Welcome back to the endoscopy room. Today I'm performing two regions. Takashi Toyama from Kobe University Hospital and Dr. Sakaguchi from Kobe University Hospital kindly assisted me and the professor hugged me. Of course you may know he is belonging to Keio University. The region is a little bit anal side and antero side of the professor Saito's procedure. I'm now in the retroflex position. Now I can control the endoscope very well. So I'm starting the procedure from the anal side region. Now I'm only using the saline in the stomach without anything. The purpose of using non-colored solution is to observe the submucosa layer and the muscle layer much better. Is that right? Also, color is not necessary for me. I want to see more details. As the submucosa is blue, there is no guarantee for 100% safety of the muscle perforation. If the color hides the surface pattern of the muscle, you may touch it. But if you want to put the color, it should be very shallow. At least for the beginners, blue color helps so much to recognize the submucosa layer. When we started ESD, the blue color is too thick. But now a small amount of solution is recommended. So the direction of the incision is totally different from the IT knife. IT knife was pulling manner. We are creating from near side to far side. By the way, what kind of device are you going to use? Thank you very much for your kind question. I'm using the FLASH KNIFE VTS. As Professor Yahagi's lecture, is it better to clean the device? Yes, it is always very important to have a clean knife tip. Otherwise, it doesn't cut well and sometimes causes bleeding during the procedure. So it is very important to have a clean knife tip all the time. Carbonized tissue was not heated efficiently. Current transfer is not possible. That's why it is better to use a clean knife tip. But it is difficult to place the mark on the big knife. That's why I conducted very long. That's why my knife was dirty. Now you can see a polished one. I hope it can work very well. You are using magnification endoscope even for the therapeutic procedure. Yes, because I want to see every single small finding. Because in ESD procedure, we usually keep relatively close distance. That's why it's sometimes unclear. That's why magnification function is quite useful. I have created a starting point. Now I'm inserting the knife into the starting point. At least the backside of the ball should be under the mucosa. But in this situation, the manipulation is very unstable. That's why I'm contacting the mucosa by using the tip of the scissors. I control the direction to the aiming direction. Then I conduct the end-cut mode I one time. Then next I control the end-cut. Direction 4, please. The incision length was a bit short. Then I control the cut. You have seen that the incision length was elongated. Because I elongated the cut duration. Now, if you have such a sense, it seems to be a continuous cut can be done. But every single stroke I'm dividing into steps. Much more used to cut in such a manner, like Professor Hagi performed, something like rotating incision can be done. But for the beginner, I strongly recommend you to start with 1, 2, 3, 2, 3. Such a slow and steady procedure. Please consider about such incision manner. It is slow, but as a result of precise cutting, the final result becomes quite a quick procedure. That's right. If you fail every time, you are wasting time. That's why a slow and steady procedure provides you a smooth procedure. As a result, the procedure time becomes shorter. Now, Dr. Toyonaga is hooking the edge of the incision mucosa with the ball-tip part. That's why the tip of the instrument is very stable. Also, additional injection can be done by the knife. Please imagine, if the sick vessel is located under this mucosa, as if the sick vessel is there, if you scoop up the knife and mucosa, then cut it by shifting the cap, the knife tip doesn't reach to the vessel level. That's why you can prevent the bleeding during the incision as much as possible. Then, if the injection was not enough, you can inject by the knife itself, because this knife associates a water check function. I don't need to repeat the explanation. Now, he is controlling direction by talking his wrist. It's not necessary to control right-left channel. Just talking wrist and using up-down channel, we usually can control direction very well. I have shown you the greatest tip to inject the saline into the mucosa by using the knife itself. The knife tip was already inserted into the sheath. Then, you can contact the mucosa directly. Then, injecting, flushing the saline in such a tapping manner, you can provide time for the water to be spread into the mucosa. If you just touch and it works, the knife opens. If you do it in an open manner, the water is coming back. No efficient additional injection can be done. So, this is the greatest tip to inject saline. That means we should touch the target tissue with the sheath part. Yes, with the sheath part. I don't want to create a gap between the tissue and the knife sheath. Please simulate. You can see here some bundle. One and two. It will be branching to create a Y-shape. So, this is clear evidence that this is a vessel without a pore. But, if you are a real patient, this vessel is very active. That's why I want them, please. I'm simulating the vessel sealing technique. I'm inserting the knife back side of the ball, then also controlling the device and compressing the device and conducting 4 square, 0.48 watt, 6 volt. Now, the vessel is already white, but during this manner, the red vessel turns to white. Then, if you confirm the color change and the shrinkage situation, I will pause. After creating a bit of space, this is a branch vessel, you see. Then, the vessel is isolated. I forgot to isolate beforehand, but after isolating, such a pre-coagulation is done. Then, by scooping up or sliding, the right-hand side vessel is coagulated and the left-hand vessel is coagulated, and you can cut it. This is a very effective manner in which we can avoid serious bleeding during the procedure. As a result, we don't have to exchange instruments during the procedure. So, by reducing the tension of the branch vessel, the incisional edge will open. After that, you can create the entrance to the submucosa. This is the conventional way to create a mucosal flap. So, I strongly recommend you to dissect between muscle and branch vessel. It means here. Because underneath the branch vessel, only you need to treat the branch in the incisional edge and also the penetrating vessel. This theoretically minimizes the branch vessel control. So, if we dissect shallowly, we encounter lots of branch vessels. That means the chance of bleeding is getting higher. Then, by inserting the cap into the mucosal flap, you can create the lifting. This is the contraction by using the cap. But this is the conventional flap-creating method. Now we can see the very beautiful lucent submucosal layer. We can easily recognize the dissection frame now. Then, without magnification, only we can see this image. But if you adjust the focus, you are much more confident. This is the submucosal fiber in the muscle level here. That's why I want not for a detailed diagnosis, but also to adjust the focus. I'm using the low power of the magnification. OK, so what should I do? Should I go on like this? But what should I do? It's boring. OK, but I have some stress to dissect here because the submucosal space muscle area is located in front. A very careful approach can be possible, but I'd like to show you how the cheaper traction device than the track motion. OK. Only lying may work, but only pulling back doesn't work so well because after proceeding the dissection, the submucosal space becomes very thin. That's why push and pull traction will be much better without using such an expensive device. This is the re-openable clip. In Japan, the endotrack is commercially available, but not yet in the US. That's why we made it by using the scissor of the... Scissor? Snare? Snare. Oh, sorry. Never mind. Snare of the flash knife. Scissor of the flash knife. Yes, the day before yesterday I used the scissor of the snare, thin snare. It was soft. That's why today I decided to use the scissor of the flash knife BTS. But we can use any kind of scissor. Yes, yes. But too thick is also good. BTS has a thinner... This is BTS, right? Only 2.2 mm. Thinner than an injection needle. But the tip of the scissor is the usual diameter 2.6 or 2.7 mm. And now the scissor is also inserted alongside the endoscope. So it means the independent traction can be done. Oh, the gel is on. It's on the front. It's dirty. I want to remove the gel. How to heat it? Probably you can just flush the water then you can clean the space. Yes, but it's very sticky. Okay, okay. And also, as if I'm using a 2.8 mm working channel endoscope, still suction is possible. By the way, how can you decide the area to apply the endoscope? Good question. First, we are confirming the oral side. The scope is coming here. And the direction will be right, left, lower side to center maybe. Then, most anal side, I'm placing the clip. Ah, okay. Then a bit in this moment, left-hand side. Here, left-hand side is much more difficult. That's why I'm placing here. Then, anal side. How about this? Is it okay? Okay, that's good. So, okay. One o'clock? Okay, open. I'm observing the lower side of the jaw. Then, okay. This one is re-openable. That's why after temporal close, you can confirm the situation. I don't want to grasp the muscle layer. Yeah, in case of catching muscle layer, it's really risky situation. Therefore, we should avoid catching the muscle layer. At that moment, we need to remove it. Now, only putting the device, initial edge was already open, but I want to see more clearly. Then, pulling back. Too much pull, we see some layer became thinner. That's why you need to control the traction force or traction direction. You can see here, the thesis is heated close to the... Close once. Then, the line is short. Close, close. Now, as if you push... It's too far. It's okay. You can make different situation by changing the length of the line. Extend the line. Now, 2-3 cm more. Line can be seen from the thesis. Then, if we push... I want to see the region. I can show you which situation is creating. By pushing... Because it's going to the inner side, the tube tends to come straight. That's why something like fishing, you can change the direction. This is the great merit of this technique. We can get two-way traction. Now, you see very nicely the life show, right? Created this dissection plane. I'll stop here. So from now on, I'm of course observing the muscle surface and also the branched vessel network. You can see here the branched vessel and additional injection can be done very easily. Then this is the submucosal fiber, not muscle. Sometimes this structure can be the oblique muscle in the patient, human. The direction too, please. Because the submucosa in, so you have seen difference. With a needle in, injection is quite efficient. Out, needle out, not so much efficient. Okay, if you dissect underneath the branched vessel, no risk of bleeding. That's why I can conduct the cut more. But from now on, we will encounter the branched vessel, so additional injection can be done. Then maybe this was the branched vessel. So insert the knife and scoop up and aiming to the apex, such small vessel can be cut directly by emitting the phosphor. But if bleeding happen, this is seeding technique should be done. But if you dissect right-hand side first, region will be coming down to the difficult site. That's why I'm taking priority to perform the disconnection to the greater curved side. To scoop up the target, I'm creating the space. Then I have created the edge. Then coagulation directly. It doesn't cause the bleeding, maybe. But unfortunately, this pig has already dead. That's a no-blood flow. But we can simulate. So please, when you have the chance to perform the training in the pig model, please estimate, please image. This is an adverse tissue, but this can be also vessel. Usually, this kind of fat tissue accompanies lots of vascular network. So in case of finding fat tissue within the subcausal layer, we should be very careful not to injure blood vessel. Also, adipose tissue has the higher impedance. That's why the coagulation ability is limited. If the fat exists around the vessel, stop bleeding also becomes difficult. That's why prevention of the bleeding is much more important. Okay, then by pushing, by pushing, you can extend the edge as well. Then this connection to the other side becomes easier. Okay. So in this moment, if you pull back, region will hide the target. That's why push is much better. Okay. Now we can clearly see the remaining edge. And also I'm following the three steps. Step one, and control the knife. Step two, and conduct. Adipose tissue, yeah. Maybe dry up, that's why difficult. Okay, if from here to left is difficult, also you can change the direction from the right to left. Okay. You can skip the disconnect, complete disconnection in the inner side when you use this kind of traction. Because you can elongate the gap by pushing the device. Or by pulling. But you can adjust the situation by push and pull. Okay, then from the distance, the control is very difficult. That's why I recommend you to suck the air and come closer and decide aiming starting point. But before conduct, it's better to confirm the landing point. Now my dissection line will be from here to there. The beginner tends to seek the direction during the dissection. So at the beginning, it is better to confirm the direction. And I also highly recommend you to image what is coming. Next, because if you image before conduction, just after conduction, you can see the result. And every time image or aim what you are doing, you can get the feedback during the procedure. And you can perform much more nicely. So every time, please consider and also aim and also image what is coming next. Then try. It was a result. So it was not enough for your image or willing. You can change the manner a bit. So every time, please try to get the feedback from the procedure. So it's a kind of self-learning process. That's right. Then you can improve your skill. And also please record your own procedure and review after the procedure. Then video can teach you what you should do. Congratulations. It's very clean dissection bed. Okay. Also retrieval of the detected specimen is quite easy. Just pulling back the attraction. No. It's already retracted. Okay. So do you think such kind of modification of the device is available in the US? I think so. In Japan, it's okay because we can have the right to do it. Of course, the vendor cannot provide such a modified device, but the physicians can modify it by themselves. I have found that the flash knife sees totally work well in this. Now we can see a nice resection bed. There is no excess of burning effect. Okay. Okay, cutting margin is quite clean and the resection bed also very clean. Okay, now I move on to the oral side target. So what do we do for the next? The next region, I'm going to perform the pocket technique. So I can also use this one, but it's okay. So I don't repeat so much about the small tips. Just I create the, okay. Entrance at the beginning. Okay. So original pocket method, the entrance is very small. Then the maneuverability in the pocket was limited. That's why I'm following the bridge formation method. Not method, but the style. Methods should, all such methods should be named as the pocket creation method, including the tunneling technique. Professor Momota originally reported the pocket creation method as the tunneling method, but the tunneling, naming of the tunnel will have a risk of misreading. It just creates small, narrow tunnel. So if you perform tunneling technique, you will create, maybe your number one priority will be the penetrating the tunnel. But that is not so important. The greatest advantage of the pocket creation method is the good counter-traction can be provided by the endoscope itself, and also by, the endoscope can be hold inside the pocket, and as a result, maneuverability can be stable. As if the large respiratory movement is coming, or the big palisade is coming, cardiac palisade movement is coming. Especially when you perform the procedure in the anterior side of the gastric body, so much movement is coming. That's why both control the, create a good counter-traction in the somnambulosa, and also to hold the scope, and provide the good maneuverability, it works. Okay, now I'm deflating the air, insufflated air volume. Now, lifting also coming higher, and approach to the somnambulosa become easier. Maybe because here we have lost the tension of the mucosa, that's why healthy mucosa is coming inside. It's a little bit difficult, but. By reducing the volume of the air, we can create a nice submucosal fluid cushion. Okay. It's a little bit too close. Ah, still difficult. Okay. Then you can open, yes, a little bit wider, then it will become possible to go in. So I don't want to use the traction, because I want to show the pocket, but if difficult, you can use the... Maybe water irrigation helps to open this space. So I'm now very much fond of the water pressure method. But today, the residue is very dark. But... Just flushing the saline, yes, then you can open the flap, and catch the air through it. That's why I'm a great, great fan of the water pressure method. Okay. But you have noticed, the pocket creation method doesn't contribute to get into submucosa. That's why some experts are also using the traction device, as if they are performing the pocket creation method. But also, of course, the water pressure does work, as you have seen. Especially in the colon, or the duodenum, getting the submucosa becomes much easier than the conventional method. And also, the greatest merit of the pocket creation method is that you can reduce the breathing during the incision and the disconnection. Because in the pocket technique, we are dissecting the submucosa first. It means every single penetrating vessel will be treated in advance. Then, blood flow to the branch becomes very small. That's why you can reduce the breathing during the incision. We brought the clinical case video, and he is going to present tomorrow, if we have time, with the prevention of the breathing by using the pocket creation method. Okay, out. Okay. So if the injection reached the oral edge, okay, I can see, I don't know. Here, injection has come to the, this one is the other one, the other mark. So now, I have not injected to the oral side. But now, injection solution exists here. It means our injection from the submucosa has reached to the oral edge. That's why it is now time to open the oral side. Okay, so now from now on, pocket creation method turns to creating the tunnel. Okay. So Dr. Toyonaga is cutting the oral side. Because duration will be two. To determine the end point of the submucosa dissection. Four, please. So if you hear something difficult, please confirm your setting. For the submucosa dissection, I used the duration two. That's why break out and the incision was a bit not efficient. How large mucosal incision at the oral side do you usually make? I'm making the relatively wider, something like the same width with the greatest diameter at the central part. Largest diameter at the central part. Okay, now I will disconnect the oral side. So, I tend to create the oral side disconnection from the retroflex and the incision from retroflex even in the greater carp side because it seems to be reasonable by using the anti-flexion, but the transaction from the anal side, straight view, is quite difficult because the unit, well, not so much different now. Usually, many respiratory movements coming and also down and shift, rotate is needed. So, usually it is very difficult. That's why I prefer to perform this connection in the retroflex position, but you can do it in anti-flexion too. The duration, too, please. Okay. Okay, I try to penetrate. Okay. Now you can see here the well-opened somucosal pocket. Okay. So, the muscle area is coming up. That's why I change the direction from the oral side. Okay. Okay. So, also, you can use up and down technique The targeted region is the lower side of the image. This is also good. Then getting somucosal becomes a bit easier because the knife is coming to the inner edge automatically. Okay, many other hospitals. The same. Okay. So, but a drawback of the pocket technique for me is this opening of the pocket. So, opening of the pocket. That's why I'm creating relatively wide entrance and also by scooping up. But still, I have a stress to do it. But now, it's okay. Then control knife. Okay, I want to get into somucosal from the oral side. Now, succeeded. Still, muscle is located in front. We can see the nice root and somucosal area in the middle of the somucosal area. With this image, I'm not so much confident. But if you adjust the focus, I can see through the muscle surface and the somucosal space. I'm very confident I'm performing the safe dissection. Okay, then also, if you rotate the image, the dissection line became up and down. Up and down, 12 to 6 o'clock. So, that means you can dissect here using up and down. It is much easier. Yeah, that's right. But to keep the position is a bit difficult. But such a precise dissection procedure is needed, especially in the esophagus and the colon. So, the stomach, of course, a large movement using the IT knife is possible. But for us, fibrotic target, or thinner target in the duodenum, or colon, tip type, I prefer to use the tip type knife, such as the flush knife or the dual knife. Because a very precise dissection can be done. Okay. Now it's connected. This is a pseudo-perforation. Connect the somucosal penetrated. Okay. Okay. Okay, maybe printing. Oh, not that. Okay, here. Okay, once you create a space, it is easier to proceed the dissection. Many other process. Okay. Then I'm hooking the edge and pulling back. Or push. Okay, it is better to come from the inner side now. Nice. Okay, now I have created a tunnel by using a pocket technique. Okay. Okay. Now it's okay. So now it is time to complete the mucosal incision. Now most of the submucosal tissue below the marked area are already dissected. Then it's time to make a circumferential mucosal incision. Yeah. So which, do you think which mucosal should be cut first? On the left side because it's close to the greater curvature side. Right, right. And the gravity is coming from right to left. That's why if you cut the lesser curvature side first, vision will be brought down to the water level and further procedure become difficult. Okay. That's why you should know the conventional way. It means that by using gravity or the remaining tension of the mucosal, strategy will be created. Okay. I cannot see the mark here. Yeah, this is the mark. Okay. So additional injection can be done by the knife itself. That's why a bit slower, like a more convenient for me to exchange the injection needle. That's why I'm step-by-step creating the injection before the lift and cut it. But usually greater curve side of the gastric body associated with very thick branch vessels and it tends to bleed a lot. But in this moment, already blood flow is zero, but by dissecting every single penetrating vessel, you can, the blood flow is minimized. So now it is difficult. You can see here, opening a pocket has some risk of perforation and technically demanding because you need to carefully scoop up the edge of the somocausal. My bad. Okay. However, by creating the lateral flex after passing the somocausal tunnel, so by making the lateral flex, now you can see here, very much lifted up edge. So it's very beautiful. Back side of the scope can create the counter traction. Now, okay. I'm much more easily, I can dissect the edge. Inside, outside is better maybe. But I don't see the landing point. That's why I change the direction here up to there. I can see the landing point very well because I have already created space. Now, second one. It becomes quite good situation. Yeah. But sometimes too much traction can be provided and the target can be lacerated sometimes. That's why I please reduce the insufflation volume. And you can control the traction force by controlling the insufflation volume. Okay. Now I almost complete the incision to the lesser curve side. Okay. Already some mucosa was dissected. That's why just capture the mucosa from the back side. Or from the mucosa side. What is the duration? Four, right? Yes, yes. Because target is very floppy. That's why it's difficult to cut. That's why I injected again to provide the good tension to the mucosa. So mucosa can fold it. Hmm. Then I'm inserting the blade part of the knife and scooping up the mucosa by using the backside of the ball and controlling the incision depth and also providing the higher counter traction for mucosa to be cut. Because neck part is mostly incisive in the flash knife. Okay. I remain. Okay. I'm scooping up the mucosa. Then shift. Okay, still. Okay. Good. Very good, very good. Now, no need to come back to this. Yeah, but here, right now, right-hand side is difficult to open because it is not cut yet. Okay, still difficult to insert to the edge of the lesser curve side. That's why I decided to come back to this tunnel again and very carefully after sucking the air. Air. You can see the tip of the needle inside. From here to there, thick part is remaining. That's why if you elongate around this, sucking for efficiency coming up to 50% higher. Only thinner sheath is inserted. Now, totally different situation can be provided, okay? Okay. This is a really nice traction technique. Yeah, I named this lateral flex traction technique, but just before submitting the paper, video, I have found Terry's group already reported this technique. Oh, really? Yeah. It was named... Pocket under bridge technique. I forgot. Very long name. Yes, especially rectum. I have brought the video using this technique in the rectum. So if you have time, I can show you tomorrow. Okay. Now, from water level side, too strong traction was provided. That's why I'm sucking the air. Okay. I guess this is much better than traction motion. No, no, no. Nobody can see that. Okay. If it was floppy, so the direction is coming from right to left. That's why if you come the other side, maybe efficient dissection can be done. Oh, congratulations. Okay, thank you very much. Sorry, Elisabeth is laughing or smiling. Okay, thank you very much. Thank you very much. Any question or comment, no? No question. Okay, thank you. See you tomorrow.

endoscopic procedure

non-colored solution

submucosa

muscle layers

clean knife tip

magnification endoscopes

incisions

dissections

pocket creation method