Hi, everyone. Welcome back for our final session of live endoscopy, or a sort of modified live endoscopy. We are thrilled to be joined by our colleagues from Japan after a very long time of having them visit. We're so happy they could be back with us. Professor Saito from Tokyo and Professor Abe, who will join us in just a moment, were just waiting for the endoscopy to be available, and we have a kind of hybrid approach here. These cases have been done live in Tokyo and recorded, so we have, luckily, our two endoscopists here to narrate the videos and have a very lively discussion. I'll also introduce the rest of the panel. We have Dr. Neil Gupta from Chicago, Uzma Siddiqui, who you met earlier from Chicago, a whole panel from Chicago. I know. We like to stick together. Mike Wallace, who you know well, who's currently in Abu Dhabi, and Professor Saito, as I mentioned. While we wait, let's see, what kind of questions do we have, Mike? So I think just to preview the cases, my understanding is we have a PON case from Dr. Hirohito Inoue, and we have an ascending colon ESD case that you recorded. Is that right, Yutaka? Yes. Okay. And are those, do we have other cases? We have one more. Okay. One more from Dr. Abe. A gastric ESD case. Also featuring a sub-third space endoscopy, upper GI, lower GI. I guess we could ask the audience, do any of you perform ESD currently? We do have quite a few in the audience. And then as a reminder, we will be having, we'll be featuring live endoscopy tomorrow. We'll be in this room throughout the day. Okay. So we are ready for our first case. This will be Dr. Inoue performing PON. Hello, everyone. This is the typical type 2 acaracea patient. We like to perform the PON procedure. The position of a lower esophageal sphincter is starting at 37 centimeters, back up 5 centimeters at least. Okay. This is a good position, I think. So in this case, we would like to place a myotomy in the anterior wall. Okay. Injection please. Okay. If we make a good submucosal injection, we can recognize a good lifting of the mucosal surface like this way. So put the triangle knife on the mucosa and then give mild tension. Then attach the cutting current. Now we can recognize the needle tip is placed in a submucosal layer. And then push forward, pushing forward the endoscope. Okay. Then place a roughly 2 centimeter mucosal incision. Okay. Then we push the endoscope forward. We can easily get in a submucosal space. So first step is to find the surface of the muscle layer. We have to check again that we insufflate the CO2, not the air. If we insufflate the air, so it may cause a significant problem because of the air insufflation causes severe emphysema and non-absorptive. Okay. Now we can see the surface of the inner circular muscle layer. So like this way, our first step is to find the surface of the muscle layer. And second step is the recognition of muscle fibers. So you can see muscle fibers running parallel in this view. Then we approach vertically to the lining of our circular muscle. So we always keep the close to our circular muscle approaching closely to the surface. So esophageal lumen getting smaller and smaller. So now the lumen in the submucosal space promptly switch to our very wide space. So check it from our luminal side. Submucosal tunnel was created like this way, back up. We can see a blue dye. So hopefully we may reach to the esophageal side. Esophageal squam comuna junction located at 40 cm. In a submucosal space, this is bleeding from a mucosal cut end, doesn't matter. So this position is 40 cm, so almost reach to the gastric side. We would like to insert the second scope to check the position of the mother scope. Let confirm the mother scope already reached to the gastric side, 1 cm. Now I'm moving the tip like this way. I hope you can recognize the movement of the mother scope. So we are starting myotomy from here. Junction is located at 40 cm, so roughly 5 cm proximal from the junction. There is a minor oozing from the mucosal backside. Okay, this one. This is a bleeding from a mucosal side. We do not use the coagulating forceps. Just press the bleeding point using the outside of the distal attachment. So this is a venous bleeding, so must be well controlled, just press the bleeding point. We are starting the myotomy from here. This is a mucosal incision. First step is to jut the splay onto the muscle layer. Energy setting is a 50 splay coagulation, 50 watt effect too. Okay. Then you can see behind the bottom of our cutting area, you can see longitudinal fibers. So place the triangle plate onto the surface of the longitudinal muscle layer, flush a little bit. We would like to confirm the good image. Okay, like this way, place a TT knife and then advance endoscope and keep a little bit tension downward. Then cut the muscle. Okay, this is a very distal end of the myotomy. You can see a cut end of the distal end of the myotomy here. The other side, so this is a mucosal side. This is a level of our distal end of the myotomy. So you can see a light of the mother's scope through the baby's scope placed in her stomach in a little flex view. You can recognize the movement of the tip of the mother's scope. So we can say that the myotomy completed, it's after your side. So we can extend one centimeter or like that. Yes, this is a very end of our myotomy. So now we are injecting the submucosal layer, the blue dye, and we continue the myotomy toward the gastric side. You can see outside the esophagus some vessel structure. So we would like to avoid approaching this vessel. Just the right side, not this way, this is straightly approaching to the vessel. It's no good, not good. So we are dissecting the muscle fibers a little bit more to the gastric side. Injection into the submucosal layer creates a contrast, good contrast. Then we can recognize the anatomy very well. Okay, good. So injection, please. So when we dissect the muscle layer, particularly in the stomach, we may encounter a large vessel. So esophageal side, there are only small vessels, but in a gastric side, sometimes a branch of the left gastric artery runs. So we have to be very careful in a gastric side. So I recommend like this way, splay onto the muscle layer. I think it's enough. So we have already extended one centimeter. This is a lesser cut end, you can see it. No active bleeding. Okay, then we are coming back to a normal lumen. So we can say a junction is free open like this. So I think it's okay. So gastric side, the myotomy length is one or two centimeters. The first clip should be placed at the distal end of the myocosotomy and close it open. So left side is a little bit weak. So first clip is extremely, very important. Okay, slowly close. Okay, good, looks good. Okay, so when we place the second clip, so please approach to the close to the first clip. And then, so place the clip this position, and then place the endoscope itself to the bottom. Okay, temporarily close. Okay, looks good. Wait a moment, please. We have to confirm no overlap to a previous clip. Okay, fire. So left limb and the right limb is the same size. So it's perfect. Okay. Hello, Haru. Yeah, yeah. So how are you? I'm well, how are you? Yeah, I'm fine. Great, great to see you. Thank you for that. That was a beautiful, beautiful case. Maybe we'll have a few minutes for some questions and discussion from our panel. We have Neil Gupta, Uzma Siddiqui, Mike Wallace, and Professor Saito. So maybe let's just start, let's work through this step by step. So the very beginning of the procedure, you chose the anterior side. Maybe you can talk about the choice of anterior-posterior and tunnel entry. How do you create the beginning of the tunnel and getting into the tunnel? I must say, I find getting into the tunnel one of the most difficult parts sometime in the procedure. You made it look very, very easy. Can you comment about those first two steps? I think very much, it's a very good question. And the point is depend on the case. So type one, sea cargo, type one and type two, acarasia. So narrow segment is LES. So back up five centimeter. And then, of course, we can approach the anterior and the posterior. We can choose it. Anyway, so five centimeter proximal, we place a mucosal incision, two centimeter. So type three, we have to place a much longer myotomy. Of course, you know. Hi, this is Uzma. So you change your approach though, anterior versus posterior, if the patient has had prior Botox injection or obviously a prior myotomy? I have. Thank you so much. So if the patient receives the previous surgery, hella dull. So in such a case, we have to approach the posterior much better. So in the case of Botox, if the patient receives so much repeatedly, sometimes LES becomes a little bit tight. So in such a case, if we choose any site, creating the submucosal tunnel becomes a little bit difficult. But we can do it. Haro, we had a long discussion in an earlier session about reflux after POEM, and Moween demonstrated the technique that you've developed of fund application after POEM. You also have published on anti-reflux POEM itself. Can you comment on the modifications in your techniques to make that so? Thank you so much. It's a nice question too. So first step is to control the post-POEM gird, is to control the gastric myotomy ranks. So we routinely perform the double scope checkup to control the gastric myotomy ranks, so one to two centimeter. If we place a longer myotomy, more than three centimeter, four centimeter, so that means a total cut of a color string muscle. So the patient becomes a potential hiatal hernia, then the patient have the severe gird. So control the gastric myotomy is the first step. If the patient becomes the reflux after POEM, then we are trying to place the POEF, that is a peroral endoscopic fund application. It's a mimicking procedure to our dull fund application. So it's a note procedure. So we did so far 43 cases, so results is good. And are you doing that, so you're doing those in two separate sessions? Two separate sessions. In our pilot study, we did it in the same time in some case, 10 cases we did it, but it's not necessary to do it in the same time. So 99% of the cases has only a mild reflux, not a severe reflux. So it's not necessary to do it in one session. So if the patient becomes a severe reflux, then we can proceed to our anti-reflux POEF procedure. Neil, did you have one more question? Yeah, Professor, in your case, you had a very nice demonstration and you made a specific point about treating the blood vessel that was oozing on the mucosal side of the tunnel. Specifically, I'm assuming to help prevent injury to the mucosal side. I was wondering if you could share with us any other techniques or tips you use to reduce the risk of mucosal side injury during the procedure and the importance of maintaining the mucosal integrity there. Yeah, thank you very much. In this POEF procedure, actually we dissect the muscle layer fully. So preserving the mucosal layer is the first priority. So we have to pay attention a lot not to make an injury onto the mucosa. So for example, if the bleeding happened from the backside of the mucosa, so most of the case, just press the bleeding oozing point, the side of the food. That's enough. Wait one minute, two minutes, we can control the bleeding. So muscle side, we can coagulate a lot. But mucosal side, we have to be very careful. And another point is we have to dissect the submucosal tunnel very close to muscle layer. So compared to the ESD. ESD is approaching the middle over or two thirds depth of the submucosal layer. But in this POEF procedure or submucosal endoscopy, so preserving the mucosa with the submucosal tissue, rich submucosal tissue, it's most important. So we approach very closely to muscle layer surface. Wonderful. Thank you so much for joining us. And we obviously wish that you could be here with us in person, but that was beautiful teaching case. And we really appreciate your joining us afterwards. Thank you so much. So now we'll have our second case by Professor Yutaka Saito from Tokyo. Thank you. OK. I prepared the case in the ascending column. And I encourage anyone who has questions or comments, again, to send them in to call out. Thank you for this great opportunity, Yutaka Saito. National Cancer Center. Yutaka Saito. National Cancer Center. The region located in the ascending column, the two C-type LSTMG, the first one. But pit patterns show type 5 severe irregular in some case. So in this case, we are suspecting some causal invasion, a slight invasion. This is retroflex position using the short type ST food. And the reason why we prefer to start the procedure in retroflex is we can approach to some causally horizontally and the scope becomes stable. And first injecting glycerol, and then additional injection of the Mukwap or Liftar-K to keep a good SM elevation. This is a needle type. In this case, we are using bipolar needle knife to reduce the risk of perforation. And in the colon ESD, it's different from gastric ESD. So we just perform the very small incision, and then we immediately start the somocausal dissection. Because in the colorectum, even using Mukwap injection, the somocausal elevation disappear quickly. That's why we are performing not circumferential incision, just partial marginal incision. And then immediately start somocausal dissection. And of course, C-autoinsufflation is necessary for all cases to reduce the severe complication when the small perforation occurred. And we are injecting the glycerol through this JetB knife. This JetB knife also has the injection, somocausal injection function. And the first somocausal dissection should be a little bit shallow because we are cutting outside of the tumor. And then in this case, we could visualize the good SM layer directly due to the shorter type ST food, gentle traction for the resective specimen. And then we are starting the deeper somocausal dissection, close to the muscle layer. But don't expose the muscle layer in the column ESD, especially in the proximal column. The muscle layer is very thin. And then additional injection through the JetB knife. And we are dissecting the lower third SM layer, close to the muscle layer, but don't expose the muscle layer. Of course, when we are dissecting the focusing area of suspicious for SM invasion, we sometimes dissect just above the muscle layer. Now we can see the muscle layer, the six o'clock position. So in this situation, this is just above the muscle layer, so we should do the dissection carefully. If you have a question, please ask me, even during the... Is there an advantage of using a bipolar knife over the other types of knives? The bipolar knife, the benefit is the electric current is just limited from the tip of the knife to the sheath. That's why even if the tip is attached to the muscle layer, the risk of perforation is very reduced. But unfortunately, the bipolar knife is only commercially available in Japan at this moment. Recently, I'm also using the Boston All Rise Pro knife. It has a very strong injection function. So it is okay, even with monopolar type, because of the strong injection function. I notice there's been quite a few blood vessels, but we're not seeing that much bleeding. Bleeding? Yeah, you haven't encountered much bleeding in this case. Ah. Or you didn't show it to us. Yeah, in the colorectal ESD, the bleeding sometimes occur, but not a big problem compared to the stomach. And also, when the bleeding occur, so we will coagulate the vessel using the same knife. And this is the... We are changing the IT knife nano for marginal dissection. And the IT knife nano is also the very strong power for the coagulation. Even for the thick vessel, we could dissect and coagulate the semicosal layer with vessel without bleeding. By using the... We are using the spray coag mode. The setting is the same as the point procedure Professor Inoue presented the effect too. Why did you switch the knife here? Yeah, of course, concerning the cost, the one knife is the better, but as shown, the IT knife also has the small insulated tip at the end of the needle. So, the risk of perforation is reduced. And in addition, using this long blade of the IT knife nano, we could perform the speedy dissection and without complication. Professor, in this case, you had some pre-procedure concern for some submucosal invasion of the tumor itself. Is there anything that you would be looking for or that would alter your resection plan during the procedure if you started to see the tumor growing into the muscle layer itself? And how would you manage that situation if that occurred? Yeah, that's really a good point. In this case, fortunately, there's no fibrosis or there's no cancer submucosal invasion observed during the procedure. And, oh, this is a very thick vessel and this is like a tunneling method. Using the IT knife nano, we are pushing forward the knife a little bit and then move the knife along the muscle layer. Using this technique, we could speed up the procedure. And now, six o'clock, the muscle layer, and 12 o'clock is the region. And, of course, when the region will be the submucosal invasion, so we could see the whitish or the brownish submucosal tissue in the SM layer. So, in such situation, our decision was maybe two, to stop the procedure. If the submucosal invasion attached to the muscle layer, so in such case, if we continue the procedure with R0 resection, maybe perforation knockout. But if there's some space between the cancer tissue and the muscle layer, we will perform the dissection below the tumor. But, of course, in such situation, after histopathological analysis, additional surgery will be necessary, so we will do the tattooing for the marking. And now that the tunneling is completed, it's almost the 80% of the dissection is completed. That- Do you always choose a tunneling method, or does it depend on the size of the lesion or the location? Oh, recently, if possible, I prefer to do the tunneling for every cases. Because even without the traction device, we could get a really nice traction, like this. So, in such, if we perform the tunneling technique, so we need to keep the lateral side and the left side without cutting. Professor, do you use position changes of the patient- Yes, yes. In order to ensure traction throughout the procedure? Yeah, frequently. And also, always we change the patient position. The lesion is opposite to the liquid. That is really important. In such a situation, even if the small perforation occur, there is no intestinal fluid leakage, so there's no risk of the peritonitis. In Japan, so we are doing colon ESD without general anesthesia, just conchal sedation. And also the Japanese patient, usually very smart. It's very easy to change the patient's position. Professor Saito, in this case, where you have clearly visible blood vessels, what's your threshold to stop and prophylactically coagulate these vessels you see approaching now? Ah, yes. It's also a really important one, question. When we visualize the very thick vessel, we are using the 110 pre-coagulation that Professor Toyonaga always explain. The very low wattage of the first coagulation is very useful to pre-coagulate the vessel. But when we are using IT knife nano, even for the thick vessel, we could dissect without bleeding, especially using the spray coag mode, effect two. Spray coag mode is really powerful dissection effect without bleeding. So I really prefer to use the spray core, even for co-rectal ESD. This is a bit of a change. Historically, we might have stopped here and gotten out of coagulation forceps and used a separate device. But now with some of the coagulation settings, it's very low wattage, very low power coagulation, and you're able to cut through this with the same device. Yes, that's right. Of course, if you feel in confidence with the coagulation using the ESD knife, one option is using the coagulator spur or hemostat Y for the pre-coagulation. And of course, even using these techniques, when the sprouting bleeding occur, so the best choice is to choose to change the coagulator spur or hemostat Y. And in the colon, it's important, don't perform too much coagulation to reduce the risk of delayed perforation. And now this is almost the final dissection using the IT knife. And also the suction of the air during the procedure is really important. Now, after this is the comparison of histology, the fortunately, even in a depressed area, we're showing the type V bit, the cancer invade the same slide, and the lymphovascular invasion was negative. The curative dissection was achieved. For those in the audience that aren't doing ESD, can you comment, when you find this on a screening colonoscopy, are you advising not to biopsy? Are you advising to tattoo or not tattoo? How do you manage this lesion at the index colonoscopy when it's found? Thank you very much. It's really important. So in Japan, so we recommend no biopsy before endoscopic treatment for every cases. We recommend to use the imaging endoscopy or chromoscopy pit pattern to diagnose the lesion. To neoplastic lesion or non-neoplastic, and also the depth diagnosis. And in this case also, we never performed a biopsy before endoscopy. And maybe in the West, the pathologists diagnose only cancer when the cancer invade to the subcausal layer. That's why in this case, even if we took several biopsy, the biopsy result could be just high-grade dysplasia or adenoma. So the biopsy doesn't change any endoscopic treatment or surgery strategy. And also- In the event, though, that you found a lesion and you weren't sure, is this a deeply invasive cancer? You don't obviously have your expertise at chromoendoscopy, but what's your advice for American endoscopists that don't have that level of expertise at distinguishing a superficially invasive lesion from a deeply invasive lesion? You still advise no biopsy? The diagnosis between the intermucosal SM1 and SM2 is effectively possible if we use the magnified NBI or chromoscopy using crystal bite stain. But without optical zoom magnification, sometimes it is difficult to diagnose the SM1 or SM2. I believe in the near future, the AI technology will help such kind of the diagnosis. I think- I was just gonna say for our audience, the Americans, you know, anytime there's potential for submucosal invasion, I think it's really important to discuss this case, you know, with your surgeons and oncologists, because again, the risk for lymph node metastases goes up. The deeper it goes into the wall. And if you're not capable of doing such a beautiful ESD, you know, you need to have another plan for this patient. I would just ask, do you ever close these lesions or place any type of gel like we saw suggested in the earlier case from Milan? Thank you very much. In the correct ESD from our series, the incidence of delayed breathing or delayed perforation is very low. So when there is no muscle damage, we don't perform closure routinely. But of course, when we experience some of the small muscle damage or with the maybe high risk for bleeding with patient with anticoagulant, we try to close the defect. In this such closure, so ESD defect is usually very large. So we are using the clip nylon closure method, using the long nylon and the clip and close the one by one. Thank you. That was a beautiful case. Thank you very much. Very beautiful. Great discussion. Thank you. And now we'll move on to our final case by Dr. Satoru Abe, Professor Satoru Abe from, also from National Cancer Institute, Tokyo. National Cancer Institute, Tokyo. Good afternoon, everybody. Thank you so much for your kind introduction. I'd like to show you the case of gastric ESD. The patient is male in his 70 with past history of curative gastric ESD. An extensive gastric region was found involving the lesser curvature of the lower gastric body and antrum. The biopsy showed well-differentiated adenocarcinoma and patients were referred to a hospital. This is a gastric ESD two years ago, index ESD, and curative resection was done. Retrospectively, the region was found. This is a white-red endoscopy using the brand new high-definition white-red endoscopy. So extensive region was found, leading to lacrimal closure involving the lesser curvature of the lower gastric body, incisura, and antrum. This is an image of TXI, and texture and color enhancement imaging. It allows us to visualize the region clearly. And we marked around the region based on the careful inspection of the NBI magnification. And the region is very extensive, so I really wanted to shift the region approximately because the region is involving both gastric body and antrum. So in this case, I get started with a procedure with the half circumferential mucosal incision. After a submucosal injection, I performed a two-ply cut of the left side and the right side using a Deore knife. I performed a poly-cut. Quarterly current setting is the end-cut eye, effect one, duration three, in Albee Bio3. And what is your solution that you're using here? This is a normal cell line. We also sometimes use the highly viscous solution, but in this case, I selected the cell line. Here you can see the mucosal incision of the distal side using IT2 knife. So using the long blade of the IT knife, we can efficiently do a mucosal incision. And also, I would like to recommend the following procedure, trimming of the submucosal to expose the dissection plane. But in this case, you're working fairly far away from the scope. I assume that's because it's just in a difficult position on the lesser curvature. Exactly. You seem to be offsetting that sort of difficult position by using an IT knife to help protect from deep injury. Exactly, you're right. So in this case, IT knife is suitable because we can access easily. So in this case, I think the needle type device is not so suitable. I think it's technically challenging. Can you comment about other methods of sort of handling this difficult positioning? I know we increasingly are seeing use of traction methods, using some sort of a suture clip or other traction methods. Would that be suitable here? That's a very nice question. I'd like to show you later. So in this case, patient already has ESD. So I'm afraid of severe post-ESD scar on the distal side. In that case, I do a submucosal injection, sorry, submucosal dissection without area, area without fibrosis to expose the fibrotic area. So this is a right side. And also the left side, fibrotic tissue is found, yes. So now we can do a safe submucosal dissection on making the communication between the left side and the right side. So when you were planning for this procedure, how much time did you anticipate it was going to take to resect? Oh, it's a good question. So in this case, I participate about two hours to remove this region. But really depends on the bleeding and the scope access. So as you can see, it is a little bit difficult to get close to the region using the standard endoscope. So I change the scope with a long bending portion. So using this scope, multi-bending scope, so I can access closely. And also apply the long blade of the IT knife to the edge of the submucosal and manipulate the IT knife parallel to muscle layer. In gastric ESD, the optimal dissection level is the bottom of the submucosal. I mean just above muscle layer. If you dissect superficially, you encounter the rich vessels, which makes your procedure longer and longer. So after a half circumferential mucosal incision and dissection, next step is the mucosal incision and dissection of the proximal side. I make another pre-cut. And then this is a mucosal incision of the posterior side. As I told you, the optimal dissection level is bottom of submucosal. So now you see the muscle layer, this is optimal level. And also the minor bleeding should be stopped immediately using the long blade of the IT knife. Now you can see the fat tissue. So in the fat tissue, there are lots of vessels. So I'd like to recommend you to dissecting below the fat tissue. After that, now you see a clear submucosal dissection plane without the vessel. And do you change your cutting current or do you switch to coagulation, different mode with this fatty tissue? No, I didn't change current, but we always use forced coagulation at 7.5 for submucosal dissection. Now I manipulate the endoscope parallel to the muscle layer. So the posterior side is well exposed right now. However, the anterior side is not opened yet owing to gravity. So I decided to use a traction method. In this case, I use a clip-on line. So now it's a line, a dental floss will tie to the tip of endoclip. And then clipless line is deployed to the backside of the specimen. So I'd like to deploy the clip with line to the anterior side. I like this. Without the help of the clip-on traction, it is almost impossible to do ESD within two hours. Now, thanks to the traction, so the submucosal plane is well exposed and lifted up with good traction. So now we can efficiently dissect submucosal and also that we can see the muscle direction which allows us to do a safe submucosal dissection even for this kind of the extensive region. And during the procedure, it is very important to identify the muscle direction. And now the muscle direction is three to nine. And if you find the small breast cell, please dissect slowly, slowly with coagulation current like this. So as you can see, as we can do the submucosal dissection and hemostasis at the same time. Once again, so now the muscle direction is a two to eight o'clock position. This is the advantage of IT9. Of course, it is a little bit challenging to get close, but we can identify the muscle direction which can prevent a perforation during the procedure. Can you comment on the electrosurgical settings, particularly in the last generation of the ERBE generators, we have this capability of so-called precise sec, which I think has changed the dissecting mode for many of us. Can you comment how you're currently using electrosurgical generators for this dissection phase of the? Okay, for submucosal dissection, I always use forced coagulation. And some Japanese endoscopists like swift coagulation and precise sec. That really depends on the preference of the endoscopist, I think. And now, the bleeding point, yes. So sometimes we see the massive bleeding like this. In that case, we intentionally cut the tissue little by little to expose the bleeding source like this. How about the RDI mode when the bleeding occur? RDI is very nice to visualize the bleeding source and also reduce the endoscopist stress. Now, the bleeding source is well exposed and we do the hemostasis using hemostatic forceps. The RDI mode is a new mode. It's available on Olympus generators. I believe it stands for red dichroic imaging. And it's using a filtered light that allows you to essentially see through the blood to the source of the vessel. Is that correct? I've not used it myself yet, but you're using it routinely in this setting where you have a bleeding vessel? Yes, so I routinely change the RDI mode when massive bleeding occur and it's really useful. Thanks for the discussion. So unbroken resection was achieved. The procedure time was one and a half hour. So this here, you can see the extensive mucosal defect involving the lesser curvature of the gastric body and antrum. So now how do you handle potentially doing any kind of closure? Because we know gastric ESDs do have a higher potential for delayed bleeding. Yes, so the standard procedure is a prophylactic coagulation, as shown in the video. And also sometimes we do a clip closure on the visible penetrating vessel to prevent delayed bleeding. And also it is almost impossible to close this kind of extensive huge mucosal defect. And the heart-shaped specimen was removed, nine centimeter in size. And histologically, it's a well-differentiated carcinoma with the deepest invasion to mucosa. Curative resection was achieved. Thank you so much. Thank you. Can you talk a little bit about post-resection care? Do you admit these patients? Medication use? Yes, standard of care is we use a PPI to prevent post-ESD bleeding. And also as a patient with anti-coagulant, antithrombotic agent, the risk of delayed bleeding rate is higher. So we need to take the patient longer. Also in Japan, the patient can hospitalize even after one week, 10 days. It's covered by insurance. And apart from proton pump inhibitors, do you use any other supplemental agents, sucrofate or any other agents for bleeding prevention? That's a very good question. So first, several randomized control trials was conducted to reduce bleeding. So all study were negative. They failed to reduce the risk of delayed bleeding. We used to close the mucosal defect using the end loop and end clip, but we couldn't reduce the delayed bleeding. So it's the next challenge. So I think the X-TAC device is very helpful to close the mucosal defect, but it is not available in Japan. So we should try it in the future. And you mentioned the prophylactic coagulation of the visible vessels. In the EMR literature, as you know, Michael Bork did a randomized trial in post-colonic EMR of prophylactic coagulating visible vessels, and it was a negative trial. It didn't prevent post-procedural bleeding, whereas clip closure of the lesion did. I notice in the ESD literature, you still typically do prophylactic cautery of visible vessels. Yes, our retrospective study from our hospital shows the prophylactic coagulation is very effective to reduce the risk of delayed bleeding. I think the situation of the gastric ESD and colorectal ESD is totally different, and also the bottom of the submucosal space and the density of the vessel is totally different. Because I think in the colon on the right side, especially, I think the hypothesis is that the submucosal layer is a little more lax. So perhaps the vessels that you're prophylactically coagulating are not the ones that are gonna get exposed later. But then in the stomach, it's a little bit different situation there. Yes, and it seems like you're definitely going deeper on the gastric ESD than you are on the colonic side as well, right? Specifically to cut blow all those vessels on the gastric side. Yes, exactly. Particularly on the middle and upper side of the stomach, there are plenty of the big vessels so we should coagulate. This patient was a recurrence of a lesion. Can you comment? Was this a true recurrence at the previous site or was this a metachronous lesion? And a follow-up question to that is how do you surveil these patients after you do this resection? Okay, in this case, this is a metachronous cancer after resection and index ESD histologically reveals a curative resection, R0 resection. And also the risk of metachronous cancer, the annual risk of metachronous cancer is about two to 4% in Japan. So we need annual surveillance after curative gastric ESD. I'd like to point out to the American audience here that early gastric cancer is not uniquely an Asian phenomenon. We have this in the United States. We certainly have at-risk populations. They may be first-generation immigrants from high-risk areas, but also anybody with multifocal intestinal metaplasia and gastric atrophy is at risk. And the current guidelines, even in the United States, suggest that we should be doing surveillance for such patients. So I would encourage you, if you take a biopsy from the stomach and you get back intestinal metaplasia or gastric atrophy, to consider enrolling these patients in surveillance programs because we can find these early gastric cancers in the US and we can treat them as you've seen here. Great, thank you, Mike, for that comment. That was a beautiful case. Thank you so much for sharing that with us. We're gonna close out this portion of the endoscopy. I'll just invite my co-directors back up just for some final comments and a goodbye. Thank you to the panel so much for this session. Thank you.

live endoscopy

PON procedure

type 2 acalasia

submucosal tunnel

lower esophageal sphincter

ascending colon ESD

suspicious lesion

gastric ESD

metachronous cancer