Welcome, now we are going to show the wonderful ESD procedure conducted by Professor Sergei Kanzaboi, and he is going to make ESD using Dual Knife-J. After that, he will suture everything. But this time, he is planning to use track motion to give counter-traction for the tissue. Okay, let's start. So, the strategy will be... okay, needle in. Can we take it out and switch to the dual knife? So, my strategy is to create a small amount of submucosal tissue injection, and after that, I am switching to dual knife, and with dual knife, I will continue to expand. First, we will do circumferential incision, and after incision completed, then we will use track motion device to facilitate the dissection. Could you tell me the reason why you make only small submucosal injection at the beginning of the procedure? There is no cut. The reason is that the dual knife will inject very well into submucosa, but pig's tissue, this explanted pig tissue is very thick, so the dual knife will not be able to inject through it, and that's why the initial incision has to be done with the initial injection with the needle. Yeah, but what is the reason why you don't use injection needle for all the submucosal injection? Oh, it will be just waste of time, and this way, can we close it? Yeah, this way I can inject, and which one is the knife, and which one is the scope? Tape is device. Yes, tape is the knife, right, yeah. So, the dual knife provides, is it not? No, it's not, it's white, right, it's not blue? I don't see any blue color. It's okay, it's not a big deal. Can you open it, please? Please open, no, it's okay, not a big deal. So, if we use the needle, by the time I reach that submucosal amount will dissipate, and that's why I prefer just inject as much as I need to. Can we close it? And the other thing is that in case of puncturing the live tissue, there will be some risk of making bleeding. That is another disadvantage of giving submucosal fluid cushion by using injection needle. Yeah, from that point of view, dual knife is much safer injection than with the needle. Please close. But when you're injecting using dual knife, you have to be in the submucosa, otherwise it will just bound. It's not working, it's not working, it's off. The water is not coming. Could you try it again? Here, you see, nothing. I don't hear it. I feel like I'm in a hurry. Can you disconnect and flash it? Let's connect, maybe the knife would work or something. Ready? No, it's not going. Can we add, it has to be more, probably the power. Oh, but the liquid itself is coming. So probably you should open, close, open, close the tip of your knife. Yeah, yeah, yeah. So it got stuck. Once again. All right, can you close, please? Sometimes tip of the knife becomes dirty. That's why we should clean the knife tip all the time. It's quite simple. Just open, close, open, close and flash the liquid through the knife. Then we can clean the tip. Okay. Can you keep it open? Let's try to inject like this. So I'm using a pure cut mode. No cut area so that the margin will continue to stay clean. And here I did not cut through the full thickness of the muscularis mucoda. So I will trace it again. Now it completely opens. Usually we use blue colored solution for submucosal injection. Then right after mucosal incision, we can exactly recognize the blue colored submucosal layer. Please open. Now we can see the blue color of the submucosal injection. Then fooking the edge of the incision line with the tip of dual knife and continue mucosal incision for the inner side. It's very important to make sure that I'm not leaving any bridges from the muscularis mucosa. Otherwise, it will be hounding me back later on. Okay, it nicely opened. Yeah, so we will move to the other part of the... Please close. And each time when I press on the pedal, I want to make sure I'm pressing the right pedal. Open. I don't want to press on the cut when I intended to just inject fluid. Open. Now, he is tracing the inner edge of the incised area to make sure the opening of the submucosal space. So I'm cutting from muscle, away from muscle towards the lumen, so that I will not accidentally damage the muscle there. By making a mucosal incision, pushing manner, it is relatively safe because knife tip tends to go luminal side. On the contrast, if we make a mucosal incision by pulling back manner, it usually goes to deeper side, that is dangerous situation. We should be careful when we conduct mucosal incision. Now we can see the both edge of the incision line, and he is going to connect the incision line. Now Dr. Kanzaboi is controlling the direction by torquing his wrist, and using down angle, he can keep the good contact to the target tissue. This is very important technical tip. Most of the beginners try to control the lateral direction by using right-left channel, sometimes using right hand, that is really bad manner. Because if we release the shaft of the endoscope, sometimes scope position suddenly changes. Therefore we should keep the endoscope, then should control the direction by torquing our wrist. That's usually good enough. Now circumferential mucosal incision completed, then he is tracing inner edge of the incised area to direct the opening of the mucosal incision, and we can clearly see the blue colored submucosal layer. So we finished with circumferential dissection, now we will use the track motion device to facilitate the traction, and to facilitate dissection. So track motion is mounted on the same endoscope which I was using, and it is designed so that single operator will be using it. And I open this track motion device, I come toward the edge, and I grab that edge. And that is why it was so important to complete circumferential incision properly. Please open. Now we are switching to KAUT remote, because there may be some small blood vessel in the submucosa and we don't want to create extra bleeding. By the way, this is latest Fuji endoscope, which has 3.7 mm working channel. It is mandatory to have big working channel to use the track motion? Yes, track motion device will not be working through the small channel endoscope. And you can see that I can adjust my traction as far as I want to, or as little as I want to. And I'm cutting only tissue which is under the traction. And this is the effective way to do endoscopic submucosal dissection. Identifying tissue which is slowing my progress, and by cutting it I expand the submucosal dissection. And I decrease the traction and look into this part. Can you close? Each time I will add some solution to make sure that I will not damage any muscle. I try to be as far from the muscle as possible. And I think this blue color helps us to identify the submucosal tissue. Yeah, dramatically. It helps very much. Before I had a very vague idea where was the submucosa and where was the muscle. It happened because the muscle tissue is dense, and it doesn't absorb blue color. But submucosa is very kind of mushy, so it's loosely located fibers, and contrast and submucosal solution easily find the way in between. You can see that the exposure is ideal. Can you please close? Just want to have a better identification. Please open. Now we can easily recognize the third dissection frame, which is a blue layer. And the specimen is white, continue to be white, and the muscle also white, and submucosa is blue. So you can see when I cut the fibers, which are slow in progress, then immediately it expands the defect. And Dr. Kanzabou, I already mentioned, this is completely single operator device. Yeah, so it was a big, relatively big defect, so I let it go, and I will grab it in different place, so that the traction will be again more effective. Now we can see nicely the edge of the remaining submucosal tissue. Then following procedure becomes much effective. And once again, it is single operator procedure. You don't need any additional help, and I like that it's completely independent. So I do as much or as little traction. Now you can see that my device is bended, so I unbend it, and I push it away from me to expose this edge. So, by pushing the track motion device away, I put more traction on this corner. Now I want to have access to the other corner, so I bend the device and see if I can have a better... I'm sorry, if I have a better view. So I'm using track motion to push everything away from me to clear that area. You saw that, now he's at this maneuver. Yeah, sub mucosa is located a little bit lower side. Yeah. Oh, very nice. This is nearly the end of the procedure. It was very quick. And you probably noticed we did not have any bleeding. Sure. It was a good control of the bleeding too. Okay. Okay, so the whole scene is dissected, very even, and here was a little bit deeper than I wanted, but we will close the defect with endoscopic suturing device. And now I'm using this track motion device as a retrieval. So I'm holding... Thank you. We don't need this one anymore. So we need just a suturing device. So I'm pulling out, and track motion device is my retrieval device. That's great. Can we switch to the upholder? Now we are switching the endoscope to put an over-stitch suturing device to close that defect. So sorry, the airport. No, yeah. We have an extra large. We can bring an Oreo for the... It's all right. It will take five minutes. I will not delay. Okay. Okay. Do we have a... Because of the big working channel of this new endoscope, we can also use over-stitch, which requires 3.7 millimeter working channel. Don't worry. Not a big deal. So we're mounting the over-stitch, and it goes also to the bigger channel of the endoscope. And then we need to adjust position. So I prefer it to look like this. And then before I put the endoscope into the patient, I need to run a dry cycle to make sure that the suturing device working appropriately. So the dry cycle will be like this. I advance the suture out to create some slack and pull back. Now I close the suturing arm and transfer needle to the suturing arm. And now it's back. So I finish full cycle, everything is in working order, and we're ready to suture. Okay. So this is our defect, and it's very important to prevent formation of the dog ear. So we're starting from here, grasping this edge, transfer the needle back to the suture holder, transferring needle back to the suturing arm, grabbing again the edge. And now I am ready to go to the opposite side. I'm constantly checking to make sure that I did not create any criss-crosses when I was moving the suture. Okay, so this corner is done. Now we can just approximate anterior to posterior wall, and that will close the whole defect. How large amount of tissue do you usually catch? I usually want to have at least five millimeter of the tissue, and I leave about five millimeter in between my punctures. So here you see there's the criss-cross, so it has to be corrected right away. And I rotate the scope, and I get it like this, and go under. And now I can grab the needle, and it will be corrected the criss-cross. So you see, now I will just pull a little bit of my original suture so that it will not be on my way again. So approximately five millimeter of mucosa in each bite, and also five millimeter in between. So this was, where is my previous puncture, here. You see that previous puncture? So once again, just like with track motion device, you don't need any assistant, you do everything yourself. So I don't need to ask somebody to close the device, I close it when I want to, and I open when I want to. And that's the big beauty of this suturing device, it's completely independent. And very fast. Yeah, very fast. So most important point of this technique, to avoid the pocket formation after suturing, therefore you carefully start the proximal side, and nicely tighten the space. And even if you are suturing through the healthy tissue, sometimes you can get into the blood vessel, so you will see some minor bleeding, but at the time when we tighten the suture, the bleeding will stop. So it's not a problem. And in case of causing mucosal tear during the suturing, what should we do? Mucosal tear caused by the device? I would just put an X suture next to it and completely close it. So we are on the end of the suturing, this is the last corner. I do not like to drop the needle into the defect, I like to drop the needle on top of the mucosa so it will be easier to recognize when the patient will come for follow-up. So you usually make an extra X suture on the top? Yeah, like this. So we're done with the suturing, now I am releasing the needle and it becomes a T-tag. So I drop the needle, and when I will be tightening, you can see that there is a slack, and so this slack we will eliminate. So all you need to do is just push it through, and if you could hold it for a minute, please. You need a little tension. So you can see that my needle is not touching the mucosa, meaning that there is some slack in the system. Now I will be tightening it until it is touching the mucosa. There, you see? You see how it moved in? Let me show. So it's now no longer visible, so it's right at the mucosa. So the needle was pulled, it's tight on that end, now I'm checking to make sure that it's tight on the other end as well. And this is the time when we can apply the cinch, please. So we open up the stopper, and can you please squeeze it? That's it. So this is the end of the procedure, and here you can see there was a defect, and now everything is completely collected. The place where we made the first puncture, that's where my cinch is positioned, like this, and you don't see any muscle exposed, and the quality of the suture is just the same as surgical suture, and we finished at 2.28, and my plane is at 2.30, so we did everything in less than half an hour. Yeah, yeah. Congratulations. Thank you. Thank you very much. Do we have any questions? How long training is necessary to be sufficient level to use overstitch? I believe that people usually come for training courses, they spend the day in the animal lab doing training, and then Monday they're ready to work with the help of Apollo. Apollo reps will supervise, help to assemble the device, teach how to use the cinch and so forth. So they require about three, four cases under supervision of Apollo rep, and after that they can suture on their own. Oh, that's great. I recommend suturing electively first, suturing electively, because if you are dealing with perforation or some emergency, then it is much more difficult, so elective cases have to be mastered first. Thank you very much. Thank you.

endoscopic submucosal dissection

Dual Knife-J

dual knife

track motion device

traction

over-stitch suturing device