All right, so let's go ahead and move on to our ESD demonstration. So we'll also do that in the stomach. And let's start with just one knife, there's no particular knife, we'll show several different ones here today. And I think once I mentioned about the samurai swords and snares, well, ESD knives are very similar. So you'll see everyone with their own knife or two knives and why they use this one or that one. If you're going to adopt ESD in practice, I think you'll end up seeing that basically everyone ends up finding the one knife or the two knives that work for them. And that becomes their go to tools for the procedure. All right, so as we start with ESD, once again, first step submucosal injection. And so here what we're using, we're using a device that has basically an ability to have a knife and inject with it a little bit at the same time. This is a dual knife. I'm just gonna flip my foot pedal. Yeah, go ahead. Need a hand or you got it? If you can hold that, no problem. Thank you. No problem. Needle out. Oops. Let's see if that's how well this works in here, let's see. Do you want to switch and give it a shot? Why don't we just try with the needle then let's just do that first and get this started and then we can switch back. Because we got this out. Here we go. We can lift with your injection technique. Yes. Oh, perfect. We'll do this. We'll demonstrate a good tangential injection for our audience here today. All right. So as I mentioned, every company has their own solution. Here's another one. I mean, it's kind of funny when you think about it, like literally they all look the same. So different package, right? Different syringes, right? Blue coloring, pretty viscous. And so here's a different one. This is the endoclot. And so let's see, let me connect this guy here. Oops, sorry, I did not listen to my endoscopist and I just did it anyway. So needle is out. And so we'll get a nice tangential injection here. Inject. Injecting. I think I'm injecting. Let's see. Yep. Injecting. Injecting. Injecting. Here's another one. Not getting much of a lift in this area. Some of these pig stomachs are a little fused and stuck together. So let me try a different spot that's easier for you. Needle back. We can try a different spot and see if it works better. Needle out. Needle out. Inject. Injecting. It's definitely better. One bad thing about using viscous solutions, which doesn't necessarily affect us as the endoscopist, but affects me right now as a technician, is that they're really hard to inject through a needle. So be cognizant about that when sometimes we're having your assistants having a hard time injecting these things is because they're really viscous. Yeah. Again, not much of a lift in this area. You want to go next to the area that we already cut and see? Yeah. That's a good thought. Let me try that. Let's try that. Needle out. Out. Inject. Injecting. Injecting. Yeah. This is lifting. Okay. Maybe it was a location thing. Yeah. Let's just put a bunch in here and then we'll start cutting there. So let me get you one more syringe of stuff. Inject. Injecting. Needleback? Let me just finish this syringe for you. Okay. All right. Needleback. All right, let's just start cutting through that section there. I think it was just the location of the site we were picking. No problem. Good lift. All right. Great question coming up for a particular lesion. How do you choose between EMR and ESD? Oh, boy. All right. So first off, all throughout, there's, I think, a little bit of a guideline paper out that talks about some recommendations about how to deal with this specifically in the colon. But this is a big controversial subject, and so I'm going to give you a 100% biased answer, a Neil Gupta original biased answer. So just take that with a grain of salt, because I'm sure if you came, if you were here in person, or even attending virtually and you asked this question during the lectures from different faculty, you're going to get a couple of different answers on this. So I'm going to try to answer at least from a conceptual standpoint of how to approach it. If you're not worried about malignancy in the lesion you're dealing with, and that's true whether it's in the esophagus, stomach, small intestine, or the colon, if your inspection of that lesion says, hey, this is all Barrett's and dysplastic Barrett's, I'm not worried about a submucosal cancer here. This is all gastric dysplasia, not worried about a cancer here. This is all adenoma in the colon, not worried about a cancer here. Then really EMR, whether on block or piecemeal, completely acceptable, and I would argue in the US, is probably the preferred technique to deal with that lesion, because you're safely going to take care of it, and you will adequately treat it. And second is it has a lower risk profile for taking care of that patient's problem. The tricky part comes in the fact when you look at a lesion, and now you're worried, based off your pre-resection inspection, that there is some risk of cancer in that lesion. So then I think your choice between EMR and ESD comes down to the size of that area that you are worried about has cancer in it. And if that area that you are worried that has cancer in it is small enough for you to resect out on block via EMR, then I think it's completely acceptable to go ahead and resect out the concerning area by EMR, you have that specimen set aside, pinned, you have your pathologist evaluate all the deep and lateral margins of that area, just as if you had taken out the whole thing by ESD, you've taken it out on block by EMR, and it's completely fine to now clean up all your lateral margins and take out all the non-neoplastic but pre-neoplastic surrounding area by piecemeal EMR. The challenge becomes when you have a concerning area that is, that you're concerning about cancer, and it is too large for you to safely or confidently take out on block by EMR, and then that's where, let's argue that yes, ESD 100%, then the go-to, you do not want to piecemeal EMR a cancer area and cut it in half, because then you'll never know whether you adequately treated that patient or not. And so I think that's my approach, at least today, we're dealing with these lesions in this world of where we are in the US, much better at EMR than we are ESD, and we have a higher safety profile for EMR than ESD. Perfect. Thank you. All right, so we've lifted, let's go back to our ESD knife. And so I think I showed you this is a, this is just standard dual knife. See, I can show that to you. And so it is a straight knife. And it opens. It is just literally a straight tip with a little tiny ballpoint on the end. That is it. So that is your dual knife. And so this is a good all purpose knife. It can be used for both incision and dissection. And so what we'll have you do is I'll have you start with some incision just to demonstrate the dual knife technique for incision. And then we didn't size this area. Yeah, why don't we say let's imagine that we have we have some incision already on the right. Yeah. And so why don't we extend that incision from the right, maybe over to the top. Right. So you can see the Would you like me to go in that direction? Yeah, yeah. Why don't we try that? If that's easy enough, or we can start on the left side. Maybe coming down would be easier. Then let's do down. Let's do down. Yeah. That's fine too. And let me I'm just, I will apologize. You can keep going. I'm just gonna switch the program just for the sake of the pig model. Knife out. Okay, should be out. So the thing about this knife different than for those of you do ERCP or who have used a needle knife before is that this knife is specifically designed when you open it, it only extends out a fixed amount from the tip. And so this one has a I believe two millimeter extension. And so that really is designed to ensure that your incision when you have this up against the mucosa only goes down to the submucosal layer, it does not is not long enough to penetrate into the musculars proprio layer. Yep, so what you want to do is you want to get this right up against the mucosa so you can press it so that literally the flat end of that knife is up against the mucosa. You can push it out even more. Yeah, there you go. There you go. And then just bring it down. Yep. And it'll just stand on the yellow stand on the yellow. It should. Well, you know what would help by actually connected the cautery to the device. There you go. This is why you have a bad technician. Don't have Neil Goop to be your technician. If you're doing like a real life, real life scenario. Yeah, I did that on purpose. Little troubleshooting tech. There you go. And you'll see these nice incisions coming down. And this is a cool thing. You're seeing how all that gel starts leaking out of the submucosa as you cut into it. This is a real phenomenon that you will see as you do these kind of cases. All right. And just keep extending it down if you don't mind. Let's see what happens. Just a little bit of retroflex position. Yeah. Nice. Beautiful. I think my my cut is not deep enough in this area right there. It's not because you don't see that blue yet. And so you can go a little bit more right over it. It's decompressing the stomach a little bit because it's more for like a retroflex position. It's got a little bit more challenging than it should be. And I like what you did is when you as you decompress there, it actually brings a little closer to you. All right. Which helps. Still feel like I'm a little bit more superficial than I would like. Why don't you go when you come down a little bit on that? Because I think where we had cut already right in there. Why don't you see if you can go right over that section? Yeah. It's better. Beautiful. Nice. Nice and slow. Yep. Right across. Just keep going across. There you go. So now you expose that nice blue. And so now if you can let's see when you see even cut it across a little left. But actually, how about this? I think this would be good time. I'm going to demonstrate a different knife. Right. I think it'll be fun for us to show because you've seen kind of the the dual knife. Let's take this out. Let's switch over to another knife really argues probably the one of the safest knives out there for those starting out is the I.T. knife. Open this box. So here I'll show this. See this. And it shows the design of the knife. Basically, it has a ceramic ball on the end. So if you look at the picture, the ceramic ball on the end is an insulated ball. So no current and no cutting will occur by that ball. So you have this protection. Instead, what can cut is the bar itself right there. And you can see this little T on the backside of the ball. That backside of the ball T can also cut. So there are two ways to use this knife. One, use the bar as a blade to cut across mucosa and then use the backside T to cut up towards you. So you basically dig the ball into the submucosa and then use either the bar or the T to cut the mucosa or submucosa a safe manner while the ball is on the stomach side. So this was really good. Once you've gotten an initial incision, this is a very nice device to use to do gastric ESD, especially early on because it has that level of protection. So what I have you do is you've got that lateral incision. Yeah. Why don't you continue that lateral incision by digging the ball in there and then using the blade of that knife to continue on to the left. And you can even if you need to take it to the right too. So we can take an either direction. So I'll take the ball out for you. So now the ball is out and you can see you can dig it. So yeah. So here I'll bring it in. So let me step out so you can see that out there and you can see the T on the backside. So it's the bar itself and the backside T both can be used for cutting and see you can be completely safe. Right. Yeah. This is really nice. Yes. Right. Great. Right. And so you're using the bar and then you can even use that backside T part. The only challenge with this, it's a little it's you can start an incision with this, but it's a little challenging. So you can So you cannot start an incision with it. Yeah, there's like a way to do it, but it's not fun. I do feel like I better control. Yes. And it's because of the position. It's because that safety. Well, yeah. Why don't you even cut that way? Cut down a little bit. See what happens. Right. Right. And so you can go really fast because of that protection and safety and safety that that ball gives you, you know. But like I'm going to attempt to start incision. You don't think it would be a good idea to start? You can. You can. It's a more advanced thing. You got to use the backside T. So you got to like. Yeah. And you'll see it's harder to do. It's not as easy as because the ball is meant to protect you. It's definitely easier to extend this incision, but start the. All right. So we had a great question here. You see an ulcerated polyp concerning for cancer. Do you proceed with ESD, obtain a biopsy and CT to look for lymph node and mets? All right. So it's a great question. And I think anytime you see an ulceration in a lesion, I think especially in the colon, I think this is an area you need to be worried about cancer. So my approach and I think is probably recommend approach. If you see this during a screening or initial diagnostic exam, that exam, you're not doing ESD right then and there. So don't do that right then and there. And then the best course of action right then and there when you found this lesion is to one, if it needs to be tattooed for a location, then tattoo it. So if it's, you know, in the middle of the colon, you need a tattoo. If it's right next to the secum, if it's in the rectum, those areas you don't have to tattoo because they're easy to locate, but anywhere else you should tattoo it. And when you tattoo, not tattoo in the lesion or right next to the lesion, tattoo a little away, either, you know, folds away opposite wall. So that way, you know how to locate this lesion. Biopsy, I think is a little controversial. I think if you see an area of ulceration in a polyp, I think that alone tells you there is some cancer in there. And that is enough, at least for me to say there is cancer in here and you don't need a biopsy to tell you that. So then really the discussion comes is, can you take this out endoscopically or not? And so I think on that first exam, you've photo documented this lesion. I think that's critically important. Lots and lots of photos of the entire lesion, the surface pattern, the edges, you know, some closeup pictures, some faraway pictures. So, you know, either you or the person you refer to to cut it out has the full look of this lesion. Second, yes, I think a CAT scan for these patients is critical to look for lymph nodes and make sure it is a localized lesion because size alone will not tell you whether there is lymph node metastases or not. So that size lesion, while you say, oh yeah, it looks small and it just has a little ulcer, you will miss. So get the CAT scan. If the CAT scan is normal and there is no metastases, then that is when for an ulcerated lesion, this is not the one to start learning ESD on. These are extremely challenging. And so this is one where you would want to have somebody who has a lot of experience in either ESD or full thickness protection take a look at and say, okay, yes, this is doable and it is doable, you know, at a certain skill level to try. And then you can go ahead and give it a shot in there if it is kind of doable on that standpoint. But the ulcerated lesions are extremely challenging for ESD because of how much deep and stickiness there will be in the submucosa. So you will be going not through a clean submucosa, you will be going through a submucosa that has either inflammation or a desmoplastic reaction or even cancer in that submucosa and they are very challenging. So it is not the ones to do in your first 20, your first 50 cases. This is once you have had a lot of experience in ESD in the esophagus and the stomach and you have done a decent amount of colon, then you tackle the ulcerated colon lesions. Thank you. All right. So let's do a little bit more. And how about we show right now is I think you have extended the incision. Why don't we take that incision up? So I think you got on that side. Let's go ahead and do that. And then you want to take it around. Yep. And once again this is that ceramic ball gives you this kind of freedom all right and it gives you that protection. All right and you can see that spillage that we talked about right once you cut through and expose stuff it will spill. Right now I'm just like kind of going through and seeing that did we I think that we can cut a little bit in this area. You can double check and just cut through and make sure you got it all the way through there. There you go nice. Yeah all right just probing around I think we got it. Okay since for the purpose of today we said we talked about hybrid ESD so we've got our incision all the way around so we're going to go ahead and let's switch back to our snare. I remember where that is yeah yeah so we'll use a different snare here. So this is just a different 25 millimeter Olympus snare a little kind of I don't know what what call shape you call it. I don't know I'm not going to call it a duckbill it's kind of like a weird oval call that. All right let's put this down and in this hybrid technique we've made that incision all the way around. So the goal here is to go ahead and get our snare wrapped around the lesion by using the incision edges as the guide to lodge the snare into. And similar endo cut settings for a hybrid ESD as well. Yeah I mean basically what you would do is you would switch back to your snare settings. Okay. For the actual resection. I'm gonna have to request you to open here. Yep. Oh my hand is not big enough. All right I'll try to push the snare out a little bit. Looking pretty good. Yeah. To close for you. I just want to make sure that I got the other end the distal end of the polyp. Looks promising. I think it looks pretty good. Okay so we're gonna cut here. Okay. And yes we did get all of it. Beautiful. Very nice. Thank you. All right. So hope you enjoyed the first half of our demonstration today. So we walked through some EMR stuff, hybrid ESD. We're going to take a little break. About 5-10 minutes. We'll swap out models. We'll do a we'll call it one function break. So you can do one function. Whatever that function is while we're on break. And then we're going to come back and we'll have our colon model up. And we're going to do some fun colon things. So see you in about 10 minutes. Bye-bye.

ESD procedure

endoscopic submucosal dissection

ESD knives

submucosal injection

endoclot device

EMR vs ESD