Good afternoon, ladies and gentlemen. I'm Mitaka Saito from National Cancer Center, Tokyo, Japan, and Seiichiro Abe, the same institution, and Professor Toyonaga from Kobe University. So today, we are going to show you how to perform the gastric ESD using isolated pig stomach. So now that we already made a marking on the region, this is anterior wall side of the gastric body. Today, we are going to show the ESD using IT knife 2 and ORISE Pro knife. So this is the lesser curvature anterior side of the gastric body. First, inject solution. Needle out, please. Injecting, injecting, just a moment. Injecting, injecting. Injecting. Okay, stop. Injecting. Injecting. Okay, stop. Stop. What solution is this? Injecting. Injecting. Stop. Keep needle out. Injecting. Injecting. So we are injecting the solution around the marking. Okay. The needle out. Injecting. Stop. Needle out. Injecting. Stop. Injecting. Stop. Stop. Injecting. Okay. Injecting. Okay, stop. The last one. Injecting. Okay, thank you. And then water, please. So some... Now the... Okay. After injecting, we are going to perform the first marginal incision using an O-Rise Pro Knife. We are going to use the IT knife, too, for most of the gastric ESD, so the pre-cut should be in this situation. That's the curvature from 12 o'clock to 9 o'clock. 12 o'clock to 10 o'clock. Okay. The IT knife, too. Now the pre-cut completed from 12 o'clock to 10 o'clock. And the IT knife movement is... Basic is from far side to near side. So always pulling the IT knife and suction the air and then using end cut mode. In this situation, the cutting is difficult, so the mucosa we are going to cut should be stretched. Yeah, yeah, yeah. Because hold it, current density becomes very low. That's why the cutting effect is not so efficient. And also, suction is very important, but unfortunately, this channel is a little... Only 2.8 mm. But this endoscope has the magnifying function. Oh, magnifying function. That's why for delineation, usually magnifying endoscopy is needed. Because gastric region is very subtle. Yes. And suction, because in the air insufflation, dissection, marginal incision and dissection become a little bit challenging. And also, there are some risks of perforation when insufflating. From the distance, good control is not possible. Yes. Okay, after marginal circumference incision completed, again we inject solution into the sub-mucosa area. Now, after deflation, it's really nice view. Usually, using the big channel, even with the IT knife inserted, we could perform deflation. Needle out. Injecting, please. Because you are using the 3.2 mm endoscope. Yes, usually stop. Injecting. But maybe you have noticed, sucking the air situation has been dramatically changed. Yes, dramatically changed. Stop. We can approach to the dissection plane horizontally. Stop. Okay. Okay, the IT knife, please. So, it's very important in this situation. Before inserting the IT knife, the suction is complete. Now, as previously mentioned, the IT knife dissection always from far side, from outside to inside. So, to find the edge, needle out. To find the edge, and then hook the knife and decide the direction to cut. After two or three cuts, it's very important to find the dissection plane. And check. And not only from left side, so from both sides, dissection is very important. And check. Now, and also to find the edge of the dissection. And of course, if some causal lifting is not enough, we additionally perform some causal injection. Only the limitation of this IT knife is there is no causal injection function. It's different from All-Eyes Pro Knife or Rush Knife DT. So, someone thinks the IT knife dissection is always blind cut, but it is not true. So, if we can have the really nice injection and nice approach, we can see the dissection plane. Under direct visualization, we can perform some causal dissection like this. This is very safe, because IT knife has an insulated tip at the end of the needle. And of course, if we find a thick vessel, we need to coagulate the vessel using this same IT knife, using Professor Toyona's recommendation, very low wattage of the post-coagulation. Using the BIOS III, the effect is 0.4. We use the effect 0.4. Same with the Rush Knife, but Dual Knife has a smaller tip, that's why Hargi is conducting 0.3. 0.3, it's very low wattage. 6 watts, to be precise. And 0.4 consists of 8 watts, but more than 20 percent difference. That's why it makes a difference. Now, the old ways to find the edge, that is very important. Find the edge and set the knife. And also, at most, two or three cuts, and then to check the direct dissection plane is appropriate. And then, from the right side as well. Now, of course, the target is explant, that's why no blood flow. That's why such a fast procedure can be done, but the actual clinical case, we need to prevent bleeding or stop bleeding, that's very important. And also, another important thing is to first make the final goal definite. So if the dissection of the final goal is too shallow, the final dissection becomes difficult. So sometimes, if the dissection is incomplete, we additionally perform the dissection of the final goal point. So the final approach, you need the approach behind the region. That's why it's difficult to see, but if you disconnect first, you can see the edge. That's why before approaching the final step, it is better to disconnect to the outer side of the margin of the region. Now, this is almost the final dissection. Now, at this moment, this is the final dissection to set the IT knife to the edge, and then to find the direction, and then move the knife. This is the final one. Beautiful. Congratulations. Thank you very much. Clean the lens. Thank you. So you have created the two regions. So do you perform different procedures on the second region? Yeah, for the second region, we are going to show how to use the traction device, track motion. But before doing that, we need to remove the specimen, right? Oh, you can leave it. We can retrieve the specimen. So the ulcer bed, so no muscle damage. It's a very plain submucosal, and a small amount of the SM layer is already also left. Okay. Okay. Do you have the grasper? Or hemostatic forceps? Okay, we changed the scope to the double channel. Thank you very much. There's no way the direction is going to be the opposite. That's frustrating. Okay, this is the Fuji new scope, double-channel, and we are attaching the track motion. This is a new device for traction for ESD. Okay. Could you see the track motion? Track motion is already attached. This is the track motion. Okay, the next. The marking is already made. This is. Okay, the injection phase. Oh, thank you. Of course, in this situation, the two matching separation is not good situation for ESD. Not only gastric, but also for esophagus and colorectal. But this time, working channel is 3.2 and 3.7. That's why good suction can be done. Yeah, yeah. As if you're inserting the device. Please stop. Inject, injecting, injecting, injecting. Point Injecting... So in this situation, already we are using the edge of the first ESD, so we use the IT knife from the beginning. As shown, if we, For the device, maybe we should use the left channel. How do you think? Maybe this opposite could be much user-friendly for us. Especially to insert the device. But for the traction, maybe right-side traction could be? I don't know. If the traction is on the left-hand side and the device is coming from the right-hand side, that's fine. Maybe it's okay. Now we need to stretch the mokosa. How have you done to stretch the mokosa? Don't push hard? Don't push hard, yes. And press down the blade? And the disadvantage of the IT Nano is sometimes horizontal cutting is difficult. In such a situation, we could use the needle type knife. It's very easy to cut. And also, for this, not to stretch the mokosa, we need to cut short lengths and then set the IT knife again. So, it's very important. Now for the left side. Before, we used the IT knife 1, so the horizontal cutting was relatively difficult. But the IT knife 2 has a short Mercedes-Benz type backside electrode, so it becomes relatively easy. Actually, this transaction was very difficult using the IT knife 1. Yes, yes. But now you can see. Okay, yeah. So, we again inject and deflation. The left side channel is a little bit difficult to insert the device. Now, inserting the injection needle, needle out, injecting, injecting, injecting, OK, again, injecting. AUDIENCE 2 So you are using the track motion. Yes. Even using a traction, you need to add the semi-causal cushion? Maybe it might be not necessary. No, sorry. The final injection, needle out, OK, injecting, OK, needle out. At this moment, do you think we can apply traction? Or after some trimming, just a small trimming, and then we will apply track motion. To create a grasping point? Yes, yes. Because sometimes when we use the traction device, so there is some risk of catching the muscle layer. But of course, the catch of the mucosa is possible. So we don't care about catching the muscle layer. So re-openable? Yes, re-openable. If we use some device, SO clip for the traction, maybe if we catch the muscle layer, it's very difficult. This is also, we need to see the dissection plate like this. But if we use the traction device, it is not necessary to do this kind of. Device can open the dissection plate. Yes, device can do this kind of checking. It seems to be traction also not necessary in this moment. But just for the demonstration. Yes, yes, yes. Now, good counter-traction by the gravity was created. Yes, yes. Then, out. Ah, I see. This is a traction device. Open. Hold here. The mucous membrane was also bitten. Then, please catch here. OK. Okay, you could understand how the traction is working very nicely. It is not necessary to check the dissection plane. Automatically, the dissection plane is open. Maybe we should be a little bit careful not to have too much traction. Sometimes, the mass layer is also... Now, already, the mass layer is retracted, so you can see the tip of the... Now, rotate the scope to the good position, then it's important. Even if we make a mistake, this direction is a little bit challenging, so maybe rotate the scope to the direction of some causal layer. It's very important. At the beginning, the knife is going to down-blow, but if you rotate, the knife is coming up. It means the up-blow, a safer direction. Yes. And also, one more point is, if we use the long blade of the IT-2, the dissection speed becomes much faster. Well, I guess just putting back will be also one of the options, the knife. Yes, yes. It's much safer. If we put the IT-9, much safer dissection could be possible. Because the situation doesn't change, and always you can see the device. Yes. Now, the... Just a little bit left hand side, or up to up? To adjust the traction device, and then we can see very nice cutting plane. Based on the direct visualization, we could cut. Okay, from right side. There are some concerns. When we use the IT-9 blade type device with traction device, some difficulty could be because the traction... This is edge, so it's always very important to find the edge, and then put the IT-9 to the edge, and then move the knife along the muscle layer. Even IT-9-2 has an insulated tip at the end of the needle, so the risk of perforation is really reduced. But still, if we cut into the muscle layer, the risk of perforation exists. Now, this is the final edge. Okay, this is the edge of the left side to hook. And then... This is the final cut. Okay, congratulations. Snowman was created. Thank you very much. And another advantage of this track motion device, we are now catching the specimen just This is the specimen with the scope. Excellent grasping force. Yes. That's why no need to... Open. Okay, congratulations. Okay. So, this is the rejected specimen. So this is a straight forward view, straight forward view, the anterior side of the upper gastric body. And then using the retroflex position. So this is our alphabet, okay. Only this point, the small amount of the muscle layer is damaged. Because the traction created the muscle layer sharper. Okay, thank you very much.

gastric endoscopic submucosal dissection

ESD

pig stomach model

IT knife 2

ORISE Pro Knife

submucosal cushion

coagulate vessels