Welcome back. We're going to be performing... Oh, I'm sorry. If I use the chat track, there's a lot of gravity, so it doesn't make much sense. Welcome back. My name is Norio Norio Fukami. I'm Makoto Nishimura. And behind, Professor Toyonaga is waiting to hear your questions. Oh, there are questions. No, not really. All right. So, one thing I wanted to show you is, again, the tunneling method. We heard briefly from me and Dr. Saito mentioning the tunneling method is actually a part of the traction method. And that can be really utilized in a difficult case or in a colon universally. And I want to ask both of you, do you utilize tunneling method often or in selected cases? Which type of cases are more suitable, you think? Sometimes I do such kind of like a modified, like a combined pocket creation method and tunneling method. Absolutely. They are very similar. Slightly different. But essentially, you create a semi-causal access and create the straight line pocket to ensure that you have a good access to the semi-causal space. And once you're inside the tunnel, you have a natural traction. That's why we call it a small traction method. I'm using a pro-knife to mark it on the greater curvature side, so the bottom of the gravity, so that we can demonstrate how it works. I don't know about location if it's suitable or not, but we'll do it anyway. I'm using a Fuji ST hood, which is a newly released tapered hood that make the access to semi-causal much easier. But I found that this has a little more different features that it looks a little deceivingly short. So if you protrude the knife too long, you're actually cutting really deep. So you have to adjust to your liking. This is not the same feeling that you used to be, you should have with a short ST or straight cap. Do you agree? Yeah, that's fine. Short type. That's an example. Short one is probably much easier. And also this knife is a 3mm pro-knife. It's good for pig stomach. Yeah, many times the pig stomach is very thick. But for the real fish, maybe 3mm is too long. Or maybe for corn, it's much shorter, maybe 2mm or so. In the esophagus, your access is much more parallel, so length is not a major issue. Yes, and many times I use a 1.5mm for colon and esophagus and 2mm for stomach. But even stomach, sometimes I use a 1.5mm knife. Back to the pastoral preference. Okay, so for marking, I use this pro-knife. And because of the pig stomach, entering the esophagus can be a little more difficult. So I'm going to use the pro-knife to enter and then demonstrate speedboat. It's a bipolar knife with a special shape. So now you can see the water is pooling down. So it's at the bottom of the gravity, which is a little more difficult to access. Because of the water, a lot of lack of traction by the gravity. So for tunneling method, you have to start with the distal part. Yes, I purposely made it small. What we recommend is to insert the distal part much longer. Now, you have to think that this is a rather small lesion. So if you insert too much in the distal side, water may escape. So the proximal to your, in this case, it's the oral side. You have to create a nice big pocket to ensure the semicolon access. Injection? Injection. I think that's a good point. One way that Terinaga is explaining is that you can just do the proximal side closer to you first, ensure the access, and go to the distal end. Inject? Injecting, injecting. I want to see how much of the injection is happening, so I'll step back a little bit. Injection. Inject one. Injection. Stop. So, you didn't realize, because you're too close, the injection is pretty robust. Makoto was really strong, I didn't realize. Assistant. Sorry. Inject. Injecting. Injection one. Two. Two. Stop. Controlling the amount of injection is really important. And, you know that? Know what? Oh. Control. So, this one is a little bit lifted. I didn't expect that it extends to the proximal end. So, needle out? Needle out. Inject. Injecting. Stop injecting. Needle out. Look. Well, I'll take Dr. Terinaga's advice. I usually do distal end first. But, let's ensure access to the proximal end and semiclosal space. And, here we have just normal water injection and also endocrine injection. Well, as I mentioned, it looks like this is my 3mm, but if you do this, it's probably too long. So, if you withdraw, probably this, I'm using almost 3mm to 2.5mm. Right? This is a little bit different feeling that I used to, I'm used to. But, this is a marking. Go away from it. And, you ensure that you have a big mucosal flap in the normal area. First, endocrine. Oh, sorry. So, the proper setting is selected. It's endocut. I'm going to penetrate through. So, I'm going to go one more time. I want to go a little deeper. So, now mucosa is getting closer. So, the knife finally went into the semiclosal space, approaching to the semiclosal space. Once you secure the access, you can grab the tissue a little bit and give it a little direction. It's a little slow. You can do it. Yes. I like the interval one. Thank you. Sounds good. I'm going to pull back a little bit to get close to it. Ensure that you're not cutting too deep, but not cutting too shallow. The semiclosure is exposed. In real life, you should utilize the coagulation process with coagulants, because I suck. But, in this case, I'm using just a little endocut one more time. It started opening up nicely. So, I learned to just limit the opening of the mucosal incision, so that it's keeping the water inside. Do you recommend limiting it to 2 centimeters, 1.5, or do you want to open it up more? Yeah, me too. Based on the cap. Right now, we are using the tape on the cap. Okay. For a bigger cap, sometimes I have to open it up a little bit wider. So, this is the cap length. You want to probably do at least 1.5. Yeah. I feel that that would secure the extension and expansion of the semiclosure space. Now, this is a speedboat. This is a bipolar knife. As you can see, the bottom is a little thickened, and there's a white plate. And there's a transition from the narrow body of the gold to the full width. Full width is an active electrode all the way to the tip. So, it's like going 360, no, 180. Then, the length from here to the tip of the knife is 4 millimeters. So, we have to utilize almost half of it. Make sure that you're not getting too much of the length inside so that you prevent accidental cuts. The transition of the gold to the white, you can see a little bit of white. That's the area that cuts better. So, go to the left up. Carson, my assistant, is... Oh, it was a hook switch. And this is a bipolar knife, so it doesn't have a need for grounding. It's really beneficial if you're doing a procedure for a patient with a defibrillator. Right up? Right up. Okay. Right up? Right up. Right up? I'm controlling the direction. I'm rotating the catheter and the handle. Catheter and handle are at the same time. Dr. Fukami, can you rotate by yourself? You can, but typically we have to resort to the assistant at this point. In the future... One or two hands is needed. One or two? One or two hands is needed. Assistant hand, yes. This is a colon length, so that's why he has to hold with the right hand support. How often are you using a split bolt? I'm using for colorectal ESD. Right up? Right up. The bipolar gives a consistent cutting effect. That's exactly right. So a little bit of activation creates some... It's not a spark with lightning. Left up? That's active electrode. There's not much charring. If you get good contact with the tissue, it cuts without much effort. Now I'm getting into semicircular space. Right up? Right up. There's no need for change in setting. When you want to cut, just use the cut. And if you want to coagulate the vessel, use the coagulation. The only thing is, at this point, this device is not that easy to dissect under the water. So water pressure method is not the best match for this knife. So make it a little dry. How about the mucosal incision? Mucosal incision really works well in the colon. For some reason, for pig stomach, they hate split bolt. So, as you can see, you have to capture the tissue. Use your contact so the machine can calculate how much of the energy is being delivered. Right up? Right up. And if it's dry, contact. Apply. Continue on. Let's say there's a blood vessel. I activate microwave coagulation. Hopefully, you can see some bubbling. Exactly the same. Yep. So if you need to coagulate with the tip, use the tip. But in general, you want to do pre-coagulation of the vessel. So you have to go from the side to compress the vessel in the microwave. So now we have a secure access to semicosal space. So we can go to the proximal end. Probably we need to do pro-knife. Seems to be very efficient and quick. Yeah. It's really thick. So now we are back into 3mm pro-knife. Pro-knife, sorry. Open. Now I have to really get used to this cap. Is this too much? No, it looks good. Basically, ST cap, ST hood is very limited view. So it's a little bit harder to see. But especially when we are going inside after a small incision, it works. Really easy to get inside to semicosal space. It's tapered, so it's much easier. I agree with you. Let's change the speed. It reminds you of an IT knife. Yeah, IT knife. So typically what we try to do is, protective hull should be aimed towards the protection. Bottom side is a tissue, so we want to protect the bottom. Or we want to protect the muscle, so muscle side or lesion side would be at the bottom. In this case, we are going to be doing this way. This is very similar to IT knife. To start a mucosal incision, we need to open up a little bit. This method is, but in a really human case, it doesn't have to be that way. So not necessary. So the same way, I'm hoping that I'm using the pro-knife. Left up? Left up? So the tip edge has to be on the direction. I'm trying to get used to this cap. Left up? You can, but I never needed to change the setting. Left up? Left up. Since there was now 3.2mm channel compatibility, I tried in a poem. Actually, muscle incision was really easy with this knife as well. So much mucus coming onto my way. So this is the entry side. So this is the entry side. This is where the incision should be. Likely a new generation is coming for this speed boat. ST hood is a little bit hard to see. Yeah, so this new ST hood has a very limited view in some way. This way. There. Okay. Do you use the ST hood often? Especially for colorectal? Right up? Right up? Short ST. Short ST. Left up? Left up. Same? No, slightly different. Left up? Left up. Right up? Right up. So for some reason, it's activated to the top of the speed boat as well. Now, one of the limitations is underwater. So right up? Right up. Right up. Dr. Afukami, how about the breathing during the mucosal incision? That's a good question. This knife has a boat cutting and coagulation capability. So one thing that is beneficial is if you see the bleeding, you activate the coagulation, which is microwave coagulation. You have to activate three to five seconds minimum, and after 10 seconds to create hemostasis. But it's not by contact, but the effect dissipates and spreads out slowly. So even though you cannot see the bleeding point, sometimes the vicinity is adequate, so the thermal effect goes nearby vessels and shrinks down. At least bleeding is slowed down. So I'm doing a semicodal dissection here. Or rather, it's trimming. And at this point, I'm a little nervous about displaying to the camera. That seems to be only one incision you could successfully go into the sub-mucosal layer. Right. Yeah. Sometimes, because of pig stomachs, we cannot cut and we cannot go into the sub-mucosal layer by one incision. And for the funneling method, defining a distance is really important. So now you are opening up wider. And deeper. Wider and deeper. That's right. Some of the difficulty I'm having is dryness of this area. Usually in colon ESD, I try to go close to the muscle layer so that you can see, barely seeing the muscle layer, but that would be adequate depth for the end point. Right up? Right up. For stomach, which area is not a good location for the tunneling method to perform? I think everything is good for the tunneling method. Everything is good. The only thing is if it's small enough, it's an easy access antrum, a small lesion is probably not worth doing the tunneling method, do you agree? And also, unlikely you need to use a traction device, right? That's right. So this is a traction. You can see, once you're in the sub-mucosal layer, everything is kind of folded down. So you see the tenting sub-mucosal tissue. So if you trace the sub-mucosal layer along the muscle, you are creating effective tunneling. And this seems to be palm, very similar to palm. That's right. So if you touch the muscle, will it damage the tissue or? That's a good question. So monopolar would have both top and down electricity current, but in this way, you have only this white width to go across. So even though you touch the muscle, typically the most contact area, like this is the top of this tissue, it being incised. So the muscle injuries is very rare, unless you go onto the muscle layer like that, or going this way. So that the effect... The contact area can be cut. That's right. Once you contact, it's going to cut. Monopolar, the current goes to the deeper. That's why in this way, it can be easily damaged. Absolutely. Because you have to go all the way back to the return electrode. I'm touching the left side, the left side is cut, if you go to the right, right side is cut. So it's more of a, what you call, somebody called the Okubita. So in this view, I think I'm using like 4mm, which is not the common thing we should do. I'm going to pull back a little bit, so that I can get a little more, a shorter contact. And keep going right and left. See, before I step on, I always, I'm confirming, I'm not touching the muscle, my direction is right. Pay attention, this is the muscle direction, right? Then I have to just redirect, right up. Of course, if the device is in the muscle direction, it will be a problem. Absolutely. The amazing part is, what you see, what you get is what you cut. And the speedboat doesn't discriminate. Now seems to be no muscular damage. It's very clean. Very clean, yeah. I think I'm almost there, sometimes I overshoot. Yeah, I think I went to the upper side, so I probably overshoot it. You start to see some air bubble, that's a sign that you're going to be done. That's the reason why I cut this submucosal end point much wider, usually. Yep, I knew it. So another overshooting. Okay, so let's cut this line, right up, left up. I'm going to go to almost 9 o'clock. So Dr. Afukami, is this a good method for a beginner in the pedal? Yeah, so I think this is a safer device that limits the electrosurgical current damage, but as you can see, maneuvering can be a little more challenging. So you have to get really used to it. For me, it took probably 9 cases to be really efficient and comfortable. But on the other hand, in the UK, one of the physicians was only trained by a ski boat with ESD, and she's doing marvelous work performing ESD very safely. So the learning curve may be shortened. I don't want to get too lost here. Oh, here. So that's a tunnel, and the right side is almost untouched. Remember, this is the bottom of gravity, so there's no traction per se, except for the cap. Left up? Left up. So we're going to be doing a little more. With IT, you're going to go from distal to proximal, but this knife is a tip knife, so you capture the tissue. Left up? Left up. Almost along the muscle line? Perfect. And seeing what you're cutting, go little by little. So this protective hull on the bottom actually makes it slide much easier. I know it's a little difficult to comment on the tissue reaction in the dead tissue but what do you think about this effect? That seems to be less tissue damage. It's very minimum charring, right? Yeah, I couldn't see nothing. So many times the other knife, often we need to come out and we need to clean up the tip of the knife. How about this speed boat? No need to retrieve that speed boat and clean up by the toothbrush? Unfortunately, some of the dead tissue just stuck on the knife. So cleaning a knife is really essential to make it efficient. I have no device. Just alcohol. No need for toothbrush. Can I have an injection? So we're going to do a Mykozo incision, complete the 360 Mykozo incision from now. And then I'll show you how it looks afterward. And after the Mykozo incision, access to the Samikoza gets really easy. Need help? Need help. Inject? Injection. Injection. Stop. It's open so we're going to be injecting from bottom up. Inject? Injection. Injection. Stop. 0.5. 0.5. Thank you. And let's go on the right side. So right side is a mouthpiece here. Inject? Injection. One. One more? One. Perfect. A little bit blurry so let me just clean up the lens. Oh, you're going to be doing assistant for me? Yeah. Thank you. Any questions from audience? Question to Dr. Nishimura or Dr. Torinaga? Okay. Speedboat. Having said that, in esophageal ESD, especially for Barrett's, I tend to do more conventional ESD. There's a complete 360 without creating a tunnel because access is much easier. I'm going to go from the left side. Using this cap and this traction, I'm going to capture Mikko as a laptop. Laptop? No? No. Now Speedboat seem to be shiny. Shiny. Shiny. You have to get a good contact and stomach doesn't extend at all. Yeah. Because of the parallel positioning, I couldn't capture the tissue well. I'm going to extend the knife just a little bit. Laptop? Laptop? Good. Speedboat has an injection function? It does. It has a 26-gauge needle and you can do on-demand injection for sure. I usually use it for semicosal injection, just additional injection. By Speedboat? By Speedboat because you don't have to exchange the knife. Here, if you're going to go too fast, you're going to cut the muscle. So, you have to really get used to this new cap. Laptop? Laptop? I'm not capturing the tissue. Yeah. So, if the tissue contact is more on the top, it tends to go to the top. If you float it up, even if you're barely touching it, it doesn't really cut the bottom part. Absolutely. So, if the tip is onto the muscle, that's really dangerous. So, that's the reason why I'm trying to keep adjusting the laptop knife length. Correct. That's exactly correct. Usually, pushing down is really the best way, but now I'm going to go right up. So, this is still too proximal. Again, this is a little more dangerous by pulling back. So, right up? Correct. So, now you are cutting everywhere, right? From the mucosa to all the way to the muscle. All the way to the mucosal region. So, the scope can pass right up after the bending? No. So, right now, the scope is straight. So, Dr. Fukami, how do you think that either speed of work works by retroflexion? Retroflexion, yes. Oh, that's good. Once the 3.2 is available, the retroflexion became possible. Before, we could not do retroflexion at all. So, this one, I demonstrated a method by retroflexion. Another feature is, I jumped on here. It barely makes the accidental perforation. I cannot explain the mechanism, but it has a little bit delay in calculating how much those levers. So, I jumped on a little calculation. It's very superficial. So, that's an additional good feature for beginners as well. Oh, yes, sure. Lift up the mucosa. Yeah, let me see. Oh, this is a nice technique. Do you try sometimes? Yes, I do. Hmm. Very difficult to see. Yeah, because of the cap. So, it's the bottom of the gravity. It should be around here. Excellent. Yeah, there you go. Yeah, it's very hard to see. So, in your technique, you perform the Mikosa incision this way. After Mikosa incision. After Mikosa incision. To open the pocket. From yesterday. Since I pushed it on, maybe the Mikosa injection disappeared. Let's do injection a little bit. Also traction. Usually, it is lion's foot. Even this is a stomach, probably that would be easiest. So, Dr. Fukami, how about you? Are you using some traction device? New route? New route. For upper GI, I tend to do lion's foot. Inject one. Stop. And then, in colon, you have to have internal traction. Yeah, it's easier this way. Yep. So then, we can do commercially available internal traction device. Inject one. Inject one. So, for now, I would like to show the short trap with a rubber band. And afterward, Juha is going to demonstrate Prodigy. Prodigy. Let's see if this is really... Lift up. And let's speed up speedboat. Speedboat doesn't like the water. Oh. Now, it's moving this direction. So, I cannot go from left to right. I have to break the mucosa somewhere here. Right up? Right up. Push me left. Oh. Do you think it's because of the pig stomach? Yeah. Yeah, this is very thick. Usually I use similar to all the knives, we use a pro knife but a dual knife. I stay in the stationary area until the tip sinks in and then starts cutting through. Left up? I don't know if it, oh there you go. Thank god. So with the tension it gets so much easier. Right up? Right up? This is the angle problem, left up? Not the problem but you have to just optimize the angulation. So right up? Now you are completely opening up the right side. Right side, yeah. I thought the right side was easier but the right side is more difficult. Do you think of the direction of the channel? Yeah. But this channel seems to be almost 6 p.m. Almost 6 p.m. Always try the different direction. Left up? Right up? A little more to the left though. Hmm, this direction, but I have to optimize or I might be torturing myself. This is becoming a little more interesting, just right up. Always you want to go into semicircular space. I found that if you limit the exposure or touching of the probe knife to the tissue, it cuts much better. The tenting, just like IT knife, it doesn't really work well. Let me see if retroflexion really helps us. Yeah, this knife seems very interesting and very unique. Yeah, so I'm retroflex, I can push it out without problem. If I can see the area. It seems to need a nice assistant. Dr. Saito, I need IT. Oh, he's gone. And of course, this is a hands-on course. We have so many different types of knife. Sometimes I cannot engage into it. There you go. Hmm, this one. Okay, of course, the lesion. More points here. This one, right side is actually overshooted. No, almost. Dr. Fukami, do you need to train the endoscopy staff for speedboat? Or everybody gets used to? What's that again? Do you need some special training for speedboat? There's no need, but... For endoscopy staff. Oh, endoscopy staff, yes. So this right up, left up combination, to get used to it, it has a little bit training is needed. So definitely, I encourage the team approach. In this case, probably we would do... Let's save time with the pro knife. No. Can I have pro knife? Yes. And also, you can train the advanced fellow for assistant. Advanced fellow as well, that's right. Oh, advanced fellow is actively engaged in this training as well? You know, so that is good for advanced fellow. It's a thing to perform. Dr. Toyonaga, in Japan, how are you teaching? So let them assist some 10, 20 cases, then they can start or? After 20 cases of observation. After 20 cases of observation. Including assist, I can handle this control. Like a stomach case? Not necessary. We can't select the issue. Oh, okay. Well, certain location, certain tool works better. So I want you to see, this is now circumferential incisions done. And even though it's at the bottom of gravity, once you go into semicosal space, you have a really nice access to semicosal area that you have to incise. But that's the beauty of the tunneling method. Right here on the left, 9 o'clock, if you cut, it opens up. Left side, if you cut this one, it opens up. So let's do just one, two dissections of semicosal. This moves so quickly, so we're so unhappy. Sometimes we use a four millimeter length. The problem is, you're not looking at the vessel at the time. So you tend to see a lot of vessel, I mean, bleeding if you rush. Don't you agree? And now he cleaned up the speed of autonysis, so now it's shining. Very nice. So first, you have to really see what the direction you have to cut. Sometimes you lose the direction. So it's going to be like 10 o'clock, left up? And rotate a little bit. In this situation, everything is in the middle of the vessel, and the region is in flux. That's right. It's mostly cut off, from the, yeah, already. This way. So you have to be careful, alternating coagulation, and seal the vessel. In 10 seconds, there's auto-stop, you see it started bubbling. By this time, the blood vessel is coagulated, so it continues. The bubble is one of the signs that the blood vessel is coagulated. Exactly, you reach the 100 degree, and it's just sealing the vessel on the right side. I'm going to do the same thing. And stop. Also, you can see the color change. The color can change to white. Then you... So we need to see that nice bubble in the middle. Then you... So we need to see that nice bubble and the nice color change, then we can cut. That's right, so blanching effect, bubbling, those are very important signs that you have to see. Thank you, Dr. Tanaka and Dr. Nishimura. So, I'm using a cap to just hold it down, and capturing the tissues, seeing what you need to cut. Slowly, one by one. Also, this conical shape, as if it's a sheet. Nicely, right. You can see that, if you use a special tool, opening the pocket becomes very difficult. I'm mainly using this red one. That's why... I think that's a good point. There are pros and cons in using this cap. It's very nice in the focus area, but sometimes things can be difficult. So this one, I'm using a 4mm length. If you're comfortable... You touch... And those are the sweeping motions. Let's use the traction method and see. Okay. You can change the cap, right? Correct. When you are going inside, you can put the ST cap, and then afterward. Afterward, yes. You can put the ST cap. It's an additional cost, but sometimes it just saves you time. Tunneling really helps maintaining the access to the semicircles. That's a key point. Another one. Short track is a rubber band traction method. It comes with two portions. One is a clip with a rubber band. This is a rubber band. Now we are using a traction device. I'll just show the audience. Go close to yourself. In a white coat. There you go. It's protected in a plastic case. You open it up, and there's a clip with a rubber band at the tip. There you go. That stretches up to 5 centimeters. That's what I heard. You're passing through. It's a rubber band. You don't want to have too much friction. You wet it with water, and pass through the channel. Let's come back out. I usually do access to this side. Now, Makoto is rotating for me, but the rubber band should be top of the lesion. So that you can nicely access and grasp the clip. I'm going to pull back a little bit, and lift it up, so that I don't grasp the excessive tissue there. Okay. How is this? Yep. Only the lesion is grasped. Thank you. Next one is to connect this guy to the opposite wall, typically. The second component comes in the box. It's just the existing clip. Just clip. There you go. Open, close. There you go. Perfect. Okay. Let's see if it's twisted. You made a knot. Close. The second is you hook with one of the arms. You always have to deal with it outside. Open. Open. Let's go to the right side. Rotate a little bit right. Perfect. Let me see the arm. More to the right. Left arm. Are you playing with it? Close a little bit. Open. Perfect. Don't move. I'm going to hook it gradually. It's like a docking station. Close. Then I'd rather put it up to the opposite wall. Stretch. I'm going to the anal side. Push it up and stretch it. Open. Onto the wall. Go slow. It's kind of too shallow. Open. The other side is one way. If you flip, you're going to open the axis here. Close. Let's push it to the oral side. We'll go this way. Do you like the oral side? Make it a pocket. Alright. I would love to have the oral side. Open. I'm going to just gently stretch. Close. Close. I hope the rubber band is still there. Maybe it's released. Open. Open. I knew it. Open. I think you aim to the oral side. Uh-huh. First place you put it will get pumped to the oral side. That makes sense. Open. Slow. Open. Slow. Close. I have something. Good. Deploy. Traction has already set the proximal end. I probably should have gone more to the left side. This way, I probably need to put more air to expand to make the traction more visible. More traction. Just because I'm putting more air to expand the stomach. It's not working. It's going away. For some reason, this stomach is not cooperating. Right up. Perfect. Right up. A little more. Right up. Now you have good access to the semicosal layer. You can see from here to the left. I can probably do from this side too. I'm using a cut current again. Left up. Right up. Right up. Good. The difference is so visible. You have to keep adjusting the angle. That's why you need to train your tech. For some reason, the traction is more on the right side. I think if I release the right, it's going to open more. Right up. It's visible, so I can still see what I'm cutting and the direction I'm going. Sometimes you can deploy two traction devices. If the effect is not ideal, you have to correct it. What I'm doing is adjusting my direction before I activate the cut current. Right up. I'm going down a little bit. I have to make it dry a little more. Left up. Good. You are using the cutting current. Exactly. If you want to cut anything, it's a cut current. Right up. There's no dissection mode. It's only cut or quad. It's a microwave coagulation. It's really just a foam for hemostasis. No charring at all. I'm quickly moving because of the traction. Even though I could have done without traction, traction is really ideal in any case. How do you create the traction? Left up. Right up. It's really the key. Don't you agree? How often are you using traction? It depends on the location. Right side is really easy. Should I cut it off here or should I cut the left side? How would you approach? I agree to cut here. I think there's too much left here. Even though there's a lot of traction. Left up. There's still so much tissue. You have to get a lot of tissue contact to cut it. Change the direction. Cut. There's no need to rush. It's so quick. I'm using a 4mm. That's why the length was rather quick. Right up. That's it. This requires rotation, but once you catch the nice tissue, it's much quicker. Left side is done. Traction is still helping me. Go to the bottom side. Go back to knife. Identify the area. Right up. That's it. Left up. That's going to be the end of it. That's it. Now we retrieve this receptive specimen. It was a little clunky because of the bottom of the gravity, but the key point is even bottom of gravity, if you apply the proper technique, you are able to access the semicosa, maintain the tension, use additional tools to enhance the cut ability, and coagulating vessels is really important first. Then complete without muscle injury ideally. If it's in a gastric, would you close? Usually I do not close. Only if the patient is taking 2-3 blood thinner in that case. It's possible. Yup. Post resection vessel coagulation is shown to reduce the risk of re-bleeding. If you close, bleeding risk goes further down. Depending on the risk of patients, anti-coagulation, anti-platelet, those are things that you have to consider into the management. Any questions? Nothing? Thank you so much for your commentary and help. Thank you. Thank you so much.

tunneling method

endoscopic submucosal dissection

ESD

colon

submucosal space

natural traction

modified pocket creation method

knife selection

speedboat knife

mucosal incision