false
Catalog
ASGE International Sampler (On-Demand)
Endoscopic Submucosal Dissection
Endoscopic Submucosal Dissection
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
Our next speaker is going to be Haruo Inoue, and of course, everybody in the world knows Haruo because of his poem. Haruo is currently the professor at Showa University and chairman of Digestive Disease Center at the Showa University Koto Takashi Hospital in Tokyo. He is, of course, not only a fantastic endoscopist, but also has currently become the president of the Japanese Society of Endoscopy. Haruo, thank you very much. So I'd like to talk about the ESD and beyond. This is my COI. ESD, this is a guy who first performs an ESD, Dr. Ono, and the several Japanese doctors started the ESD at the same time. So, ESD started roughly 20 years ago, and then now, recent advancement in this field is using the counter-traction. This is a marked advancement, technically. So this is one of the techniques of the traction. So we use the regular snare and some clips to give our tissue tension. So approximate margin of the specimen was already dissected, and now we fix the snare using the clip onto the approximate edge of the specimen, like this way. We place, normally, three clips, so we can keep a nice traction to the submucosal tissue. The space itself widens, so the procedure itself becomes safer and easier. So, like this way, so this is a light after wide ESD in the esophagus. So, one of the extension of our ESD procedure is getting deeper, getting deeper. So, one is the endoscopic muscle layer dissection, and second is the much deeper endoscopic subsilosal layer dissection. And then, finally, endoscopic full thickness resection. So, this is a case of advanced esophageal squamous cell carcinoma. So, patient receives the radiochemotherapy first. EOS demonstrates the cancer invaded to muscle layer, fourth muscle layer. This is the actual procedure. You can see muscle layer was involved in cancer invasion. Of course, this is a case of a patient has no clinical lymph node enlargement. Then we decided to do the endoscopic. Now we dissect endoscopic muscle layer dissection. And then, finally, I hope you can see distal end. You can see a defect of the muscle layer. So, another technique is much deeper. So, we keep the counter-attraction in the same way, place a loop. So, this is a case of a gist in the stomach. So, now you can see a small gist. But previously, we performed FNA, and we have already confirmed this is the gist. Anyway, so, we have already dissected muscle layer. And you can see the serosa, stomach serosa. And behind, you can see the surface of the pancreas. So, we can preserve the serosa layer. But muscle layer has already been dissected. And after that, we have to close the defect using clips tightly. Yes, so, all these procedure attraction technique works very well. So, next, I'd like to introduce endoscopic food thickness resection. This is, again, the case of a small sub-mucosal tumor in the gastric phoenix. Or FNA demonstrator gist. So, now, we place the attraction like this. And in this case, the gist tumor is touching the serosa layer directly. Then, we have to complete the full thickness, full layer dissection. So, you can see the bottom of the image. You can see the defect. And then, we can get in a lateral peritoneal cavity, and we can see a spleen. Anyway, so, we wash out a little bit. And then, after that, we close this defect using loop and clip. We call loop 9, anyway. So, we close a defect using this loop and clip technique. So, another extension of the ESD technique is a sub-mucosal endoscopy. So, sub-mucosal space is the third space. And now, we can do the several procedures, poem, stop procedure, poet, and the gastric poem, and some other, Tsinghua poem, some other. Anyway, so, 2010, we have reported, we reported the poem procedure. The world's first case was 2008. So, please note the date of the procedure. The anterior wall is the world's first case of a poem. After injection place, a mucosal incision, and this is a sub-mucosal space. Now, we perform the circular muscle dissection. And after completion of the circular muscle layer, in the acarasia case, we complete the procedure. So, right after procedure, two months after procedure. So, volume contrast media pass very smoothly. Anyway, so, this is another application of this sub-mucosal endoscopy, our stop procedure. At the same time, we report as a poet, our endoscopic tumor dissection. This is a case. Our tumor is directly connected to the fourth achoic layer. The tumor is located between trachea and the descending altar. And then, so, in a sub-mucosal space, we are dissecting the circular muscle. And then, after total mobilization, we take out the specimen like this. And after that, we have a big defect. We can see our trachea and the membranous portion of it like this way. But we preserve the mucosal layer intact. So, nothing bad happens after procedure. So, a good application of the procedure is tumor size is less than four centimeters. So, bigger ones should be treated by a tracheoscopic or laparoscopic approach. So, other facilities reported similar results. So, gastric poem for gastroparesis is another important procedure. So, we access in a greater curve and then dissect the pylorus muscle. Dr. Moen Kashab, he reported the first case. So, this is a light after procedure. Myself, Dr. Moen Kashab, and Dr. Stavropoulos, we are together at the Johns Hopkins 2013. So, he reported his experience. So, this is my experience in Japan. So, the patient has a tight junction pylorus. And this is a light after dissection of the pylorus muscle. You can see both sides, the cut end of the pylorus muscle. And behind, you can see a shallow muscle layer. This is the duodenum muscle. So, just close the mucosal entry using clips. So, another good application of the osteomycosal endoscope is for a tsenker diverticulum. This is a case. You can see a tsenker like this way. You can see the septum in the patient pharynx. First, we inject and dissect the mucosal layer. And after that, we get in the osteomycosal space and start to dissect the septum muscle, glycopharyngeal muscle layer. After completion of the muscle dissection, we close the mucosal entry using clips. So, this is a mucosal defect. We close it using clips like this way. So, after healing, the volume flows very smoothly. So, last, I'd like to mention a bit about the postponed GERD. In order to avoid it in a surgical procedure, we place the do-fund application after helamyotomy. So, now we think we can do it, this do-fund application endoscopically. 2017, we performed the first case. So far, we performed 43 cases. We reported it. So, like this way. So, we place the anterior wall, some mucosal tunnel, and then get in the abdominal cavity through this tunnel, and then place the suture onto the anterior wall of the stomach, and then fix it to the abdominal esophagus. So, to this procedure, we use the needle holder. Now, we are approaching dissecting the peritoneum through the submucosal tunnel. And then, now we open the peritoneum. Behind, you can see the backside of the left liver. Then, get in the abdominal cavity. Now, we are scooped. We penetrate the needle through the full thickness of the anterior wall of the stomach, like this way. So, this is the pediatric scope placed in the stomach. We can see a monitor, monitoring the needle is coming in the stomach and then out. Then, we can see the nice mucosal folding cover the open hiatus. So, this is the data. So, pH impedance improved. So, now we think this poem, fundaplication, is very close to Doe fundaplication, I think. So, thank you very much for your kind attention. This is the ESD and its extension. Thank you. Thank you, Aru, for your brilliant videos. I think you always seem to break the barriers as an endoscopy is going. Then, I think we'll start to get questions in this, but I'll start by asking that to do all these procedures, do you have to be a surgeon or just even a physician endoscopist can do? So, I'm proudly saying that I'm an endoscopist, therapeutic endoscopist, but my background is surgery. So, a poem procedure, so any institute, almost all over the world, the physician performs the poem procedure, most of the institute. And this poem, fundaplication, a surgeon is much better, I think. Dr. Inouye, you showed how you remove, I think it was a gist with full thickness, resection, and closing the defect. Can you just touch on your selection of gists for full thickness versus most gists, I thought you don't need to do full thickness resection, is that correct or am I incorrect? Yeah, so thank you very much. It's a very important question. So, any case, when we apply to approach to the gist, we are trying to preserve, we are trying to preserve the outer muscle layer or cirrhosis, we are trying to preserve it. So, if we need to make a full layer resection, at the time, we do it. So, step by step, case by case, we select a minimally invasive approach as possible. And the advantages of the z-poem for the zenkers versus kind of your standard approaches, do you use any specific selection criteria or do you can use z-poem for all of the zenkers? Yes, thank you very much. This is also a very important question. So, before this zenka poem procedure, so we do the cutting all. So, mucosal layer, muscle layer, we cut the septum, septectomy, we did it so far. Now, we switch to our small mucosal incision and then get in a semicircular space and then cut the muscle. So, we have less risk of a leakage or less risk of a mediastinitis or bleeding post-procedure, I think. So, we are totally switched to our zenka poem procedure.
Video Summary
The video features Haruo Inoue, a well-known endoscopist and professor at Showa University in Tokyo. Inoue discusses the topic of endoscopic submucosal dissection (ESD) and its advancements. He explains that ESD involves using regular snares and clips to provide tissue tension, allowing for safer and easier dissection. Inoue also discusses the extension of ESD procedures, such as endoscopic muscle layer dissection and full thickness resection. He demonstrates cases of esophageal squamous cell carcinoma and GIST tumor, showcasing the steps involved in the procedures and the use of counter-traction techniques. Inoue further discusses the use of submucosal endoscopy for various procedures, including POEM, STOP procedure, POET, and gastric POEM. He also mentions the application of submucosal endoscopy for Tinkers diverticulum and fundoplication to manage GERD. Overall, Inoue highlights the advancements and benefits of ESD techniques, emphasizing their role in minimally invasive procedures performed by both surgeons and physician endoscopists.
Asset Subtitle
Haruhiro Inoue: MD, FASGE, PhD
Keywords
Haruo Inoue
endoscopic submucosal dissection
ESD advancements
tissue tension
counter-traction techniques
×
Please select your language
1
English