Okay, so we have a big, relatively big, rounded defect and we are going to do a closure of this defect using over-stitch endoscopic suturing device. So I'm making the first bite and that's the place where when I finish suturing my cinch will be lying. So transferring the needle, grabbing it again, and then going to the opposite side. So the goal is not to create any dog ears. So I have to do it properly and especially on the angles. Transferring the needle back. By the way, how can we decide where to start and which direction should we go? So the purpose of direction is to make the lumen bigger, so not to make the lumen smaller. The stomach is actually not a tight space, so it doesn't make much difference. But in places like colon or esophagus it's very important that we follow the proper direction. So we also have to suture by eliminating any criss-cross. So we should not cross the leading suture and that's what I just did. I pushed it away from me. And now I did the first couple bites and you can see I'm tightening it and the incision is getting smaller. Transferring again to this side and grabbing it opposite side. You can... So I pull back and you can see that the incision is already starting to close. Now again I'm going to this side. Like this. Do you sometimes control the volume of the air inside? Yes, yes. I can do more or I can do less, it's entirely up to me. And here I don't like what I see a little bit somehow. transferring the needle and remember it was a little difficult to grab it from that side now it's not so I'm grabbing it again and I'm making a good bite and my goal is to take a submucosa into that bite not just mucosa because submucosa is the strongest part of the GI tract wall you cannot achieve that if you are grabbing only mucosa I'm not grabbing muscle only mucosa and submucosa uh how large do you usually take a bite about five millimeter or less in between and here you see I'm grabbing it from inside out you can do both ways oh really it's just more comfortable and that's what you do and uh the uh the defect is getting smaller and I need to release the overstitch because I went from inside so the overstitch was kind of pinched in it so I released it transferring the needle back right again going from inside out you see it yeah from inside out transferring the needle back to the suturing arm And now there is a crisscross, so I need to correct that crisscross by releasing it, opening up, and then closing on the opposite side. Now again there is no crisscross. Now this is a defect, and the defect is getting very, very small. Now again I'm grabbing it from the inside, and this time because there is no difference left, I may need to grab from inside again. So this is the defect, so I will position my suturing device in between, right into the defect, like this. And then when I close the needle, it will grab only one side, transferring the needle back. And this is probably the end of it. Again, if I grab it here, it will be crisscross, so I need to grab it on this side, then it will be no crisscross. And that will be my last biopsy. At this point, I will double check to make sure that everything is closed. So I'm pulling this initial place, right? So you can see that there is no visible defect left. It's always amazing looking at your procedure. Your suturing technique is very quick, very precise, and completely closed, even for the large defect. Thank you, thank you. I'm releasing the needle, and now I'm pulling back, and you see that the needle is right there, or I will pull back until the needle is completely closed. You see that? I pulled it, right? So now the incision is closed all the way, and all we need to do is just put in a cinch. By the way, if we pull the string too much, what will happen? Then it will be just ischemia. It will tighten it to the point that it creates ischemic changes. I don't want that to be done, but the truth is that we completed it. What happened? So how can we recognize that? You just want to approximate it, but you don't want to bunch it up together too much. And that's probably enough. And I can make it tighter, but there is no reason to do that. Okay, thank you. Okay, so now we are done and all I need to do is to deploy the cinching mechanism and cinching mechanism will be at the place where I did my first puncture. So this is the cinching mechanism, can you please deploy it? So Greg is squeezing the handle, I hope that you can see it, and it cuts the needle and at the same time it deploys this uterine device. So that's it, we close completely that, but the beauty of the overstitch device is that at this point if I wanted to put a second stitch, all I need to do is put another needle through without removing the device from the patient and then I can do a second suture and third suture, unlimited number of the sutures. But you see the defect like this, you cannot close to this quality with clips and it will require a lot of clips. Here we just did it with one suture and you cannot do it as fast as you do it with overstitch. Yeah, that's right, it took only less than five minutes this time. Much less than five minutes. So also there I am using overstitch to grab the piece like this and then we can come out and taking it out. So that's wonderful. That's how it is. Do we have another defect there or no? No, only one defect. Why don't we do another defect bigger than that? Yeah, yeah. This time you will do it bigger. Okay. And the other thing is that when the defect is linear, then yes you can close it with clips, it's easier to close it with clips, but if the defect is rounded like we had it here, closure with clips will be very very difficult. But with endoscopic suturing device, the shape or size of the defect doesn't matter, you can close any defect and even if it is in an unfavorable position you can still do that. By the way, you can do it in retroflex too. For example, if it is somewhere in the fornix of the stomach, so you can just retroflex like this and you can suture it in retroflex direction. You see that? So I'm in a very high retroflex position, looking backwards into the scope, but you can still manipulate, the suturing device will open, the suturing device will close, so you can still do that. It's not a problem for endoscopic suturing device. It's rather property of the endoscope. If the endoscope can bend, suturing device can suture. Any questions? Oh, you missed it. It was two minutes. Yes, less than five minutes, much less than five minutes. But what we are going to do, Dr. Yahagi will create this time real defect, that was too small. So let's do the big defect and after that we will close it so that it will take a little longer. I don't even see where it was. So the closure is so good that I cannot even find it. Where it is? I think it's located at the lesser curvature side. Here? Yeah, yeah. So can you recognize that place? So it's completely closed and obviously you cannot achieve closure like this. This is a surgical type of closure. Even if there was a full thickness perforation, closure like that will hold and there will be no leak or anything like that. All right, so we are pulling it out and Dr. Yahagi will create a bigger defect this time. So yeah, and we will suture it. Yes, yes, in another five minutes. Yeah, thank you very much. Thank you. So this is the specimen and all right. Okay, congratulations. Thank you. Or they want to do a track motion, or you want to do it regular track motion? Oh, you may do it. Yeah, sure. Would you like to explain the technique to the audience? Sure, sure. So I am using the dual j knife and for that I create just a very small mound. Can you close please? And then now I will be injecting fluid through the dual j knife and this is much faster than to use a needle open and in addition when you inject through that knife then you don't have to you will much less chance that I will damage some blood vessel. Of course it's not relevant in this situation but in humans it may be of relevance. Please close, close. Yes, actually dual knife j is very convenient. We don't have to exchange the device during the long lasting EST procedure and we can keep the safe situations. It's very convenient. And I think that it's also safer to inject through that because less chance with the needle to damage the blood vessel. Yes. Please close. That's right. So that's why I prefer to use that. Open. Close please. But the important thing is that you always push water in front of your open. You don't want to cut if there is not enough amount of the submucosal fluid. Oh very nice. Thank you. Please close. And each time before I inject I want to look down to make sure that I'm pressing on the right pedal and I don't press on the electricity pedal when I wanted to inject fluid. It's very important to keep the safety. Unfortunately it happened to me more than once before I learned my lesson. Now Sergei is using 2.0 millimeter dual knife j which is suitable for gastric EST procedure. There is two type of device. One is 1.5 the other one is 2.0. 2.0 is only used for gastric EST procedure and 1.5 is suitable for colorectal and esophageal EST procedure. And hooking the edge of the incision, Sergei is nicely conducting mucosal incision. Gently touching to the target tissue he could make a really smooth mucosal incision. And always move in the direction away from the muscle towards the lumen so if my knife will slide, then it will hit the air, rather than hitting the muscle. So that means cutting from proximal side to distal side is good, but cutting by pulling back manner is a little bit dangerous because it tends to go deep. So, Sergei is injecting solution just before starting mucosal incision, that's why even with this difficult situation he can conduct nice mucosal incision very smoothly. So, key point is to create a nice submucosal breath and catch the edge of the incised area, then keep the white ceramic tip on the surface of the target tissue and conduct mucosal incision in a constant manner. And you don't want to leave any bridges of the muscularis mucosa, otherwise it will be much more difficult later on to trace them. So you have to go with your incision to the full thickness of the mucosa. Please close. So in that sense, it is necessary to check the blue color of the submucosal area through the incision line. Once we see the blue color of the submucosal area, it is good enough. But if you can't see the blue submucosal area, we should trace the same line until it completely opens. And then if you missed it and you trace it right away, then it saves you a lot of time rather than creating some superficial incision and later on it will be much, much more difficult to correct. Please close. Open. Very nice. For the actual human procedure, we usually trace the same line after making mucosal incision using coagulation current. Because just below the muscularis mucosa, there will be a rich vascular network. Therefore, we trace the same line using swift coag or precise sect to avoid the bleeding occasion. Then we can widely open the submucosal space. Okay. Now, pink mucosa is usually really sick, therefore we should trace same line a few times until it completely opens. Thank you for watching! Close, please. Yes, this is a relatively difficult area because this is located at the gravity side and behind the hold and it becomes a little bit flappy but probably it's possible to make a mucosal incision after injecting certain amount of submucosal fluid cushion. And I am staying outside of my markings to have a good clean margins. It's quite important that we should keep at least a few millimeters outside the marking dot. And I hear that, do you do markings in the colon? No, usually no, because border of the colonic region is quite obvious, therefore we don't have to press marking dot. Unfortunately from time to time I get patients who already had several attempts to resect colonic polyps, in that situation when it is third or fourth attempt I put markings just for that reason to make sure that because there will be some scar tissue at the border and I want to make sure before I started to inject that I completely did it. So now you can see that we separated it everywhere, right? So I will just go and double check that there is no mucosal bridges and if there are any then I want to eliminate them before I started to do any dissection in the submucosa. Can you close please? I want it completely separate. And if there is any concern I would rather go second time there. Okay, so the reason why I did circumferential incision and did not work with this sector is that we are trying to show you how to use a new device, which was created by Fuji system and it is called track motion device. So you can see that it is practically grasping forceps and you need to grab the polyp at its edge and then you can lift it and that will expose your submucosa and from that point forward procedure becomes very, very easy. Please close. Even with traction I will still want to have a good submucosal space and that's why I'm making some additional injection into submucosa. Open. So now we're switching to the calculation current. So this device allows you to come as close as you want or to work from the distance. And you see I constantly manipulate it, so that's why it is dynamic and it's multi-directional retraction. I can pull it any direction I want to. And if I make it a little less curved, then I can put it into the endoscope and decrease the distance. For this device, at least 3.7 mm working channel is necessary, therefore Fuji already developed that kind of double channel endoscope, which has 3.7 mm working channel for this device. And this is the same endoscope that we use for suturing, so I will not need to change endoscope. After we finish dissection, the same endoscope we will be using to close the defect. By the way, this is through the working channel device, so even though we can change the direction of the traction, is there any difficulty controlling the knife for submucosal dissection? No, but you should remember that the device is connected to the endoscope, so when you move the knife, then you move the device as well. So this is just a little bit of inconvenience, but as long as you remember, it's not a big problem at all. Can you close? So when you use this device, you should understand the mechanism of this device completely, otherwise it becomes a little bit challenging. And in the same position, I can change the amount of the traction that I'm using. For example, right now the device is straight forward, so there is not much traction, it's just going forward or backwards, right? But if I press this button, then it started to bend, so I can rotate it and then you see, at the same place, but it is a totally different amount of the traction. Then you can conduct the submucosal dissection using the right, left and up-down channel. So you see how quickly our dissection is progressing, and it's practically effortless dissection. Nahid, do you want to take over? Oh no, please, finish your procedure. You want to do with that device? I'm not good at controlling track motion. Oh, okay. No, but it's just if you want to experience it. And that's the beauty of the dynamic retraction. I can do as much of the retraction or as little of the retraction, it's entirely up to me. Can you close this? And you didn't change the scope position too much. I didn't change the position of the retraction as well, so far, open. But just to demonstrate to you how easy it is to do that, I will drop it in a second and then I will regrasp it in a different place. So right now I'm far away from the edge, right? Of course I can continue to work on this area, but when it will be, can you open, close, open, sorry, close, open. So you saw how I just changed the position of my traction. So, already nearly two-thirds of the seven causal layers are dissected, with a single endoscope position. And that's the beauty of the retraction. And now I will intentionally let it go and grab it in different place. This is the great merit of this traction device. Most of the traction device cannot change the position, then we should apply another traction to the other area. But by using this traction, track motion, we can grasp target lesion again and again if it is necessary. Yeah, and I grab it closer, so I restore my traction, because there was a lot of tissue already, so the traction was not as effective. But it is so easy to change that I can change it without hesitation as many times as I want to. And this is also the difference when you are using the clip-based traction devices. You apply clip in one place, and if you need to change, then you have to use another clip. And this device doesn't require that. I can grab it as many times as I want to. Yeah, that is the great merit of this device. And once again, the device is commercially available in the United States, so anybody can use it. I'm just checking the position to make sure that I'm in there doing... And you probably noticed that I even stopped injecting, because the traction put the tissue under so much stress that I don't even need to inject here. I have a good view of the fibers which are under traction, and those are the fibers which are my target. Once again, I will let it go and grab it in a different place. So let me see how much more we need to do. We're practically done. I'm kind of flipping the polypone itself. Can you close? When there is very little submucosal tissue left, you want to inject because soon if there is no submucosal tissue, you will not be able to do any injection. So you want to inject when you still have some tissue to accept your solution. Pull, pull, pull. So, for example, in this situation, I am pulling the polyp away from me to restore my view. So, you clearly see the tissue, which is under traction, the fibers which I need to cut are easily identifiable, and that's why the procedure is relatively very fast. I'm opening the retractor again. Sorry. I'm trying to see how much more I need to do. And by the way, if I don't want it if I use it, I want to use as a distal attachment. I can do it without this device, either like this. In that situation, I don't need the traction. So I'm just closing this track motion device pulling it back and working like regular ESD. opening, grasping, closing, rotating it to see where I need to work. Can you imagine that you can have full control of the pulley like this, effortlessly? And another merit of this device is it's controllable by a single operator. That's a huge advantage. You don't need a second person and you can do everything yourself and it's minimal help. I prefer my independence and I don't want to depend on the second operator. So, this is a relatively large region located at the gravity side, even though this is a relatively difficult region, Sergei is conducting sub-mucosal dissection very fast, and this is almost the end of the procedure. Yeah, and I never needed to change position of the patient, and I never needed to implement anything else. So, congratulations. You see, the lesion is removed very quickly, and now I will be using it to remove it, so I don't need another forceps, I just grab it like this, and we're out. So, here's the lesion. This is a really big lesion. Here's the lesion. And more than 5 cm lesion. And how much time did it take? Oh, it was very quick. Very quick. Is it easy? Yep. So, can we ask the Apollo, I need it again, the suturing device. I think we have it somewhere here. You see? Oh, yeah. But we need the needle, another needle. Can I have a wet 4x4? So it was practically effortless, you saw it, right? Anybody can do it, and it doesn't require much effort. Oh, I don't know what I lost. I'm sorry. So, switching to suturing device practically requires no time, and all you need to do, just stick it into the large channel of the endoscope, adjust the position like this, and that's it. We're ready. Can we have a needle? So this endoscope is really convenient because you can use both track motion and overstitch, and exchanging device is not so time-consuming. Sergei already attached the overstitch to this endoscope. It took just three minutes to change everything. It was very fast. And probably he can complete this large suturing of this large defect, probably around five minutes. Less than that. It will not take five minutes. So what is the time? Where is the time? 4.10. 4.8. 4.10. 4.8. Okay. Yep. All right. So we are starting to close, and it's relatively big defect, so I'm starting in this angle. The first bite, then pulling the suture, re-grabbing the needle, opening it up, and go to the other side. So I want to do a good closure of this corner. I don't want any dog ears or anything like that. So you are selecting relatively close position at the beginning. Yeah. The only thing is that I don't want to go above that wire. You see that? That is why I want to change. So I will re-grab it on the opposite side of this leading wire. So here it is, and I go from here and grab it there, this way. Now you will see the difference. So you see? Now it's not crisscrossing. And I will grab it from here. That is the corner which I'm working. And now again, I will transport it to the opposite side so that I never crisscross. You see that my wire is under, and I'm grabbing this corner. You can do it from inside out or from outside in. It doesn't really make any difference. Whatever you are more comfortable with. And it is a relatively big defect with a big distance between the borders of the defect. So to put a clip would be very difficult and problematic, and it would require multiple, multiple clips. But look how easy it is with the suturing device. So this wire I'm just pulling so that it's not in my way. And I'm grasping only mucosa and submucosa. You see that I'm not grasping the muscle. I can if I have to, but in this particular case, it is not needed. So I don't do that. But if I wanted, I can grab muscle as well. For example, if there was a full sickness defect, then I would do it full sickness without any problem. So here I need to correct crisscross, so I need to grab it in between. Let me show you in a second, you will see it. You see? I remove my suture from that side. And, again, it is a very user-friendly device. Just like with track motion, I did not need a second person to do it, and the same story here. I don't need a second person to do it. Here you see that it's going, again, criss-crossing, so I need to correct it by transferring the needle back here, taking it on the opposite side. You see what I did in AHESA? So now there is no criss-crossing. And again, this side, a good bite. You cannot do it with clips, but you can easily do it with this huge device. Big bite. Yeah, at least five millimeter, big bite. And then, again, opposite side, transferring the needle, grasping it again on this side. And then we're practically done. So it was 10 minutes on my clock here, and it's 14 minutes now, so four minutes to close the defect of this side reliably. Oh, it's already done. Five minutes. Less than that in AHESA, it was only four. Okay, so this is the last puncture, so I'm dropping the needle, and then Greg will put the cinching mechanism. So the place where I did my last puncture, that's where the needle will be positioned, and the place where I did my first puncture, that's where the lock will be positioned. So you can see how good is the line of incision. It's practically surgical closure, and you don't need to bunch it up too much. All you need to do just so that they are touching each other, but you saw that the defect was rounded, so it was difficult to approximate edges if I did not have suturing device. But when it heals, it will be difficult even to find the scar tissue, because there is practically no distance between the edges. It will be a very neat scar, and there will be no stricture, nothing like that. So I'm getting it to where it was, and I don't want to tighten it too much, so something like that, but I want to make sure that the needle is at the level of the mucosa. I don't want the needle to be outside, so let me double check here, at the edge here. So you see the needle is there, so I removed all the slag from my suturing line, right? If I created crisscross, I would not be able to close it like this, but because I did not create any crisscross, then that's what it is. And now all I need to do is just position the lock where I want it to be, slightly tighten, please cinch, and then we're done. Yeah, congratulations. And as if there was no defect, as if we did not remove such a big piece. So, to summarize all this, track motion make procedure, ESD, really easy, and suturing device makes suturing very, very easy and very complete. Congratulations, great demonstrations. So, I found that your closure technique is very, very effective and very fast, but I believe that it is necessary to have some certain experience. How long will it take to be a sufficient level? How many cases would be necessary? I do training courses, so people come to me on Saturday and we spend the whole day in the lab, but by Monday, I think that they are ready to suture on the human. Oh, they're ready. That's great. But they have several hours, they have six, seven hours together with me. And then Monday, they just need a polar representative to guide them through the process of setting up equipment and troubleshoot if things are going wrong and things like that. But Monday, they are ready to do it on their own, and I think that it takes three, four cases under help with Apollo, not needed to be supervised by physician, under help to troubleshoot by Apollo. And after that, Apollo reps don't even come. So, that is how friendly this suturing device is. By the way, for this overstitch device, it is necessary to have 3.7 millimeter working channel, which is a double channel endoscope. But unfortunately, our country, in Japan, we don't have such an endoscope. Even Fuji endoscope is not available? No, it's not commercially available, even though Fuji is a Japanese endoscope company. So strange. So, in that situation, we should use a single channel overstitch. But I don't have any experience using single channel overstitch. I would not recommend trying. This double channel suturing device, I was in development of this. I spent a lot of time, a lot of effort. It's a very, very good device. The other device, I did not participate in development, and I don't like it. And everybody whom I talk to, everybody is complaining and not using it. It's not to the level of this device. So, the handling of this two channel endoscope is quite smooth. It looks quite smooth, but how was your feeling? It's a very easy endoscope, and I like it. As I showed before, you can do suturing with that suturing device, even in the retroflex view. So, for example, right now, I'm in an extreme retroflex position. And I will show you, here is the endoscope, right? So, I can suture in G-junction, for example. In the retroflex view, I can suture in the fundus of the stomach, any places. I would be very careful and try not to retroflex in the colon, because of the danger of damaging the colonic lumen, which is a very thin wall. But in the stomach, I suture in both, direct and retroflex position. Okay, everything looks fine. Thank you very much again for your wonderful demonstration. Thank you.

doctor

closure

overstitch endoscopic suturing device

colon

esophagus

suture technique

submucosa bite

efficiency

precision