Okay, so my case is gastric and esophageal ESD case, so I will talk about troubleshooting for the unexpected massive bleeding during ESD. So do you know the general emerging endoscopy? Okay, no, so I introduce so very simple method, so ____________________________________________________________________________________________________________________________ Okay, so you can see the two bottles, so left is the gel and right is the water. So you can see in the water, so ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ But so, yeah, you can see the water and blood immediately mix, so it is not good. And so this part is easy to collect the blood. So change to gel. So you can see that in the gel, so blood is the move, it becomes slowly, and so continuously the inject gel. So you can see that easily the deep bleeding point. So there is a respiratory movement, so it is very difficult, but so we can catch the pinpoint, catch it, and coagulation forceps well, because this gel has no electrolytes. So we should avoid the head on, approach to massive bleeding. So firstly, the tips of this method is firstly, and the food is toward to the wall, and so fill in the gel in the food. And so find the bleeding point with continuing injection of gel. So this second case is esophageal case. So I didn't know why I cut it, but so, unexpected, sorry. But so this is a lower esophageal, sometimes very massive bleeding. So I give up, so change, early time, so change to the gel, and gel emerge on. So you can see the firstly, the toward direction of food, toward to the wall, intentionally wall. So but firstly, fill in the food by gel, so and slightly, and slide, slide, find the bleeding point. Where, where, so this is the bleeding point. And so I can afford the massive bleeding, but we can secure the visual field, and so pinpoint, so we can find the bleeding point. So, catch, and no bleeding, and retry, it's open. And so pinpoint, we can catch the bleeding point. Yes, so this is stop. And coagulate it, because this gel has no electrolytes. So this method is one of the option of the gel in bleeding. Thank you. Thank you very much, very interesting video. Unfortunately, this gel is not commercially available in the United States. Yes. Only in Japan, I guess. And recently, in China, available in China, yeah. By the way, how much is this cost? Cost is, yes, and one bottle is about $15. It's quite cheap. $15, but so it's the same as a lunch. No, no, no. No, no, no. Norio, how was your impression of this technique? Oh, that was really good. You know, the utmost importance is to find out where exactly bleeding coming from. And the bleeding, especially in the closed area, like if you do the pocket creation or semi-closed tunneling, bleeding can fill the cavity and you should lose the sight quickly. So this is great. What kind of gel did you use? Biscochlear. This is called Biscochlear. Biscochlear. Biscochlear, a product named Biscochlear. So first, gel is the food to prevent dehydration. The food, but so the food is to prevent dehydration. So that has electrolytes, natrium, cadmium. So it doesn't work in the gel because the... Electrolyte current disappears. Current is displayed, yes. So change to the electrolytes, free gel. This is free gel. So that means in case of try to coagulate bleeding point underwater condition, when we use normal saline, it usually doesn't work well. We should suck the liquid completely before applying electric current. But in his technique, there is no electrolyte within gel. Therefore, they can easily apply electric current and it works very well. Sorry, what if you mix the gel with the RDI of Olympus? RDI. Oh, he didn't use RDI. Sorry. I am a Fujifilm user, so I have an experience of RDI, sorry. Any other question or comment?

troubleshooting

massive bleeding

gastric ESD

esophageal ESD

gel method