We will next go to Dr. Yutaka Saito, who will show an ESC procedure, and who is accompanied by Dr. Sawaneh Naam and Dr. Helmut Messman. Good morning. Thank you, Venkat. Our first case at the conference will be an endoscopic submucosal dissection of a large sigmoid colon. Operators in the room will be Dr. Saito, joined by Dr. Messman and Dr. Naumet Kaur. This will be an ESD of a 40-millimeter sigmoid polyp. The patient is a 40-year-old female with new-onset painless hematochysia. She's had no prior episodes of GI bleeding and is not on anticoagulation or antiplatelet agents at the time. She underwent initial colonoscopy, and we found a 40-millimeter granular homogeneous LST in the sigmoid colon. Biopsies from this procedure were consistent with tubular adenoma. After a review of the patient's history and endoscopic evaluation, the plan was to proceed with flexible sigmoidoscopy, an endoscopic submucosal dissection of a large sigmoid colon. Thank you, Antonio. We will go to live case demonstration now by Dr. Saito. Dr. Saito, you are live. Good morning. Good morning, ladies and gentlemen. Can you hear me? Yes, we can. Okay. I'm Itagaki Saito from National Cancer Center, Tokyo, Japan, with Yasuhiko Mizuguchi, and also in this room, Sawani and Hermit Messman, as for the moderator. The region located in the sigmoid colon, and the estimated size is about five centimeters in diameter. The sigmoid colon is an RS junction. Now we are changing the patient's position to the right side down, considering the gravity. The region is like this. It's somewhat bulky, and this region is sub-classified as LSD-NG, non-granular type, and flat-derivative type. But the center area, now this is the oral side of the region, and the region is from here, like this here, and to here, so the more than half circumferential region. This is the center of the region. Switching to the NVI, we can estimate the J-Net classification with magnification. This is not the optical zoom, but the near-focus, but we could evaluate the J-Net classification very well using this near-focus system. Now this center area, we are diagnosing the J-Net type IIb. It consists of the irregular vessel pattern and the irregular surface pattern, suggesting high-grade carcinoma. And I have the biopsy from the center area showing the high-grade dysplasia. That means intermucosal cancer in Japan. So, this is a really nice candidate for embryo resection, considering the risk of the intermucosal or submucosal superficial cancer. But there is no endoscopic feature, suggesting SMD invasion. So, a good candidate for ESD. But not the best candidate for the live demonstration, considering it is somewhat challenging, especially outside. Okay, we are going to start the ESD for this region, changing the scope to a well-bending one. Injo, comment, please. Yeah, well, the scopes are changing. I think in Japan it might be really a good indication for all the regions. The situation in Europe is quite different. I think 95% in Germany would do a piecemeal MRI. Are there still any Japanese centers who would do a piecemeal MRI? No. We are doing now a randomized trial in Germany with this region. LST, non-minimal type means, and PERS-2T. Because in the rectum, I think, the majority of our patients will have ESD, but the colon is a bit different. I think we need more data to convince my colleagues in Germany that ESD is the appropriate treatment. I heard in the French group, they are now ongoing for the RCT. Yeah. It's ESD versus piecemeal MRI. Okay, so we are going to start the ESD after changing the scope. Yes, hi. Hi, Edward here from London. Hi, how are you? Oh, Edward, hi. How are you? Excellent, and lovely to be with you and Helmut, and thank you to the organizers for the very kind invitation. Yutaka, I want to ask you, it looks like a challenging lesion, I must say. Good luck. What is your strategy? What is your ESD strategy for this? Yes, if the retroflex position is possible, changing the scope, we are using the modified, expanded target creation method or tunneling method. Yes. Okay. And also, if possible, we are going to use the dental floss traction. So, if I understand you correctly, you're going to go beyond the lesion. Are you going to use a gastroscope for this, or is it a colonoscope? Gastroscope. Okay, so that you can retroflex, and you will make an incision at the oral side and then come back and make a pocket from the anal side? Yeah, that's right, correct. Okay. Thank you. Good luck. Thank you. While we're waiting, we have a question from the audience about traction devices. There is mention of the Dilumen device, I'm sure you've heard of it, to provide you with some traction. You mentioned the dental floss traction method. Are there any advantages or disadvantages to different types of traction methods in your mind? What would you favor? Oh, thank you very much. So, in Japan, the airsoft grip traction, it's like a spring connected to the grip, is commercially available. So, in the right side colon, we prefer to use airsoft grip traction. But in the left sigmoid, considering the cost-effectiveness, we prefer to use dental floss traction. And we know the traction wire by Covedium is now commercially available in the U.S. So, it will be a nice option for the U.S. doctors to use the traction wire. Okay, I get you. In our unit, we tend to use Professor Yamamoto's technique, the pocket creation, but we also use saline immersion. So, instead of using gas, we use saline jet. And that helps a lot with counteracting gravity because the lesion floats, you know, and we don't really need to apply any traction for that. We obviously change positions sometimes, but we find it helpful. Do you ever adopt or use saline immersion or saline jet as also described by Professor Yahagi? He used the water jet or the saline jet. Oh, yeah, you mean the water immersion? Saline immersion, because saline allows the knife to cut better than water. Yes, we also use such kind of technique in each session of the ESD. The water immersion technique is now the basic technique of ESD. We need to use the water immersion ESD in every difficult situation. And before you start, I'm sure you've got a strategy in your mind. So, you're going to use the short ST hood for this? Yes, yes, we are using short ST hood every correct ESD. And your choice of knife? For the marginal incision and the first subcausal dissection, now we're recently using the All Rise Pro Knife from Boston. No, no, from Boston Scientific. All Rise Pro Knife. Yes, and I believe that the Pro Knife has several advantages because it's a multi-modality knife. Yes. And it also allows for injection as well. Yeah, the injection function is really nice. I'll ask Helmut so that Yutaka can get on with it. So, Helmut, in your experience, do you have any preference for injection types of injection solution, lifting? Usually. Now, this is a little fresh. Injection, please. So, usually we use a flash knife technique with an IT knife or a tool knife or a hook knife. And at the beginning, you can use mainly glycerol, which is cheap. In lesions with fibrosis, there are pre-treated. I think, in fact, solution as used now can be really helpful because of a longer lifting. Helmut, may I ask you, how many in the UK would do an ESD intercetation? Helmut, I can't really hear you. If you could have a microphone. I was wondering how many people in the UK would do an ESD intercetation. How many percent? Oh, I think, yes, that's a very good question. So, the number of centers in the UK is increasing where we're doing ESD. In my center, certainly, we would definitely do an ESD here. Of course, we're probably going to be slower than Saito-sensei. It would take, I think, four or five hours to do this, in my opinion, or maybe three hours if we're lucky. So, I think the skills are there. There are more centers and they get referred, these cases. But, of course, we are still on the slow side. That's what I feel. Is that the same in Germany? I completely agree. I think, in Germany, it's still not gold standard to do here ESD. I think, because of safety reasons, there are not so many centers in Europe. We recently performed an ESD registry in Germany and we saw that, even in centers, the complication rates for perforation in colonies is higher than in every other part of the EI sector. Ed, since you're asking that question, I mean, the majority of the people then would be performing piecemeal EMR in this situation? I think that the paradigm shift has happened in the UK. There will still be people who will touch this with a piecemeal EMR. But, I think education is coming to a summit in the sense that if high-grade dysplasia is detected, and the knowledge of centers where this can be done on block is leading to referrals. So, our center, for example, is doing about five ESDs a week, which is a way step forward from what it used to be a few years ago. So, yes, I think the rate-limiting step, rather than perforation or complications procedurally or immediately after, is time. It takes us a long time to do this. I mean, in that case, I think it would take us about five hours or four hours. So, Ed, I could argue that maybe you could do this piecemeal EMR in an R with almost similar outcomes. So, why go for that five R ESD and not just do that? Because we really don't know if the outcomes are that different, do we, Ed? I think I'm a convert for ESD, and the reasons for that are plenty. Number one, it is a definitive procedure in the sense that you're going to get a result, and the histopathologist will be able to inform you much better, especially if it's a younger patient. I mean, if this were an 85-year-old with comorbidities, there would be question as to the strategy and different options, and I'm sure that we would favor an EMR in an elderly patient with multiple comorbidities if we're going to take it out. But in a younger patient, for certain, I would definitely favor ESD. Number one, for the reasons that Yutaka said about high-grade dysplasia, and it is much more definitive in terms of an answer. But number two, the burden, as was mentioned by Ale earlier on. I mean, a lot of the burden on endoscopy units relates to surveillance, and if you have a piecemeal EMR, we know that the recurrence rates can be up to about 20%, even in the right hands. Our good friends from Australia, Michael Burke, have shown that if you adopt certain strategies, you reduce the risk of recurrence. But we know for certain that there are recurrences even in the best of hands. So are you going to condemn a young patient to lots of surveillance procedures and at the same time burden your unit with surveillance, or would you prefer to spend a longer time resecting the lesion with a better outcome and a definitive stance? That's my question. Right. No, good points, Ed. I mean, and I do understand the issue related to surveillance. On the other hand, if there is, on your imaging, no evidence of cancer and you're dealing with high-grade dysplasia, I think the recurrence rates can be well managed. But I think your points are well taken about, you know, the entire overall comorbidities of the patient, what kind of lesion, what kind of surveillance, you know, you're looking at. But I think just to be aware that, you know, how we approached it in the past, and yes, recurrence rates, but I think with STSC or burning the margins, I think you can really reduce recurrence rates. Yes, and I get that. But I also, and I'm still going to defend the corner here, because that's why we're here, to debate the different stances. In my mind, ESD is moving to a place, I don't think it will ever quite get there as universally as EMR is. But as we get better, especially in countries outside Japan, we will favor it more. And the industry is helping us. For example, this tool we're seeing made by Boston, this is a multimodality instrument that allows you to have an insulated tip. You can inject through it. Yes, of course, other knives can inject. But what I'm saying is the industry is listening and it's helping us make ESD faster and safer. One point from my side is, and I agree with Ed, this is a definite treatment. And talking about green endoscopy and ESGE published its position statement on green endoscopy, this patient does not need a control endoscopy after six months, if it's a zero. The next control should be in three years. And this is another advantage, I would say. And talking about green endoscopy and resources, I think we save a lot of resources doing one procedure correctly, definitely, and avoiding unnecessary recurrent treatment or surveillance endoscopies. Yes, and I would like to emphasize not only the local recurrence, but why for this kind of large region, the M-group resection is necessary, is a precise histopathological analysis. Because this kind of region, even if the biopsy reveals the adenoma, the risk of the inter-mucosal carcinoma or sub-mucosal invasion is still the problem. And if we do the piecemeal resection, detailed histopathology for the sub-mucosal invasion or lymphobascular invasion is really difficult. So if without correct histology, we'd miss the proper treatment of the additional surgery. That's why, especially for this kind of a large region, in both pre-section and detailed histopathology, especially for the SM invasion evaluation and the lymphovascular invasion, and also budding grade quality differentiated components, such kind of the estimation is really important, yeah. Yeah, good points, Yutaka. And there are a few questions, Yutaka, for you. And I guess a lot of our debates and answers will be answered by the RCT, which is currently ongoing, comparing piecemeal EMR with ESD. So we will get better information. Yutaka, for you, there's some questions. Is what is the best position of the patient for a rectal ESD? Best position? Yeah, patient position. Is it on the back? Is it left lateral? Is it right lateral? How do you decide that? Oh, it depends on the tumor location. In this case, so first in the left side, left side position, the region under the water. So we change the patient position. It depends on the tumor location. So it's better to locate the patient, the region just opposite to the water. Dr. Saito, this is nice demonstration and a good discussion. We will come back to you. So we'll go back to Dr. Saito. Dr. Saito, you're live. Okay, so now, first we start the procedure using retroflexion. But retroflexion position is somewhat very difficult to use, move the scope. Then, so we change the strategy to a straightforward view. And this is a pocket creation or expanded pocket creation method. From the anal side, we are doing the partial marginal incision. And then some causal dissection continuously. So now that this is like a poem, poem toning procedure. This is the anal side and the marginal incision of the anal side is almost completed. And we are doing some causal dissection like this. And this is a region. This is a region. And this is a muscle layer. So it's better to dissect, inject super. Dissect just above the muscle layer. But probably due to the large tumor size, lots of vessels exist. So we are doing the ESD. And when we encounter the thick vessel, we pre-coagulate the vessel. Yutaka, beautiful demonstration, Edward again. Thank you for showing us this, amazing. I have a couple of technical questions. One, do you have any preferred diathermic settings? Because I know the audience has asked. And number two, what do you use to pre-coagulate the vessels with the knife? I mean, I presume that you're using the knife rather than a coagulation forceps, correct? Okay, thank you, Edward for nice question. We are using the dry cut mode, dry cut 4.7 for marginal incision. And precise sect for some causal dissection, effect 6.0. But in this case, lots of vessels exist. We are using swift coagulant 5.0. Okay. Thank you. And we are using starch, starch for the phytosome causal injection. And then move to change to the All-Rise Pro. I see, good strategy. Another couple of questions, another couple of questions regarding strategy. So you're nicely making the pocket now. Would you have a point in time when you start opening the pocket and presumably you'll start going gravity side first? Yes. Yeah, so maybe it's better to proceed the pocket until the end. And of course we need to check where they go. So sometimes we need to see from the lumen. And then even the pocket is going through the end of the tumor. So we need to start the marginal incision finally of the outer side. And then start the longitudinal incision of the gravity side. Now that we are in this situation, the sum of causal elevation is very nice. Let's put it in there. So this is the IT nano. You developed this yourself, if I remember correctly, right? I think it's very safe and very fast. Yeah, yeah, very safe. IT2 is mainly designed for the gastric ESD, but IT nano is designed by me and Professor Ono, Hiroyuki Ono, for the colorectal and the esophageal ESD. Yes. And it's got good coagulation properties as you can see here. A question, another one, Yutaka. So as you know, there are some new technologies that have recently come out, namely made by Olympus, RDI, so red dichromic imaging, which is designed to try to help us identify bleeding point in difficult bleeding. And the data is very limited so far, but through your personal experience, I know that you use Olympus at the National Cancer Center as well. Yeah. What is your impression of RDI? Is it helpful? Because the original Japanese study did not show that it slowed down, it sped up the time. There was no difference. Yeah, unfortunately. So we are also involved in the study of the RDI. Study result, unfortunately the study results was negative, but to tell the truth, we always use the RDI when the active bleeding occur, because it's really easy to recognize a bleeding point. Today, unfortunately, we cannot- There is no bleeding. Yeah, yeah, no, no, lots of bleeding, but unfortunately we couldn't use the RDI mode here. Yeah. This system. I see. And also it calms the endoscopist down because it removes the red. Yes. That was the study's message. When you remove the red color, the stress in the room is lower. Yeah. The secondary end point of the stress of endoscopist is dramatically decreasing using the RDI mode. That is really nice one. Yes, yes. And while we're doing this, so when you have difficult bleeding in ESD, it can cause a lot of problems. Number one, it slows down the procedure. Number two, it disrupts the planes. Yeah. Do you have any tricks up the sleeve to sort of stop or if you have very difficult bleeding, do you use Puristat? What is your strategy, Yutaka? So the most important thing is stop bleeding before. And we also using the 110 mode proposed by Professor Toyonaga. The 110 mode is in this BIOS III. The setting is 0.4, 0.5. Forced coag, yes? Forced coag, yes. But what if you are unlucky and you strike a very big vessel and you can't stop it? What would you advise? Let's say you have a difficult situation. So for this kind of sick vessel, we need to dissect before the marginal surrounding mucosa and then surrounding mucosa and then change to 110. Sometimes it's helpful to change the position of the patient using your gravity that you have a better view. Yes, yes. I use RDI, the coagulasper, to get the- But for the correct ESD, well, the coagulasper, we usually use the bipolar one, TITAN from Xeomedical or Chemostat-Y from Pentax. Pentax, Pentax, Pentax, yes. And while we're talking about bleeding, because it's one of the things that slows down ESD, bleeding and fibrosis. So, and the rectum is one of the worst places to do ESD for this reason. I'm going to ask you another question. So my good friend, as you know, from GC Medical University, Tomo Noriano, came up with gel immersion endoscopy, which allows you to pinpoint the vessel. And I wonder if this would work synergistically with RDI. Do you have any experience with gel immersion for bleeding? Ah, that's a good question. Yes, gel immersion, we sometimes use in very severe uncontrollable bleeding, the gel immersion technique is really excellent. Now, dramatically, the endoscopic view become clear. And that's a really nice one. In slow motion, in slow motion. Yes, yes. Very, very good idea there. Dr. Saito, this is good demonstration. We will come back to you. Okay. Dr. Saito, we're back to you. Oh, welcome back, Injection. So we are now going, performing the final marginal incision of the right lateral side. Toning is already completed. And the left side marginal incision is also completed. Now that I can see, okay, the region is ideal. We are starting the toning from the inner side and then toning completed like this. This is inner margin. Now, this is a tunnel. We are dissecting a little bit more to the right side, but this is a real tunnel. And the left side, marginal incision completed. So we are completing the dissection from inside to the left side. This is a left side gravity position. And then we are finally performing the right side marginal incision using IT9 nano. And then the strategy is completing the tunnel to the right side and the left side. You talk a brilliant demonstration, Edward, again. Can I kindly ask you, for people who don't do the pocket creation method often, are there any tips to sort of make the opening of the pocket safer? Because sometimes you can get very close to the muscle when you're opening the pocket. It's the most difficult bit of the pocket creation method. What are your safety tips and how can you make it more efficient? Yeah. So sometimes, yes, you're right. Opening the pocket is difficult. So we are using IT9 nano for the opening the pocket. It's the incision chip at the end of the needle. That's why maybe if you continue completing the pocket only using the needle knife, sometimes difficult. So in such a situation, IT9 nano, or maybe scissor type is easy to open the pocket. Do you agree? Yes, yes, I totally agree. I totally agree. And as I mentioned earlier on, you can sort of float the lesion as well and open it from the inside outside. But your IT9 nano technique is very clearly safe and efficient here. Thank you very much. So we're very close to finishing, I think. We're very close to finishing. Now the incision is completed. Yes. Yes. And I wish to ask you, Yutaka, do you ever find a situation where you change the position of the patient for gravity to help you while you are opening or while you are dealing with difficult scenarios? Hmm. Yeah. But using the tunneling or complete, tunneling method, tunneling or pocket creation method, well, patient position change is not so frequently necessary. This is, you can see the vessel, but using the IT nano, if you dissect slowly, even for the thick vessel, of course, using the direct visualization. And also sometimes from the both side, dissection is very important. Only from the one side, sometimes tumor orientation become really challenging. And now the hook is a knife at the end of the dissection plane, and then dissect. It's a three-step to see the edge and then approach the IT knife to the edge of the dissection plane, and then dissect. Yes. I see very nice demonstration. Hmm. The topicals are now without any touch devices. Yeah, yeah. This is because of the gravity. Because of the gravity and the tunneling. Yeah. Yes, yes. Amazing demonstration. And you are still using the same settings, yes? I think you said precise sect for the section. Yes. We are using the, ah, no. When we are using IT knife, we are using spray coag mode. Ah, spray. Okay, so it's a bit more powerful. Yeah. Same setting of the poem procedure. Yes. So that's a bit more powerful and it affords you to even coagulate vessels while you are dissecting. It's more efficient. Makes it more efficient. But beautiful demonstration. No muscle injury. Yeah. Very challenging lesion. Yes, thank you very much. Dr. Saito, we'll go briefly to Dr. Rex and we'll come back to you after. Okay, please. Now that we are completing the subcausal dissection of the left side. Left side. Ah, this area is just under the gravity. So, we are doing the dissection, some water immersion. Water immersion technique. If possible to leave the right side, I leave it, but the right side already dissected. So, only the left side is still remain. Yeah. Now we are changing the final dissection to the All-Eyes Pro knife here because the lesion is coming up straight forward. Yeah. Precise. Okay. See if you can show part of it. The swift coagulation, please. Now that this is injection water, injection is really nice. In the difficulty, another option is finally to change the patient's position. Yutaka, I can see that because of the lesion size, it is flopping around and making it a bit more challenging. So in our unit, we would flood it and allow it to float, but there's another way, which is mostly used in Europe. It hails from France, and this is the dental band clip, which is very cheap and useful. Do you ever use it, and if so, what tips do you have about using it? Yeah, we frequently use the dental construction for this in case of the challenging case. Yes, that's a very nice advice. And if you were to use the dental floss, would you apply the clip to the proximal margin, to the distal margin? Yes. Which side would you go for? Yeah, so that's a really good idea. For the finally, even in esophageal ESD, so... One option could be also to change the position of the patient. Yes, yes. I mean, as you see, the water is under water, so there's still the gravity now, and it's a bit disturbing. Yes, yes. If it starts bleeding, you are lost in this position. Yeah. Yeah. And this is the anal side, so to... But I didn't see any red blood cells during the procedure, so definitely no bleeding. Yeah, yeah. No chance to show the RBI system. Oh! However, finally, after dissection, we will spray the... Puristat? Puristat, puristat, puristat, yes. Yes, yes, yes. To decrease the risk of the delayed bleeding, because I heard this patient will go home today. Yes. Do you still admit them in your unit, Yutaka? Do you still admit these patients for 48 hours observation, or are you discharging them now? Yeah, we are using the five days clinical pass. The patient admits the one day before, and then... A total of five days admission in Japan for correct ESD. Okay. Yes. Yes, and a question which may arise from the audience. Yeah, I think... What about the use of prophylactic antibiotics? Helmut, do you... Well, it's not necessary in this situation, I think. You don't use them? In the rectum, if it's close to the anal verge, we give antibiotics, but usually in the colon or in the upper GI, we don't do any antibiotics. Yes. And what's your practice, Yutaka? When the region is very close to the anal verge and lots of hemorrhoids, sometimes, yes, also patients show the fever, so we use the antibiotics. Yeah, yeah. But in other, so we don't use prophylactic clips. Okay. Sometimes the last five hours are the most difficult. Yeah, indeed. Because the lesion gets sloppy, as you said, and either you use now a clip device or a traction device or the gravity. Yeah, yeah. This can be the most challenging. Yeah, yeah. But I think it's almost done. And as I said, if pathologists confirm the arterial resection, from my point of view, the next control is necessary in three years. Oh. Yeah. There is no risk for recurrence. Yeah. For the local recurrence, no risk of the local recurrence. But maybe for this kind of the region, patient with the large LSD, we recently published in Gastroenteroscopy, the five years long-term outcome. And in the case series that we experienced 1% colorectal cancer, it's not the recurrence, but the metacronal region. Yeah. That's the reason why we have the patients under control and the surveillance. So now I use all two observations in Propofol sedation. Yeah, we are also using the Propofol sedation, but no intubation in the collector ESD. Yeah. Then please go over there. All right, all right. Helmut, do you universally use Propofol for ESD in Germany? Or do you sometimes also use conscious sedation? Because at least in the UK, although we have some access to an e-test for Propofol and in the UK, we cannot give Propofol ourselves. We tend to use Midazolam and Fentanyl a lot still. So in our German guidelines on sedation, we tend to use Propofol. Or by physicians. So no esthesiologist is necessary. We do only for upper GI ESD uses an intubation, but in lower GI, I would say the majority Propofol sedation with the assistance of an experienced colleague of my endoscopy unit. So now we have our bleeding. Ah, bleeding. Yes, you asked for it, Helmut, you asked for it. Probably we can show now the RDI if we don't pick up the precise bleeding point. Yes. Yeah, I won't show the RDI, but this system doesn't have the RDI mode. Ah, it doesn't. Yeah, okay. Okay. But in this situation, it could be helpful. Yes, yes, absolutely. Yes, it could be helpful. Clear data. Close for the moment. Yes. And Helmut, I'm going to ask your perspective. So a lesion like this in our unit, at least I think in the UK in general, we would look at three, four hours, you know, and the doctor has made it. It is the same in Germany. Position change, finally. Aha, you're going to change positions, okay. Good. Yes, to flop the lesion over. But I was asking you, Helmut, are we still looking at long times like us in Germany? Yeah. Well, it's the same situation. As you said, ESD is becoming more and more attractive in Europe in the special centers. We did ESD register in Germany. Oh, please move the patient position. There are a couple of centers with true ESD on a high level, but the complication rate is in the core- Patient position change to the final position. Final, final position. It takes still a long time, yeah. Thank you, Dr. Saito. Patient position change. All right, thank you, Dr. Saito and team. We will go back to Dr. Saito to see the finished product from the ESD he's been working on. Dr. Saito, you're live. Okay, now that we are almost the final part of the dissection. So this is the left side left side and almost the final part. They're using the IP knife like this. Now this is, you can see the final portion to be cut. Now we have finally changed the patient position. So now the still better. So this is a part of the lots of best cell. That's why the final portion. And now, from left side to right side. Now, finish. And the region is semi-circumferential, half-circumferential, and no perforation. And... Hmm. Ah, so then we finally spray pure stuff. Okay. Now spraying PureStat. And this PureStat is reported to have the ulcer healing. It's also helpful for the ulcer healing. We are pushing the PureStat using the air and just using how many cc? Three cc. We can cover all the ulcer of this five centimeter ESD. What about, okay, finish. So we need to retrieve the tumor. Do you have the... Do you have a nip? Brilliant demonstration, Yutaka. Oh, thank you. Let me ask you, you applied Puristat and there is increasing evidence now that it's got advantages, but do you ever consider closing the defect in colorectal ESD? What are your thoughts about it? Because the evidence suggests that it might be better to close it, but it's not hard science yet, I don't think. So what are your thoughts about it? Would you ever suture this? Would you use X-Stack? Would you use clips in a certain situation? Yeah, so it's a little bit difficult question because there is still no consensus closure is effective or not for the large colorectal ESD defect. But, and also the instance of the delayed complication, bleeding, delayed bleeding is reported very low. So at our institution, we close the defect only when there are some muscle damage or the patient who is a high risk for bleeding taking the anticoagulant. Anticoagulant, yeah, yeah, yeah. I think it's a bit bigger than five centimeters, really, this lesion, it looks bigger. You will close the bigger lesion? I don't think we close universally, it's difficult. So my practice is like yours. I apply Puristat, if there are any visible vessels, I might coagulate, but there are no data to support that. So I just pour Puristat nowadays and let's see your lesion. It's going to be difficult to take it out. Yeah. Thank you, Dr. Saito. We will go to Dr. Rex and we'll come back to you after. Okay.

endoscopic submucosal dissection

ESD procedure

sigmoid colon polyp

rectal bleeding

colonoscopy

biopsy

pocket creation method

IT9 nano knife

bleeding management