tissue on endoscopy, and this limitation has precluded one-stage procedures. Identification of tissue types required biopsy, and lesion margins were impossible to determine at the time of the procedure.

Endoscopic polypectomy marked the beginning of extirpative procedures. Subsequently, endoscopic resection techniques have continued to advance, as a result of improvements in imaging and instrumentation, along with the development of chromoendoscopy and specific techniques designed as adjuncts to tissue removal. One such technique is endoscopic mucosal resection (EMR).

EMR has its basis in the anatomy of the GI tract. Histologically, the GI tract has three layers: a superficial mucosal, a middle submucosal, and an outer muscular layer. EMR is designed to help the endoscopist remove superficial mucosal tissue while leaving the deeper submucosal and muscular layers intact. These layers can be relatively easily separated from each other by injecting a liquid that spreads within the plane of injection. This step elevates the layers superficial to the injection, thus facilitating the resection of those layers. Advantages over other resection techniques include the preservation of histologic architecture (in contrast to electrocautery or laser ablation), which allows improved pathologic assessment; the ease with which EMR can be combined with endoscopic ultrasonography; and its safety and minimal invasiveness.

EMR was first described in 1955, when submucosal saline injections through a rigid sigmoidoscope were used in the resection of rectal and sigmoid polyps. In 1973, a submucosal saline injection was employed to assist with the removal of sessile polyps throughout the colon. Additional development was accomplished in Japan in 1983, when mucosal resection was used in the treatment of early gastric carcinoma in a technique termed strip-off biopsy. The technique has been refined and is now routinely used for lesions in the esophagus, stomach, duodenum, colon, and rectum. It is widely incorporated into aggressive screening programs designed to detect early GI cancers.

EMR can be used to treat dysplastic and other premalignant lesions, as well as superficial cancers of the GI tract. One must be careful to comply with all standard principles of cancer resection, including knowledge of the depth of the lesion, its radial extent, and staging. Consequently, several criteria must be fulfilled before EMR can be viewed as a curative intervention. Classification of lesions on the basis of their endoscopic appearance can be combined with information obtained through the use of chromoendoscopy and EUS to determine the potential for EMR.

Lesion location within the GI tract is important with respect to long-term outcomes. For example, EMR can be used to treat circumferential colonic lesions but is inappropriate for esophageal lesions that extend beyond one third of the circumference, because of the risk of a late stricture.

Although specific methods differ among practitioners, several generalizations about the technical aspects can be made. First, a liquid must be injected deep to the mucosal layer, allowing separation of the wall components. Although the ideal solution for injection has not been determined, the liquid chosen must be biodegradable, biocompatible, noninflammatory, and have viscoelastic properties allowing the development of an adequate bleb. Saline, hypertonic saline, epinephrine, hyaluronic acid, and glycerol solutions are all in current use. The elevated tissue is then held in place with a grasper or suction mechanism, and snares, needle knives, or lasers are used to cut the tissue at its base. Optimal results are obtained on nonulcerated lesions that are less than 2 cm after elevation; other lesions have a high probability of submucosal lymphatic and vascular invasion.

Although complications can occur, with proper patient selection and procedural refinement they are relatively rare. Perforation has been noted, particularly when submucosal bleb formation is suboptimal. Inadequate blebs may result from insufficient liquid being injected, improper needle depth, or severe scarring of the local tissues. Bleeding has been reported to occur in 1.6% of EMR cases. This complication is relatively easily handled with a combination of electrocautery and epinephrine injection. Infection in the absence of perforation is uncommon.

Overall, EMR provides a minimally invasive means to treat early cancers in favorable locations. Patients must understand that additional resection may be required if histopathologic assessment does not show curative margins. Future development of endoscopic instruments and injection liquids will likely broaden the applicability of the procedure.

The 1980s saw the introduction of EUS. Extracavitary ultrasonographic methods have been hampered by the presence of air within the GI tract, which precludes high-resolution imaging. Consequently, they had been relegated to gross estimates of disease and detection of displacement of other tissues or fluid accumulation proximal to stenoses, such as ductal dilation in patients with common bile duct stones.

Three advances have proved invaluable in allowing EUS to carve out a niche in the field of GI diagnosis. First is the improvement in endoscopes that allows transducer and receiver channels to traverse a tortuous path. Second is the development of multiple frequency options in conjunction with circumferential visualization. Higher frequencies provide higher resolutions, allowing useful differentiation of the various layers of the intestinal tract. Third is the evolution of treatment protocols keyed to the accurate staging of tumors—information that is sometimes unobtainable from other imaging techniques.

This technology has now been firmly established as an accurate way to identify carcinoma. Subsequent developments are allowing EUS to expand from the field of diagnosis into the realm of intervention. Examples of EUS-guided procedures include fine-needle aspiration, lymph node sampling, and drainage of pancreatic pseudocysts.

EUS devices come in both linear and radial transducers. Radial transducers have the advantage of providing circumferential visualization that parallels the standard modes of perceiving the GI tract. Linear images allow EUS-directed biopsies, and have the potential to provide color and pulsed Doppler imaging. Probes can be mounted on the top of an oblique viewing fiberoptic scope, or come in an over-the-wire format for use in the pancreaticobiliary tree. A series of frequencies is available, with the higher frequencies providing greater resolution but less tissue depth penetration. Lower-frequency probes allow deeper tissue assessment and a broader view, but at the price of reduced resolution. Nevertheless, any form of EUS will provide better resolution than transcutaneous ultrasonography, allowing markedly improved two-point discrimination and hence more accurate tissue diagnosis.

The benefits of accurate staging of GI tumors paved the way for EUS development. Tissue sampling techniques are further benefited by this technology. The sensitivity of EUS makes it one of the best modalities for the evaluation and detection of pancreatic tumors. Its sensitivity, which is in excess of 95%, contrasts favorably with those of other modalities, including ultrasonography (75%), computed tomography (80%), and angiography (89%). The accuracy of T staging by EUS in esophageal cancer (80% to 90%) is greater than that of staging determined by CT scanning (50% to 60%). This finding has led to the development of several staging schemes that are based solely on EUS findings. EUS has established a role in the identification of early pancreatitis; the detection of common bile duct stones and mediastinal masses; and the assessment of anastomotic strictures, thickened gastric folds, and the integrity of the anal sphincter. It has also proved a useful adjunct in the determination of whether a tumor is amenable to EMR techniques or is better served by adjuvant therapies or surgical interventions.

The sensitivity of EUS is rooted in its ability to delineate the various layers of the alimentary canal. Experienced endoscopists can easily evaluate the submucosa and differentiate intramural from extrinsic masses. Characteristic patterns are readily learned and rapidly recognized, obviating tissue diagnoses in straightforward cases. Criteria have also been established to aid in the differentiation of benign and malignant lesions. With the continued use of this technique, additional algorithms will be established in conjunction with more innovative interventional adjuncts. However, two limitations have caused many practitioners to remain skeptical: cost and training issues. Other imaging modalities, such as CT and magnetic resonance imaging, have also made tremendous strides in the recent past. Although these various modalities are often considered competitors—a view arising from the perceived need for a single imaging modality—the issue of which is superior to the others pales in comparison to the benefits that can be gained from combining imaging techniques in appropriate circumstances.

The ability to suture through an endoscope would open up an entire arena of new possibilities, including antireflux procedures, morbid obesity surgery, and advances in the control of acute hemorrhage, as well as improved ability to manage complications of other endoscopic techniques. Despite the development and commercial availability of numerous devices, however, design problems have relegated most applications to investigational status. For such devices to enter clinical practice, they must encompass fundamental surgical techniques: the ability to cut, suture, tie knots, and staple. These are critical for maintaining hemostasis and constructing durable anastomoses. Although these techniques are plausible with modern devices, continued innovation and experience in conjunction with a new paradigm of disease management will direct the future of endoscopic interventions.

A new area of endoscopic exploration is emerging-namely, the performance of intraperitoneal surgical procedures by means of a flexible endoscope passed through the wall of a gastrointestinal viscus. This approach, referred to as natural orifice transvisceral endoscopic surgery (NOTES), is still investigational, but it has generated a great deal of excitement in the surgical and gastroenterologic communities. Transgastric gastrojejunostomy, liver biopsy, tubal ligation, and splenectomy in a porcine model have been reported. In addition, there have been anecdotal reports and presentations of natural orifice transvisceral appendectomy in human beings in India; however, to date, there have been no published cases. Extensive laboratory investigation and clinical trials will have to be carried out before the true utility and safety of NOTES can be established.

Figures 2, 4a, 4b, 4c, 5, 6, 9, 12, 13 Tom Moore.