Good afternoon, ladies and gentlemen. My name is Yutaka Saito from National Cancer Center Tokyo, Japan, and Professor Seiichi Rabe from the same hospital, and Professor Toyonaga from Kobe University. Today, we are going to show the live demonstration of the gastric PST using isolated pig stomach, and we are going to use O-Rise Pro-Knife for the first marginal incision, and then IT-Knife 2 for marginal incision and some causal dissection. And if possible, we'd like to show you the usefulness of dental floss traction. Okay. And also, we are going to show the ESD using a retroflex position. The marking is already conducted. This is a curvature of the upper gastric body. So first, we are going to start some causal injection. This is O-Rise Pro... O-Rise Gel. No, no. Erebu. The viscous solution. Erebu from... Yes, Erebu. It's a little bit hard. Okay. So, needle out. Injection. Okay. Injecting. Yes. Stop. Injecting. Okay. So when you apply the traction technique in this location, do you completely incise at the beginning or partial incision? Yes. In this isolated pig stomach, we performed a complete marginal incision. Okay. Injecting. Okay. Injecting. Okay. Injecting. Usually for the gastric ESD, this kind of viscous solution is not necessary. Okay. Stop. O-Rise Pro knife, please. We are going to perform the first marginal incision in the oral side from 12 o'clock to 10 o'clock. And then we change to the IT knife. This is a typical conventional way of the IT knife dissection. The first incision from 12 to 10 o'clock. It means you are creating the starting point for the IT knife. Yes, yes, absolutely. Just for, I don't know, maybe the scope bending is a little bit tight in here. So using the full angle, it's difficult to insert this device. So we now change the scope position to straightforward nuance. And then, so this is the oral side. Okay. This is O-Rise Pro knife. 2.0 mm. From 12 o'clock to 10 o'clock. Okay. To see the depth is okay. Change to IT. So recommend, how about the recommended depth? Might, the first incision should be deep enough. At least musculoskeletal causes should be. Yes, that's absolutely important. And also this endoscope is left-handed. The device is coming from the left lower side. Maybe that's why you create the initial incision just a little bit to the left. Absolutely, yes. And then we are now inserting IT knife 2.0. And this is good for gas EPSD. For esophageal and colorectal, we prefer to use IT knife nano. The chip is smaller. IT2 is a really very nice effect for cut, but a little bit dangerous for esophagus and colon. Now Professor Saito is using the end cut knife for incision. And the duration is four. Four is okay for you? Yes. Okay. So mostly incisive mode we are using. Interval is very short. And then this is a little bit. After cutting, two or three cuts. And then from the opposite side. After cut, check. So the target stomach is taken out, so no blood flow. But in the real patient, there are many bleeding. Yes, yes. So do you have any tips to prevent the bleeding during the incision? Yes. So IT knife 2.0 has a very high effect for coagulation. So if the bleeding occurs, it's better to cut to trace the margin. Using the C-square, right? Yes. And maybe an injection again. In the human, after marginal incision, it's better to inject again. But in this situation, already injected, it is not necessary. But it is better to show. We should stimulate the VR-ESD. And also suction is important. So full air is not good. This is just a small biopsy check. Okay, needle out. Injection, injecting, injecting, injecting, injecting. Okay. Injecting. Injecting. Injecting. Okay. Okay. Need load. Yeah, I think I have two. Okay, needle out. Now we can see some causal layer. Now we can see some causal layer. It's short. Not only from the right side, but also from the right side. The right side is the lesser carved side? Yeah, lesser carved. So located until the wall? Yes. And then, it's very important. Aiki knife dissection is usually from outside to inside. And then, using this attachment, we can see a really nice causal layer. And then, you can see the mass layer here. And then, like this. And so, you can see very nice, some causal fiber. And then, always find the edge. In this situation, unfortunately, we couldn't show the usefulness of traction. Maybe another location may be good to show the utility of traction. And then, this area. This is the right side. And also to rotate the skull. In this situation, the procedure is something like deburring. Maybe we should imagine the layer of the muscle. And then, you can see the fiber. Now you can see everything. And just hook the knife and... Now this is the final part. Oh, very fast. But, I've heard, as if you are using the Aiki knife from the proximal side, approach is proximal, right? Proximal approach, like the tip-type knife. So, you come from this side to proximal. But, as if you are using the Aiki knife, proximal approach can be done. From the near-side approach? Yes, especially for the large one. So, we prefer to use the near-side approach. Because, if we start from the oral side, when the bleeding occurs, it's really difficult to stop. Okay, we are going to show another region. Where should I start? Here is good. Maybe, next case, if possible, I'd like to show Fuji 2 Channel track motion. Needle in, please. Needle in. Aura's Pro knife could perform the marking with needle in. Okay, yeah, do we change the scope? So, this is a track motion from Fujifilm. I don't know the details, so please show me how to use it. I also just one experience before, but maybe the concept is really nice, very simple for the traction. Let's take a look. Lens cleaner. It might be good to show it from the mount. That's right. Proposer. Do you have that? Cap. Distorter. So, now we are preparing the distal attachment. So, after placing the attachment, this device can be fixed onto the endoscope or in advance we can prepare? Oh, maybe we need to ask the Fujifilm guy which is better. So, putting it in advance or attach it after the attachment. So, either works. Which is better? Works, but if you are confident that you are going to use track motion, so it should be convenient to attach it in advance. In advance, okay. So, we can attach this device in advance. To the right side. Which is larger? Yes, larger side. Larger side? Yes. This is the tool I used to make the top of the head. But it's for the head. Is it going to stick? It's a 2-channel, so it's fine. Which one is it? This one? Yes, that's right. Yes, that's right. Do you have jelly? It doesn't come out. Ah, brand new. Thank you. Okay, now we are going to start the Fuji double-channel scope with track motion. Track motion is already attached. Okay, the first injection. Oh, wait a minute. The knife will also come from the left side channel. It's a little bit different from the conventional ESD. Are there any possibility of truck motion to the left side channel and device from the right side? Can you go out, please? Injection. Okay. If you change the position, you need to change the scope design. Yeah. Injecting. Okay. Injecting. As I said, it's not so inconvenient. It's okay. Injecting. Injecting. Okay. Needle out. So, we can use the effect of the previous ESD, so we can start from IT knife. 3.2 channel also available in the website. It's good for therapeutic procedure, needle out, okay? So this manipulator can be used for the colonic region. The IT knife was pressed to the mucosa a bit harder. It's very dangerous for colonic one. So only for stomach? Only for stomach and also only for pig stomach. Yeah, of course in the human, sometimes the lesser curvature, the mucosa layer is sometimes thin. And also muscle layer is thin. Yes, yes. Okay, maybe when we are going to, maybe injection again. So because the locations are anti-gravity cells, universal traction, gravity can be used. Yeah, yeah, yeah, yeah. But maybe I think when I need a face injection, injection, injecting, injecting, injecting, okay. Injecting, injecting, injecting, injecting. Okay, needle out. Maybe after some dissection, maybe we can grab the tissue. The IT knife too, please. Maybe we're disconnected, so I think we can grab. Otherwise, quickly finish without traction. So please, how do we grab? Please open, just a moment. No, no. So where is the best position to grab? Center, we can. Center will be better? Maybe insertion length is too deep. Yeah, maybe, no, no. Lift up? Here, push. After aiming, you need to proceed the device, maybe. Okay, push, push, push. Yes, catch. Okay. Is this locked or? Locked. Automatically locked. Right side. Is this traction? Okay, the IT knife. Hmm. Okay, good, good traction now. So inserting IT too, we can see the edge. And then. A little. Hmm. It's a bit limited. Yes. So if you control the device by rotating mainly, the track motion also rotates. That's why target is moving together. Yeah, yeah. So from Sergei's lecture, just create a tension, traction, and then pulling back the knife. Pulling back knife, he was cutting. Lift up. Oh. Okay. Oh, that's good. Lift up. Now this, just a little left rotation. Right, right is better. Oh, good, good traction. Thank you very much, Professor. So according to the rotation, if you rotate the track motion, you can create suitable counter traction. Yes. So combination of the assistant and the operator is very important. But Sergei Kantz boy doing that. He's always doing it by himself. He's accustomed to how to use. But when you are familiar to use this, so you can do it by one more method. Yeah, yeah. Oh, very good. Good traction. And so basic technique find. So where do you want to cut next? Right side. Right side? OK. Yeah. Well, then, don't touch. It's OK. No, no. It's OK. OK. And if you pull back the knife, maybe you can cut it. Yeah, yeah. Yeah. Just straight and straight. Uh-huh. Now that this is the left side, we can see the edge very clearly. And then put the tissue and move the knife along the muscle layer. Now we can see everything. Yes. As if we were coming from the right side, so you can see everything. Everything, the edge. At the first lesion, it was from the right side. It was something like the blind fashion. Yeah, yeah. But now some causes open well. We can see everything. Mm-hmm. Oh, it's very nice. So we could show you how effective this traction. Hello? Hello? It's like a wiper. OK. Maybe we can also retrieve the device. Yeah, by this device. Together with this device. Straight? It should be straight, yeah? Uh-huh. Oh. Oh, no, it doesn't. No. Nice. OK. Maybe we need to accustom to how to use this track motion, but it's really helpful for making the traction. OK. Thank you very much. Thank you.

gastric PST

per-oral submucosal dissection

O-Rise Pro-Knife

IT-Knife 2

dental floss traction technique

ESD