Hi, welcome back to the auditorium, the endoscopy room. So I'm Takashi Toyono from Kobe University and Professor Hagi kindly comment our session. Today my assistant is Dr. Sakaguchi from Kobe University Hospital. So I have created the two regions near the first session. You can see greater curve side here, near the greater curve side this region can be seen, and in the retroflex position the other one is created. So I start from this region. Maybe because of the injection, because the muscle is located in front, that's why to get into some causa will be difficult. So I'd like to show you the other traction device. First I need to inject, of course. So as you see the maneuverability is a little bit complicated. So basically Dr. Toyonaga is keeping a straight endoscope position. It is quite important to keep a stable condition. Then he can use his right hand to control the device. Now he is injecting normal saline without any color. What is the benefit of using normal saline without giving any color? Because sometimes it can be saved. As if I am putting the color, I prefer the very diluted one. Then it is not so much different. So for me I can see everything without color. Of course sometimes the severe fibrosis, I also sometimes put the color, very shallow one. So the main purpose of using non-colored solution is to observe the sub-mucosal layer much better. For example, finding blood vessel much easily and recognize muscle layer by its whitish color. Is that correct? Yes. But much more, so not necessary. Of course you can, if you want to put color it's okay, but more shallow one is needed. You need to see through the structure in the sub-mucosal, including the muscle layer. Otherwise, if you put a very thick color, the color will hide the muscle surface. But for most of the beginners, I think a little bit bluish color is quite helpful to recognize. Yes, I agree. Actually I also started from the injection with color, coming small and small amount, at the last I did without color. So as I mentioned, it is better to create a starting position. I move in this moment and just touch, and by conducting the endo-cut, so maybe big stomach has a very thick mucosal. Now knife tip goes into the sub-mucosal layer. Not yet maybe, because now... So by injecting from the knife, you can confirm, you have penetrated the mucosa. By the way, what kind of knife are you using now? Sorry, I'm using the flash knife, ball tip type. So you can see the ball here, 2.5 mm length, and by pushing the pedal, water is coming out through the sheath. Then I fix the straight cap. Then after creating a starting point, please insert the knife to the starting point. Then control the knife a bit, then conduct only one time. The knife has proceeded, then next control, end-cut. Then next control, end-cut. If injection is not enough, needle in. Currently Dr. Toyonaga is using end-cut of BIOS-3. Yeah. End-cut I, duration 3, and effect 1. Effect 1 means no coagulation during the cut. Then control and cut, control and cut. If you are very used to perform this concept, such a smooth incision can be done. But as if we are performing such a quick, seems to be quick incision, I'm dividing the step into three. One, two, three, two, three, two, three. So, as I see this morning, Professor Ihagi's video, you are smoothly cutting all around, but I guess also you are following such three steps. Yes, that's right. So, but beginners want to cut like this. It is very dangerous. It is better to divide every single stroke into three. If you don't slip out, you can skip step one. Step one is insert the knife into that position. But many beginners want to start from just the edge. Always they are pushing with the edge, and it is very shallow, or a mis-shot will be coming. So, to set the knife on the step one, it is better to just a little bit take back, and insert, then capture. And put the muscularis mucosa with the bow tip. That is really important. Sometimes I'm putting back the mucosa a bit inside the cap. Then, by shifting the cap, you can scoop up the mucosa. And especially when tangential approach is not possible, such perpendicular approach is only available, and also very thick blood vessels are located under the mucosa. It is better to scoop up the mucosa into the cap. Then, by sliding the cap on the mucosa, you can control the incision depth, just underneath the muscularis mucosa, which is the suitable incision level to prevent massive bleeding during the incision. Once we make a nice mucosal dissection, usually the incision line widely opens. So, if from the left to right, the mucosa will be folded, if you change the direction, you can maybe cope it. And since Dr. Toyonaga is keeping a straight endoscopic position, the movement is minimum, just twisting his wrist to the left side, and the knife tip goes to the left side. So, it's very important. The control should be done by left hand only. So, that's why I can control the incision depth at the same time. Of course, sometimes you need to hold a scope, and push and pull is needed, but at least you need, if the procedure is very precise, you need to control the insertion depth. So, right hand should be free to control the device like this. Especially, this kind of perpendicular approach is quite important to control the device. That's right. Now, he already made a nice circumferential mucosal incision. Even though it was a little bit perpendicular approach, it was really nicely done. Okay. So now, to get into some mucosa is a bit difficult. Of course, one or two inner edge dissections have been done, you can create the mucosal flap, but for the beginner, it will be very difficult. And also, according to the location, also it will be very difficult. So, one option is to introduce the traction device. So, I'd like to show you. And the other option is to use the viscous solution, such as AW or hydronic acid, but usually it's very expensive. But still, injection solution injected by Dr. Saito is remaining. He showed very nice lifting by using the AW. But that's okay. So, we need to insert the clip, because the traction should be outside the scope, long side of the scope. This is the easy clip. Easy clip is a reloadable end clip provided by Olympus, and this is short size easy clip. Okay. Please open first. Okay. But if you tie in the neck part of the arm, in this clip, this metal ring will be proceeded. When you close the clip, then this metal can cut the line. That's why it is better to tie onto the a bit middle, or not totally neck, but okay. This is dental floss, and made a loop, and tie onto the metallic part of the end clip. It's okay to tie onto the neck part of the arm. I think this part can't be cut. How about using another end clip? In the U.S., it is not available. That's why we have created a similar device with the seesaw, thin snare, and by putting back, using the tip of the snare, we have mounted dental floss inside the tube. It's okay. Now he is making a second knot and cut the tail of the dental floss. Okay. Okay, it's ready now. Okay, then by rotating the clip, it is mounted inside the cap. This is the seesaw of the thin type snare. Then we just a little bit elongate the line outside the tube. The major difference in between a simple clip and line traction and this special technique is that he can push away the target region by controlling the sees, not only pull back the target region with the line. So he can control both forward side and back side. Can you see it? Just a little bit rotate. It's okay. The line is here. Rotate. It's okay. Catching the edge. I'm confirming. Okay, now the lower side of the jaw is slightly under the target. Okay, close. So in this moment, open-close type is much better to place the clip very precisely, but the grasping force is weaker than easy clip. Easy clip is mostly tightly grasped edge, so it doesn't really deploy. So now assistant is pulling back the string, then he can give traction to the target region. So now you can see here the sees and the line, and if you push something like the fishing, you can change the direction, as you see. Then in the lateral flex. Okay. At the beginning, pulling back is better to open, but muscle is also lifted up, so you can adjust, you can find out the suitable situation. Okay. Now, sometimes beginners give too much tension to the target tissue. As a result, muscle layer also lifted up. It's kind of dangerous situation. Therefore, we should be careful and select the right dissection plane. It's really nice to re-open the sub-enclosure layer. the power is a bit too strong. I think sub-mucosal tissue is very loose. Injected solution easily disappears. I see. Also, I'm using the magnifying endoscope to adjust the focus. So, it's not so much clear, but if you can adjust the focus, it's much more confident where is the sub-mucosal tissue and where is the muscle. Please change to the duration 2. For dissection, duration 2 is plenty now. So, please simulate this type of tissue using fibrosis. Then, just touch here and conduct very short second. You are not hooking the tissue from the side. Just touch to the surface, then cut the tissue. Duration 1, please. The lifting is not so good because it's a bit fibrotic here. Then, just touch this fiber and cut. Very precise dissection can be done. This is tapping technique. So, initial part of the sub-mucosal dissection is the most important step. Once we completely open the sub-mucosal layer, it will become much safe situation. But at least at the beginning of the sub-mucosal dissection, we should be careful not to injure the muscle layer. Then, if you create the edge, please insert the knife under the target and pulling back toward the safer direction, like the paper knife. By pulling back, the safer procedure can be done. It's nicely done. By the way, do you usually use end cut also for the sub-mucosal dissection? Yes, for less vessel area, no vessel area. Of course, for the vessel, it is better to conduct the coagulation. So, you can simulate this will be the vessel, then coagulation mode should be conducted. What kind of coagulation mode do you usually use? I'm using the fourth core, effect 7 in the stomach. Also, in the edge, there are so many branched vessels. I just capture the edge, then by conducting the coagulation mode, it can be done. Now, it seems to be very nicely open, but you see the sub-mucosal space is very narrow. Because by pulling back, the sub-mucosa can be very thin. In this moment, I recommend you to push the tube, because the tube can go straight. Then, by tension of the seat, now the sub-mucosa has been lifted. You may know such differences. Just by pulling back, the sub-mucosa becomes thinner. By pushing, you can create a wider sub-mucosa. It becomes a really safe situation. Knife it out. To capture the target, you need to insert it deep enough. Then, if you conduct from here, you are creating a perforation. Just by inserting, step 1. Then, control, step 2. Now, an upper blow can be created. I'm controlling parallel or away from the muscle. I'm also pulling back the knife. It's okay. Sometimes, pulling back is better to open up the edge here. Then, capture it. Same one, same thing. Here will be the best cell. That's why coagulation. It is better to aim the apex. Capture it. I'm aiming to the apex. Then, a bit scoop up. You can open the sub-mucosa space much wider. Cutting the edge of both sides is quite important. Now, push is much better to extend the knee. Lift up the sub-mucosa. Now, he is pulling back the scissors little by little. Then, he can conduct safe sub-mucosa dissection. Then, after making the mucosa flap, you can get into sub-mucosa completely by using the cap. Now, you can see the wider sub-mucosa. Now, we can see the whitish muscle layer below the sub-mucosa. Then, from the sub-mucosa, you can see the edge. You need to confirm both starting point and the landing point. Then, to the landing point, please control the knife. I recommend you to not seek the landing point during the procedure. Before starting procedure, it is better to confirm the landing point. Aiming from the starting point to landing point. Then, the target is behind the region. That's why it is better to complete the disconnection of the edge before approaching to the outer side of the mucosa. Since it is on the mucosa, that's why the dissection is not so deep. So, well disconnected the region was. And also... If you come from the left side of the seas, maybe you can shift the target to the right. I have set the endoscope on the left side of the traction device. That's why the region has shifted to the right-hand side. Then, you can see here the space. Capture here, then control the direction. Here, maybe the vessel is in the living patient. That's why I'm conducting the coagulation mode. But too much coagulation is difficult to cut. So, coagulate, coagulate, coagulate. And at last, cut mode can be conducted to disconnect the edge. Also, you can see here the white substance. This will be the vessel. That's why I'm scooping up. Then, conducting a bit longer to stop breathing. Of course, you see a very thick vessel. So, pre-coagulation or vessel sealing by using the knife itself is helping you to reduce the risk of breathing during the dissection. So now, almost disconnected. So now, the time to approach to the final part. And also here you can see the edge. Capture it. Then, dissect and inject. Now, he showed a nice technique. Catch the edge and dissect that tissue by pulling back manna. So, it is a completely safe situation. So, this is similar with the hook knife procedure. Of course, the grasping force of using the bow tip brush knife is weaker than the hook knife. But it works very well. Plenty enough. Now, you can see here the edge. Because I have already created some U-shaped groove by disconnecting the edge from the outside helicium causa. So, of course, in the stomach, such a slow and precise procedure is not so much needed because the muscle layer is very thick. So, for this, such a precise manna will be recommended. The tubers are very soft. That's why a bit of control is not so good. But by changing the position of the tube, you can create a suitable situation. Now, you can see here the edge. Okay. But by pulling back, some causa becomes thinner. Okay, by pushing, it's okay now. Okay, out. Hmm very nice So capture it, you know, I can see the landing point That's why continuously you can dissect and the coming closer and by using the tip of the cap I have opened some of course then inside the knife then I'm observing the spark because the knife tip cannot be seen so well behind the dish. If you are using the hook knife, tip of the knife cannot be seen if you insert the device into the samukoza. That's why, but I can see through the device and also during the conduction, I can see the spark then safe level can be kept. And also by using attraction, the final approach become much easier on the samukoza. Congratulations, really good demonstration. Okay, so, okay, then also by using this, you can retrieve the resected specimen very easy. In this moment, I feel something like a fisherman. Congratulations. Thank you. Okay, we have time, okay. Next, I want to show you the pocket creation technique. For the virtual audience, if you have any question, please feel free to ask us. We can give the answer to you at any time. So basically, what kind of situation are you using this traction technique? Especially in the stomach, a push and pull is very much work, especially in the lesser curve and anterior or posterior wall. Greater curve side, maybe just pulling backwards. But in case of having some difficult, in the stomach, I use this device. But in the esophagus, just pulling back the thread is plenty enough, so only a creeper line I'm using. By the way, is it also available for right side column? Yeah, you can bring it to even for the right side column. And bring it to even for the right side column. And also, if we use a clip from the beginning by putting the band to keep the grasping, then you can do this. But in the deep column, internal traction works very well. That's why nowadays I'm using the small elastic bands. So, what kind of technique are you going to show us for the next? Next, I'd like to show you the pocket creation technique And hopefully, without distraction, I want to complete So, okay, later on I'll show you Okay, needle, please So, for the pocket, you don't need to inject the entire circumference Just injection to the entrance is plenty enough You mean the near side from the endoscope Okay, same, for the incision, it's the same. Uh-oh. Uh-huh. So, some malfunction has happened, that's why now reboosting the thermic. Working. Check instruments, probes. Can you call the technique from the RB? I think it's okay. So, call your course. Go strange So doesn't work So with enough Long spring Okay, thank you. Okay, same. Usually in the human, already we can just two, one or two conduction can create a port. Now, injection is coming, it means the breakout is enough. Okay. So, same as previous time, Dr. Toyonaga hooking the edge of the mucosa and cutting a little bit shallower in order to avoid bleeding situation right after mucosal incision. This is very important technical tip. Okay, so I'm creating relatively wider opening than the original pocket creation method because to get into some mucosa is easier when you create a bit wider opening. And by scooping up, this can be better, that's why coagulating and cut. And inject. Okay, now by using the cap, I can open the mucosa. Then here is the... Okay, a bit more wide is better. So, to confirm the mark is important. Okay. So, wide opening technique can be called something like the bridge formation method. But there are so many names for the same concept. That's why, as if the shape will be something bridge, but I'm calling this pocket creation method because the pocket creation method is the original name. Okay. Okay, now I have succeeded to get into some mucosa. Oh, it's very nice. Once you get into some mucosa, you can change the direction of the muscle usually because the cap and the scope can be parallel to the muscle layer. So, wider is better. But as you see, the opening of the pocket is sometimes difficult. But okay, now... So, to get in some mucosa, it's better to suck the air. Extending stomach is very difficult to get in some mucosa. But by sucking the air, we can soften the target. So, you can see here the muscle. And by twisting, you can make the parallel approach to the mucosa or muscle. In case of doing pocket creation method, too much separation is not necessary. Just suck the air and relax the entire region, then go into the sudden mucosa space. And now you see the injection has reached the oral edge. Now is the time to open the oral side mucosa. So, making another mucosal incision here is to confirm the end point of the sudden mucosal dissection. Okay, this is the major difference from the original pocket creation method. Some colleague name for this tunneling technique, but Professor Yamamoto changed the name from the tunneling to the pocket because tunneling can imagine a small duct. So the purpose of this technique is dissect underneath this region as much as possible. That's why pocket method is much more meaningful. Okay, so I want to penetrate to the sub-mucosa. So this is the oral side in a straight position and give additional fluid cushion directly to the sub-mucosa layer. Now we can see muscle layer on the upper side, which is whitish area. Okay, so the approach of this, lesser curve side is a bit difficult. Okay, now it's okay. Okay, now you can see here, I have changed the direction of the muscle. So Dr. Toyonaga is nicely avoid touching the muscle layer by changing the direction. And also by inside the pocket, inside the sub-mucosa, by bending the scope, you can make parallel approach because the mucosa can lift up the surrounding tissue. This is one of the great merit of the pocket creation method. Okay. For the lateral extension, how can recognize the dissection level for the lateral direction? It is not difficult to confirm from the sub-mucosa. That's why sometimes you need to come back to the endoscope and observe from the outside. Outside and inside. Okay. Now, penetrated. You can see the outer side of the edge here. Then by capturing the edge, you can create the opening. And also from here to the right. Okay. A bit more is better. Okay, now by twisting the scope, we can change the direction of the muscle. Okay. Okay. Now he is dilating the opening of the outer side. Okay, now pocket. Pocket has opened in the outer side. Now, we will finish the incision. So, which is the gravity side by... What are we coming from? A bit left, so it means that gravity is coming from right to left. So, I will keep the right-hand side mucosa for the anchor. So, I cut the left-hand side at the beginning. So, that means that in case of cutting the right side first, the area will be coming down. That's why he started to call the incision on the left side, the lower side according to the gravity first. Yeah, if you cut the right-hand side, it means the anti-gravity side, the region will be down to the gravity side, and the incision area cannot be seen so well. That's why I first incise the mucosa of the left-hand side, and I'm scooping up and complete. Okay, but if you don't, dissect the sub-mucosa completely, you can remain the tension. Okay, so... Okay, I will proceed the incision. Okay, capture. I think the pocket creation method is very good for the sub-mucosa dissection, but the final part of opening the remaining mucosa is a little bit challenging. Right, right. And also, more challenging will be the complete dissection. So, the incision can be done relatively easily, just insert the knife and scoop up the knife. And also, by creating the field using the cap, I'm stretching the mucosa by using the tip of the cap. Then, scooping up and complete. I remain just a tiny part, sub-mucosa. But, you see, here, here will be mostly dangerous and difficult to dissect. So, because the... Well, it can be done now, but I often felt the difficulty to open up this edge of the opening. So, in such situation, I guess, I hope it works. Where is the entrance from the other side? Here, here. Now, I'm coming to the sub-mucosa from the other side. And through the... I passed under the region, and I'm carefully creating the retroflex under the region. Oh, that's great. Now, you see? You can widely open the sub-mucosa space, and it becomes completely safe situation. Yeah. Now, by using the scope shaft, you can create a good counter-direction. So... This is really impressive view. Yeah, yeah. That's why, if you combine with the retroflex traction technique, without traction device, you can provide such a nice counter-direction to the sub-mucosa. We tried to submit the video, but just before submitting the video, I found this technique already reported. Oh, really? By Jitsuhi Medical School? No, maybe European colleague. I forgot the name. But also, the original naming, also I forgot. Also, it is better to remain tiny sub-mucosa to keep this traction. Otherwise, it becomes crappy. Yeah, crappy. But if you maintain the anti-gravity side, it's okay, just hanging down, that's all. But in case of some situation, by remaining that. So now, it turned to the flap. So, by making the strategy, so you can keep the good situation. Now, this is the final cut. So, I'm very pleased to succeed to show such a nicely created arch shape by the shaft of the scope. Because in the retroflex, shaft is always 12 vocal side. That's why very nice counter-direction can be provided. Congratulations. Thank you very much. It was a wonderful demonstration. Okay, we need to change the stomach, so please take a break.

endoscopic procedures

stomach

submucosal dissection

normal saline

flash knife

end-cut mode

starting point

traction devices

pocket creation technique