Hi everyone, so we're going to show another ESD demonstration for now. So on the screen you can see already marked area here. So it's basically, so we intentionally made this region on the 6 o'clock, like gravity part, and to show the efficacy of the traction. And then I'm planning to use the overstitch from Boston Scientific Apollo for the pulley method. So we have this region here. So basically I'm going to start with the injection, and then I will show how to do the pulley method using the overstitch. So, for the pulley method, you need to incise and mikoza the entire circumference at the beginning? Yes, correct. So it's a very important point. If you're planning to use traction method, you have to finish the full circumference and mikoza incision first. Because if you put the traction system, you're not going to be able to cut the area behind So it's very important to finish the incision first. Needle out, please. Okay, inject. Okay, stop. Thank you. Now, because we are planning to use the overstitch for the pulley system, that's why I highlighted starting from the rubber channel in the scope. Okay. Okay, this is the Fuji scope injector, please. Okay, thank you. I'm using the 3.7mm channel, so it's a little to the 3 o'clock, no, 4 o'clock. So it's a little different from the Cronland scope injector, please. So about stable or unstable? It's like we usually have the needle from 5 or 6 o'clock. So it's a little different feeling. Okay, inject, please. You may have some option to use the left-hand side. Okay, yeah, that's a good point. Okay, stop, please. Okay, needle back, please. I tried the other side. I'm going to inject again. Thank you. Still the left-hand side has this 3.2mm channel. 3.2, okay. Larger now. Oh yeah, this is better. It's a 6 o'clock. 6 o'clock. Needle out. Okay, inject. Okay, stop. Okay, inject. Okay, stop. Thank you. Okay, inject, please. Okay, stop. Thank you. I'm using the cap to stabilize the target tissue. It's very important. Okay, inject, please. And then I'm just like lifting up the needle so we can effectively... Okay, stop. Thank you. A little more to here. Which solution are you using now? Solution? Is this a saline? It's a boost. Boost? Oh, blue boost. Okay, inject, please. Okay, so blue boost is from Microtech. It's made of hyaluronic acid. It's the premixed blue color. Then, which knife do we have? Dual knife? Yeah. Okay. Okay. So I'm using the 3.2 channel. So we found out that the channel is located at the 6 o'clock. So it's very useful for this procedure. So for the dual knife, as you know, we usually don't start the incision from the 12 o'clock. Always, if you are using the needle type BST knife, you shouldn't start from this side. So I usually start from here. I need to out, please. And then, let's see. Starting from here to go to far. Thank you. Then the first step is to make a very small hole like this. Now, end cut, I use a clip. Is it okay for you? End cut. Duration three. Is it okay? Yeah. Okay. Thank you very much. And then, we usually don't use a small wheel. We usually use our wrist or our body motion for the left and right side. And then, I usually use the up and down angle. And now, it's time to rotate to the left side. And then, it's always important to make sure you are cutting in the right direction and reorient yourself. And then, check the next marking dot. And then, check the previous incision line. And then, place the knife. And then, direct your scope to the right direction. And then, now I think it's going down. So it's very important to stop here. And then, go back to the right side. Yeah. And then, as you can see, I'm not inseparating too much. It's very important. If you inseparate too much, it's going to press down the injective solution. So it's just enough for the visualization. And then, we usually keep this needle type VS knife a little shorter than IT knife because we want to use the full length of the knife. And also, I'm using the cap to face perpendicularly to the region. Let's see. So I think we're almost done for this case. So this way. And then, I'm rotating the scope clockwise right now. And then, I'm going to go to this side. You can see the marking dot. Yeah, so right now, you can see the marking dot. That's why the gap between each marking dot is not so wide. To not miss the direction. Exactly. And then, if you're not sure which direction you have to go, just come out to make sure we are very close to each other. So before starting, the landing point should be confirmed. Yeah. That's a good point. Perfect. Quite nicely. Yeah, very good. Then, just do a trimming. Sometimes, we see musculoskeletal mucosal tissue. And then, it makes the last part of the ESD a little difficult. So we usually cut the musculoskeletal mucosal tissue. Okay. Very good. I'm just checking. So this area is a little superficial. So you can see some white tissue. Okay. Can you move your back? And I'll inject for you. Better? Oh, I'm sorry. Oh, yeah, yeah. This one. This one. No, this one. Okay. Lift it. Okay. Needle out. Perfect. So you can see that my incision was a little superficial. So you can see this white tissue. So this is a musculoskeletal mucosa. So we need to cut this. And then, the other thing is that the dual knife has this white stripe. So if your knife is like this, it's too deep. So usually, we want to see this white surface to make sure the knife is too deep. It's not too deep. Okay. Very good. So I think we isolated. Yeah. Yeah. So I think it's time to do the attraction. So let's put the over stitch. So it's going to be very quick. So... Oh, wait. I have never mounted a device by myself, so... Yeah, thank you. And that's good. Yeah. Okay. And then, okay, so, yeah, perfect, and then can you do it, or do you want me to? Perfect, thank you. So when we use the clip line interaction, we are creating a bit of a groove to the aura side, but maybe with this pull interaction, you don't need to make a groove on the proximal side. Right, I think it's because you can choose the depth, so you can just superficially grab the Mikuza layer, so you don't need to make a deep groove at this point. Okay, so perfect. So the advantage of over-stitching, using the over-stitch for the traction, is that we can actually use the same suture for the defect closure afterwards. The same needle can be used. Yes, the same needle and the same suture can be used, so we will not waste the suture. So that's one of the advantages. If you are planning to close the defect, it's very important to use it for the traction. So the idea is that instead of just putting the one suture, and then pulling the suture from the patient's mouth, we have the fulcrum point, like anchoring point. So the idea is that we are going to put one stitch at the edge of the Mikuza flap, and then we will put another stitch at the opposite wall. By doing that, the suture will come out of here, and then go to the opposite wall, and then by pulling the suture from the patient's mouth, you can obtain the traction to the opposite wall. So it's like a 90 degree vertical direction instead of the horizontal or tangential direction. So we always want to have the traction above the lesion. So I'm going to show it to you. So basically, we are going to start with the fulcrum point. So I'm going to open, and then grab one of the... So let's see, so this is the lesion, and then we want to pull it right above this. So I'm hoping to use this fold. I think this is good enough. So I'm going to push the anchor exchange and pull it. This is the first stitch, and then for the second stitch, it will be deployed at the Mikuza flap. Let's see. And then the point is that we don't want to get the muscle. So if you go too deep, you're going to grab the muscle, and then you won't be able to dissect the Mikuza layer. So in this case, we need to tilt the scope a little, like 45 degrees, and then open, and then just grab the Mikuza edge only. So like this. Like this. The point is that we want to place the, how can I say, the five o'clock of the overstitch right underneath the Mikuza flap, like this. And then by doing this, we can selectively... Let's see. Yeah, so the key is that we avoid muscle involvement. Yeah, this will be enough. And also it is better to avoid the region. Yeah, that's true. So maybe wider margin to the over side. Oh, that's true, yeah. I should have made an incision a little away from the region. So I'm going to try to grab the marking area. So very precise control. Okay, perfect. Yeah, this should be good. And then I'm going to push the needle exchange, and then pull it back. And then open the overstitch. And then now, this is the time to deploy or release the anchor, like this. And then now, so we have a good traction here. And then I'm going to... And then next, we'll just simply pull the system here. Do we have like Kelly clamps or something? Oh, like, yeah, sorry, Kelly clamp. Kelly. Or we need some syringe. So maybe too heavy. Yeah. Empty one. This will be plenty enough. Is it okay to put it in the middle? Yes. Ideally, we need a clamp. Kelly clamp? A Kelly clamp. But I think it's okay. I don't know. So if you bite the muscle layer unintentionally, do you have any troubleshooting method? Oh, yeah. Well, that's a great question. So if we unintentionally grab the muscle for the suture pulley, I think the only way is to cut the suture, unfortunately. Or just to grab the needle part. Oh, yeah, that's true. You can release the anchor and then... Again, we can use it. Right, not to waste the suture. I've heard that this suture is very expensive. Yeah. I think I see this method in the literature. I didn't know why such expensive pulley method exists. Right. But the idea is that we are eventually using the suture for... Oh, yes. And then if we pull the suture, you can see that the opposite wall is working as a foreground. So this can be done by the clip and thread. But from the beginning, the suture is already planned, so no additional cost is needed. Yeah, that's correct. So we are eventually using the suture for the closure. So let's do the... With only the clip and thread, the first dissection is relatively difficult. Yeah. That's why the pulley works very well like this. Yeah, that's true. And also, depending on the location of the region, you can choose the foreground point. So if the region is located like here, I would choose it like this. Just the opposite. Yeah, just the opposite. Or just a little bit on the outside. Yeah, on the outside. And also, I think we can do it in a retroflex fashion. So I don't recommend this pulley point on the inner side because it works, but sometimes the ending point becomes difficult. Yeah, I totally agree. So that's a great point because if your pulley point is too far away, your traction will go to the distant side and then it's not going to work. So it should be right above it or maybe closer to you, like behind you would be the best area. So now... Traction works until the end. Yes. That's fine. Okay, open please. Yeah, very nice. Yeah, nice traction. Okay. Almost done. Yeah, almost done. So this is... I feel like I'm cheating. Swing motion is very important in ESC. So instead of using your small wheel, you can use your rotation of the scope. So always start from your right or left side and then swing your scope and then go back from here and then you have to adjust the length. I think the dual knife, sometimes with the traction method, because dual knife is made for only when you use the cap, probably like scissors type VST knife or like IT knife, those kind of like... the knife is like cooking function would be more efficient. Actually, if you create such situation, just scissors type works very well, especially for the beginner. Yeah, that's true. Because we can do it from distance, so you can just grab and... I totally understand. Yeah. You can see that traction force is always effective until the end of your VST. So when the closure is not planned, same thing can be done by the grip and thread. Oh, yeah. Additional grip can create a pulley. So this patient will be sutured after the procedure. Already such a strategy was fixed, so no additional cost is needed. Yeah, that's correct. And more stable traction can be done. I didn't agree for such an expensive... Yeah, only for the traction. But today I totally understood why such a strategy was recommended. Especially when the lesion is very large, at the end you don't have a good traction. In that case, we can actually adjust the traction force by putting additional traction force. And for large lesions, sometimes we might have to have two sutures. But I think basically the defect is also big, so we might need to use two sutures to close the defect. Okay, so this is the end. You can also do like this. So I tilted the scope for 90 degrees. Then just up and down. Yeah, up and down. So it's much easier. Nice. Okay, so you can see the other side, right? So trimming to the inner side would be better. If you don't disconnect at the beginning, you may create a pocket to the outside. That's correct. So if there's a muscular mucosa, you cannot see this incision line. So it's very important to do trimming at the beginning. Oh, sorry, I just cut it. It really works very well. Yeah, it really works. So you can see that here. So what we're going to do, we need to grab, not pulling the suture, but we need to grab the specimen, and then together with the anchor. So we can use a snare or a rat tooth or an animal grasper or something. Oh, perfect. Okay. Okay. So to release the knot, it was much more time consuming than the ESD. So as you can see here, there's an anchor. So we are going to grab the anchor together with the specimen, and then I will pull it through the esophagus. Okay, open. Close. Okay. Very good. So I'm going to... There's some friction, but it should be fine. Oh, because the line is... Yes, it's connected to the pulley point, so... Yeah. Okay, open, please. Perfect. Okay, so the specimen... Oh, it's stuck. Oh. Why? I think it's probably like... Can you see it? Oh, there's a knot here. Oh, I see. How do you do it? It's magic. Should we just cut with a dual knife? So have a dual knife, please. Okay. So usually it's easy to just pull the suture out, but for some reason there's a knot, but I'm going to cut it. Okay, open. Try not to cut the suture. Oh, this is also good trouble shooting. Yeah. Hmm, interesting. To save the suture, this is a good one, so okay, perfect. Okay, thank you very much. So we usually close the defect with this overall suture, but I think other faculty has already shown the defect closure, so we will finish it here. Thank you very much, Dr. Tatyana, it's an honor to be here. Wonderful demonstration to us, thank you very much. Thank you, everyone.

endoscopic submucosal dissection

overstitch device

pulley method

dual knife

traction

defect closure