Welcome back, I'm Naofisayo Hagi from Keio University, and I would like to show you some of my traction techniques, which is creep line traction and also the water pressure method. Therefore, I selected the gravity side in this case, yes, I already created two regions at the gravity side. Now you can see the correction of the water, this is completely gravity side. Usually this kind of location is very difficult to do ESD, because it is relatively difficult to open the sub-mucosal space. That's why I try to use creep line traction technique for one region, and for the other region, I will show you the water pressure method. Currently, I'm working together with Dr. Kato, who is also coming from Keio University, and Dr. Saito will give us some comments, and Dr. Toyonaga is also staying with us. Well, for the traction technique, it's quite easy to open the sub-mucosal layer. Therefore, at the beginning of the procedure, I would like to make a circumferential mucosal incision. Open the needle, please. I would like to start the mucosal incision from the inner side first, and a few millimeters outside from the marking dot, I would like to create a sub-mucosal fluid-cushion injection, please. And it is necessary to check the nice lifting sign, okay, that's good enough. Then check the lifting, and go to left side, and again puncture here, okay, injection, please. Now, I'm gradually pulling back the instruments, then we can create a nice sub-mucosal fluid-cushion. Okay, that's good enough. Then going to further left side here, okay, injection, please, okay, that's good enough. I'm pulling this area, okay, injection, please, okay, stop, okay, injection, please. Okay, that's good enough, and also here, it's about, just about, okay, that's good enough, injection, please, okay, stop it, please, okay, I think it's good enough, okay, needle in. Okay, I need to shift… 3.5, it's up 3.5, close. Okay, usually for the gastric ESD procedure, I prefer to use dry-cut mode for the mucosal incision, but sometimes I use end-cut eye to make a nice mucosal incision. For this region, I would like to make a first mucosal incision at the anal side first, and go behind the marking dot and using down angle and press down the knife to the mucosa and make a small hole here. Now, knife tip goes into the submucosal layer, then I can make a nice mucosal incision, and the movement of my wrist is minimal, and I always try to keep the white dish ceramic tip on the mucosal surface. Now, we can see the nice submucosal layer stained by the blue injection solution, and going to the other side, always keep the white ceramic tip on the surface. Okay, I think it's good enough, and a little bit more to this side. So, Professor Yahagi, even you are using end-cut mode, but you don't keep pedaling. Oh, it's okay. If everything goes smoothly, I can press the foot pedal continuously, but I just want to check the direction, and if it goes smoothly, I can conduct submucosal incision like this continuously, but sometimes we need to check the direction, therefore I prefer to step the foot pedal intermittently like this, then I can control the direction much easily. Now, I'm hooking the muscularis mucosa with the knife tip. By the way, this is a 2 mm dual knife shape. It has injection capability. That was Olympus Needle Master. It's a standard injection needle. Oh, you are using the dual knife. Yes, this is a 2 mm dual knife shape, which is suitable for gastric ESD procedure. Now, hooking the muscularis mucosa, now I'm connecting the incision line to the inner side. Now, circumferential mucosal incision is already completed, but because of the gravity side, sometimes it's difficult to open the submucosal space, but we should dissect the surrounding tissue a little bit more, but before that, I would like to inject solution to the submucosal layer a little bit more through the knife. Oh, it doesn't lift so much, but it's okay. Now, I'm hooking the submucosal tissue and cut here, and for the submucosal dissection, I usually use swift quark and tracing the inner edge of the inside the area and dissect the certain amount of submucosal tissue. Now, submucosal layer widely opens, so it's time to apply a clip on the line. Retrieving the instruments through the working channel and suck the air from the stomach, then I will pull back the endoscope. And could I have a clipping device? I think that there will be a clipping device somewhere here. Clip, please. Clip. End clip? Oh, this is end clip, okay. Can I have end clip and short size end clip? Yellow one, please. And initially, we should insert the end clip to the working channel and set the end clip. This is reloadable Olympus end clip, easy clip. It's very easy, just open and close, then we can easily set up the device. And touch to the end clip, then slowly, slowly open it, slowly, slowly push out. Much more, much more. Okay, stop it, please. Oh, it's already closed. Oh, strange. We need another one. Open it, please, and remove this one. So maybe recently, there is no chance for Professor Kato to use clip. Okay, open, close. Open, close. Open, close. Okay. And touch to the tip of the seat and open it slowly. Okay, okay, that's good enough. Now we can see the metallic part of the end clip, then put the dental floss and make a knot on the metallic tip. I think it's okay. Scissors, please. Oh, I can't cut it. Oh, I took it off. Is it okay if it's one layer? It's better if it's two layers. Oh, excuse me. I can't cut it any more. I'll go with this one. It looks like it can be cut, but it can't be cut at all. So we don't put it underneath, we just do it like this? Yes. We put it in the crotch area. If you do that, it may come off the moment you tighten it. I'll do it there, the yellow one. Yes. So, in order to make sure, I asked him to make another knot, then cut the tail of the line. Okay, now it's ready. And pull back the sheath into the cap, like this, and hold the line together, and back to the luminal side. And insufflate the air to the stomach. Oh. Now we can see the backside of the dissected area. Okay, and open the end clip. Okay, that's good enough. Okay, that's good. Then approach to the edge of the dissected area and catch the edge. So basically I prefer to catch the target tissue from the backside of the dissected area, but in this situation I think it's okay. Okay, fire it. Okay, it was nicely placed. Making a knot to the syringe as an anchor and let it down as a natural anchor or do you have surgical cramp? You don't have it? I think it's okay, and just write it down as an anchor, okay. Now, I'm giving attention to the target tissue and go below the target region, utilizing the transparent hood, we can widely open the submucosa space. This is the ideal situation to do submucosa dissection. Now, you can see the whitish muscle layer here, and the upper side is the backside of the target tissue. And touching here and give additional fluid cushion, but before that, I would like to make a small hole here. Okay, injection please. This one. Now, I'm giving submucosa fluid cushion through the knife. Now, we can see the blue color. Then, it's time to do submucosa dissection. This is swift quirk. By twisting the shaft, I can smoothly conduct submucosa dissection, and moving back to the central part and go below the target region and catch this area and go to the safer side and conduct submucosa dissection. Sometimes it becomes a little bit flappy, but it's okay. Just returning to the original position and check the edge of the left side and catching here and go to the safer side. Now, I'm keeping the straight endoscope position and visualize the remaining submucosa layer. It is relatively safe and very smooth submucosa dissection. Okay, and go back to the left side again, catch the edge of the left side here, and go to the right side. We don't have to control the shaft of the endoscope too much. Just keep the straight endoscope position, and if it is very stable, I can control the length of the seesaw of the device. This is a wonderful merit of the traction method. Catching this edge, it's almost the end of the procedure, and back to the left side. Oh, it's too easy. I'm sorry, finishing quickly. And retrieval of the resected specimen is also very easy. Just bring back the string, and we can easily retrieve the resected specimen like this, like fishing. Okay, so the next one is the water pressure method. Before that, I would like to show you the resected area. This is the resected area. It's quite smooth. There is no muscle damage here. It was very smooth. And the next target is here, also located at the gravity side. In order to show the water pressure method, I would like to attach the SD hood instead of using straight hood. By removing the previous cap, and clean the lens. It's okay. Can I have an injection needle? Thank you. Since there is a slit, therefore it is mandatory to align this slit just below the working channel. And we should check the passage of the instruments. Now it's okay. Clean the lens and go back to the stomach. And check the lesion. For the water pressure method, I would like to fill the lumen with normal saline to visualize the target lesion much better. Because of the magnification effect underwater condition, we can visualize the target lesion much better. Okay. Can I have an injection? I don't know. Okay. Needle out, please. Again, a few millimeters away from the marking dot, I would like to make a sudden causal injection here. And slightly pull back and check the nice lifting sign. So, Professor Yahagi, when you are going to perform the water pressure method, do you try to use the pocket creation method? I usually make a circumferential causal incision at the beginning. Is it not necessary to perform PCM? Oh, no, not at all. Okay, stop it, please. Because I can easily open the sudden causal space by giving active pressure of the normal saline. Okay. Injection, please. It's not only for stomach, but also for colorectum. Yes, colon and rectum, and of course, duodenum as well. Even duodenum, you perform the circumferential incision. Yes, that's right. Injection, please And for the water pressure methods, do you think the conventional ST food is better than short ST? Yes. Because of the long length of the transparent food, we can check the safety of the procedure. If we use the short ST food, the lower part becomes not visible. That's why I prefer to use the classical ST food. OK? Can I have your knife? So the water pressure method, I usually make a submucosal dissection from the oral side. That's why I initially make a mucosal incision at the inner side first. Then, finally, connect to the incision line entirely. Then quickly start the submucosal dissection from the inner side. Again, I would like to use endocut eye for making mucosal incision. As I mentioned before, it sometimes cause bleeding from the puncture side. And also, this is kind of the landmark. Therefore, I would like to insert the knife tip to this landmark. And I made a tiny hole here and fixed the knife tip to this small hole and start the mucosal incision. And as I mentioned, it is mandatory to keep the white ceramic tip on the surface. I'm gently controlling the direction of the endoscope. Still, it is possible to control the direction very well. One of the drawbacks of the water pressure method is the bubble, which is created by the electric current. But we can easily flush away by giving the active pressure of the water. Yes, that's right. Yes. No, even for the first region, I used the endocut. But sometimes I use dry cut. Yes. OK, now it's time to start mucosal incision from here. Yeah. Now, I'm controlling both up, down, and right, left channel together with my left hand and gently hold the shaft of the endoscope with my right hand. Then, go to left side slowly, slowly by torquing my wrist and controlling both up, down, and right, left channel. It is quite easy. We don't have to hurry. Just go slowly, slowly. But we can make a nice mucosal incision here and flush away the bubbles and suck the air a little bit if it is necessary. And because of the small sea size of Dual Knife J, still, I can suck the air and the liquid, even though the instrument is still inside the working channel. Now, I could open the submucosal space widely here. And I would like to connect the incision line. So probably, putting back mana is much easy. But be careful when we make a mucosal incision by putting back mana because it tends to go deep. Therefore, just hook the edge and go back to the oral side slowly, slowly, not giving too much tension to the target tissue. Gentle touch is usually good enough. And connect the incision line to the oral side. Now, it's connected on the left. And it's time to connect on the right side here. So catching the edge with the tip of Dual Knife and go to the lower side. And using down angle, I can make a nice mucosal incision here. And recognizing marking dot, a few millimeters away from the marking dot is usually necessary. Okay, looks fine. And connect the incision line to the oral side. Now, it's connected. And the next step is to check the incision line. If we cannot see the blue submucosal layer, it is too shallow. But in case of seeing this kind of blue submucosal layer, it is usually good enough. And just dissect here a little bit more. Okay. And at least at the beginning of the submucosal dissection, we don't have to go deep. Just tracing inner edge of the incised area using coagulation current is usually good enough. So gently touch to the limb of the incised area, then start submucosal dissection, just tracing the inner edge. Now, I just traced the inner edge only once, but it's already good enough to open the submucosal layer by giving a gentle pressure of the normal saline through the endoscope. This is the beauty of the water pressure method. We can easily recognize the submucosal layer, then we can conduct submucosal dissection in a safe manner. And flush away the bubbles from the transparent hood, and we can really easily open the submucosal layer and recognize the edge and catch the edge, and then go to the right side. I'm just twerking my wrist. I don't control the shaft of the endoscope, but still I can control everything by twerking my wrist. The movement is minimal, but good enough to do submucosal dissection. Just catch the edge and go to left side, recognizing the remaining submucosal tissue, and flush away the bubble, and go to the safer side. It's quite easy to open the submucosal space. Now, we should check both sides, and checking here, and go to safer side. It's quite easy. Okay, and flush away, and this is the edge and catching here. And if there are lots of bubbles, and if there is no visible blood vessel, we can use endo-cut mode instead of using coagulation current. But of course, if there is a blood vessel, we should use the coagulation current. Flush away bubbles, and check the remaining tissue, and this is the edge of the left side, and catching here, and go to right side. Again, flush away the bubble. Okay, almost end of the procedure, and finish into the luminal side. Okay, usually end point of the submucosal dissection sometimes becomes difficult because of the flappiness of the remaining tissue, but by using the water pressure method, I can easily open the submucosal space, and finish the procedure. Oh, it's already finished. Okay, this is the basic technique of the water pressure method. By utilizing this technique, we can conduct safe submucosal dissection, even in the duodenum. Do you have any question or comment? So, yeah, thank you very much for demonstrating really excellent procedure using water pressure method. Maybe this region located at the gravity side, so the method is almost the underwater ESD. Yes, that's right. So, in case of having region on the anti-gravity side, we can utilize the gravity when we conduct submucosal dissection. Therefore, we don't have to use the water pressure method, but for the duodenum region, it's mandatory use the water pressure method because gravity usually doesn't work so well, and sometimes mechanical force which was given by the transparent hood cause muscle tear, because muscle layer of the duodenum is quite thin, and probably it's nearly the same situation at the right side colon or cecum. Therefore, I prefer to use this water pressure method even for the colorectal regions. And do you need sometimes the traction method even when you are using the water pressure method for such as the fibrosis or... Usually, no. Even for the fibrotic region, we can easily open the submucosal layer and visualize the fibrotic area by giving pressure using normal saline irrigation. It's usually very easy to conduct submucosal dissection. Do you have any questions? Are there any questions? Is there any questions from the audience? Okay, thank you very much. Thank you.

endoscopic submucosal dissection

traction techniques

creep line traction

water pressure method

ESD

submucosal dissection

normal saline