All right, so we're demonstrating a couple devices here. We have the multi-knife from Medtronic. This is a unique knife in that it has a needle type knife, Nori will go ahead and stick that out. So this is a, they have it in a two millimeter and a 1.5 millimeter knife, and then this also can become a insulated tip knife, they call it the O-knife. So we'll be calling the insulated tip type of the O-knife, and then go ahead and put the I type out. So I've already marked, in the interest of time, we've marked and injected, and so we're just going to demonstrate how easy we can do a submucosal dissection with this particular device. This device is ideal for gastric lesions in particular, so we're going to show how we can do this circumferential incision first, and then we're going to use a retraction device. So we'll start with making the mucosal incision. So when I make a mucosal incision, I just start at one spot, all right, and we'll tip down a little bit, little indentation, and then tap until we get in, okay, and then all we need to do here is make a small incision into the submucosal, kind of tracing back. This is the entry, right. So now we'll take the I back, and then let's put the O out. So I have to close the handle. Okay, so now we have the insulated tip, or the O-knife. So I put the tip in, and the thing that you need to know about these IT type, or the insulated tip type knives, they're designed to pull a little bit, right, because you have the electrode on the back side of the insulated tip. So we're going to put this in, and you can work at a slight distance, that's okay. I got this in, and then we're using a cut current, and then we're just going to cut around. You can cut fine, but it's effect one, isn't it just in the T? So no, this is just because it's ex vivo tissue. So in a human, I would use effect two, or even effect three if there's bleeding, yeah. But for ex vivo tissue, actually, you don't want to use any effect. I'm going to get a little bit closer. If I don't want any coag, I could just tap, and then there won't be any coag phase. So I've kind of pulled that, and I've exposed that. The thing that's nice about the insulated tip type knife is that once you get it in the right plane, you don't have to worry about the depth, because you're in the submiposa. If you go through, for example, the enteral, you can't do this. On some, on this particular knife, it's pretty hard, because it's, you know, the IT2 has those triangular, and that definitely, you can injure the muscle. You don't want to go too tangential, for sure. So I like like a 45, 30 to 45 degree angle is ideal. So something like this, you're not. Correct, yeah. Okay, so we're kind of halfway around. Now I'm going to go back to the top. Put my knife in here, and then work myself, work around the other side. I want to see where my dot's. But really, the depth of the cut is controlled by the IT, right? So if you put that, yeah, and if you put that insulated tip in there, it's going to stay in. As long as I don't like put too much attention like this, if I'm kind of neutral, this, the IT, the insulated tip should stay in the submiposal space at the depth that I want. I'm kind of missed a dot there. So I'll kind of come out here. The problem with kind of coming back sometimes is you can't see where your, where your markings are. So sometimes you mark very closely. Yeah, that's what I usually do. I usually mark very close. Now I'm going to get in here. We got to come. So now we see our dots better. So that's a little too much tension. So I got to push back in. If you put too much tension, what happens is that there's too much electrode contacting, you know, the surface and you decrease the current density, right? And so it's less, less effective. And what I see people do oftentimes is it's not cutting, it's not cutting, and they put more attention on it. And all that does is it just causes the tissue to become more desiccated. So when you stall, you actually want to release the tension and just place a little bit of tension on, just give it a little bit of direction. Okay. So now what we'll do here is I'm going to just dissect a little bit more underneath and we can use the insulated tip portion of this. And then what we'll do is I just want to dissect some of this front part. So I'm going to just dissect a little bit more of this front part. And then what we'll do is I'm going to just dissect a little bit more underneath. And we can use the insulated tip portion of this. Front part so that we can put a retraction device on the front. So we're going to use the Prodigy traction wire. It is a nitinol wire. In fact, we're already a stage where we can do this. So let's go ahead and get the traction wire out. There's a 20 millimeter and a 35 millimeter. There's a wire in here. So this plastic sheath is critical. It's the delivery. It's basically a sheath that allows you to advance this into the working channel here. Yep. And keeping it straight. And then you send it down until you hit this orange stop and just pass it out. And then what you'll see is there's a wire that comes out that's attached to the clip. Now, and this is rotatable, right? So you want to rotate it so that the wire is at 12 o'clock. So go ahead and yeah. Okay. And then you can see as I pull it back. This is a clip. This clip. That's not good. That's better. No. Norio occasionally can help. Okay. So you grab right there. Go and close. And then you fire. Go ahead and deploy. Okay. So now that's the first part. The second part is a second clip. So this first clip has pretty good teeth. And it grips the tissue really well. The second clip has a more blunt as a more blunt tip and doesn't grab into the tissue as much so that when you need to take out the specimen, you can just gently pull on the mucosa and it is supposed to be relatively a traumatic upon removal. Pass that in. If I go ahead and open. All right. And so what we do is we just grab that. Now you have two options here. And I know you like to use it. You like to put it on the opposite wall. We're going to demonstrate this how its intended use statement is basically. So what you do is you drag this wire to the backside. So you want to take it behind the lesion. How much did you do? So this is a form nitinol wire. So the nitinol wire creates the tension. So as you dissect away, it slowly releases. So it's a little bit different than a rubber band that applies a little bit more constant tension. So here, go ahead and open. Grab some tissue. Let's try close. Okay. Fire. Okay. So we're deployed there. Okay. So now as we come back. Yeah. So you can see that it just totally has exposed us. Now we can come back with this multi-knife and use the IT portion to dissect this. So knife out, please. O-type knife out. Now a little bit about the current density or using the knife. So this multi-knife, since it has an inner. Go ahead and pull the O-type back and show the I-type. So this I-type is a much thinner knife because it's on the inside of the O-type knife. So go ahead and pull the I-type knife, the O-type. So see how the shaft is thicker, right? So the thicker shaft means that there's going to be lower current density for the same amount of energy that's put in there. So I typically, when I'm dissecting, I often will use a cut current. Actually, an endo-cut I current to do the dissection here because it cuts much better. And then if I see a vessel, I'll coag. Okay. And the benefit of that is because the shaft is thick, it's really good at coagulating. So pre-coagulating the vessels, it's a good diameter. But in order to cut the tissue, you really need to use a cut current, right? And so we can kind of reach this out, go from the side in a pulling motion, not too tangential. And so, yeah, what you see is as we're progressing, the wire is curling up more, right? So it doesn't put so much tension that it brings up the muscle, right? And sometimes with these constant, you know, if you use suture, if you apply too much tension, you can get inadvertent muscle pulling and tenting of the muscle, though this generally won't apply enough tension to cause that. I'll just put it in. And to just get the right angles on it. Yep. And up on the back and forth maneuver. Mm-hmm. Yep. And so sometimes if you need more tension, what you can do is you can remove this. See, this wire is kind of curled up almost all the way. You can take that out, repositioned it, and give yourself a little bit more retraction. We'll try to finish this without doing that though. Now. Yep. I think we'll have, almost have it though. Yep. Since you're working so hard, I can just explain a little bit. It's a system that's just keeping the mirror a bit closed all the time. If we have a suture, then it should be open, but if it's closed, it should be open. So here, it's done. Okay, great. So now, yeah, so that was pretty quick. So now, if you have like a rat tooth forceps or a grasper, do we have one of those? You would just kind of grab that tissue. Do we have any biopsy force, anything that grabs? Coag grasper? Clip. Give me a clip. Yeah, let's use a, we can use a clip. There we go. Now I feel truly honored. It is the radiona for me as well. Okay, go ahead and close. All right, so let's retrieve the tissue. And then what we'll finish off is we'll demonstrate the next powder. Open. Close. Now this just requires gentle traction, and then you can just pull it all the way out. Very simple. Very good. Open. Okay, so a couple things to demonstrate with this. Go ahead and show me the tip. Before you go in, you want to, let's dip in this water for a second. Before you go in, you want to turn on, so you want to do two things. You want to keep this upside down like this so that powder doesn't inadvertently get released, right? So yeah, the powder is there. Turn on the pump, and then you can even put this in and it bubbles, right? You can see that. Can you show that on camera? So that's air. So you turn that on, you don't, and leave it on, leave it on. No, no, don't turn it upside down. So until I'm ready to deploy it, keep it in that position. There's a stopper, so it's supposed not to go. I'll show you why I want you to keep it like this, okay? So now as we're going in, it's putting in air, so you don't have to pre-flush the channel to make sure that there's no air in there, right? So now we kind of come in with this. No water, no debris, no nothing. So it's actually flushing the channel as we're coming out, and you'll see that, you know, stuff is coming out. So now I have it out. Now, what I'm going to have you do is before you turn it upside down, what I want you to do is slowly open up this valve, because sometimes the valve will inadvertently open too much, and you don't want to, you want to start with the valve slightly open, right? So you want to slightly open that, and then when I'm ready, go ahead and just flip it, okay? And then if I tell you to stop, actually all you need to do is flip it back into this position. You don't have to worry about the valve. So this way, you don't have to worry about this valve. So at this point, I'm in good position. Go ahead and flip, yep, activate, and you want to keep it slightly at a distance. You control the speed by the valve, but see, I'm painting the surface. Yep, that's good. This is good. We're painting the surface. This is, this comes out as a powder, but then it'll form an adhesive gel. Let's see how you can really control, and I like to include the margins a bit, because it's really adhesive on the mucosa, right? So we're just keeping painting. Okay, okay, go ahead. Yeah, that's good. We're covered. We're covered. Are you going to make it thicker? So what we'll do, no, you don't need to make it any thicker. So you just need a single layer on there. Okay, so that's, it's all done, and that's all we need. So now, yeah, leave it upside down, we'll take it out. And then what I do is I just sprinkle a little water on this. So let's put the irrigation, that irrigation down to about 30, yeah, that should be good. And then before I go on top of it, what I'm just going to do is test my irrigation, make sure that it's not coming out too fast. So that's perfect. So as we drop water on this, yeah, it converts into a polymer. And it doesn't, you don't want to jet it because it might kind of come off, but you see that it pretty much doesn't. So it's after you put it on, there's enough fluid on there, on the surface, that it keeps the powder attached. This is just kind of finishing the polymerization. You know, this is a hydropolymer. So with any fluid, blood, water, it forms a gel. I'm just going around, kind of making sure that... No, it's not, you know, you don't have to wait at all. Yeah, yeah, it'll solidify, but it's already a gel. So as soon as it turns this blue color, it's a gel. And then this area right there, it's, you know, the gel is already solidified on top, which is why you can't convert it. But now this is all a gel. This is all formed into a gel. And then give me the catheter back. What I'll demonstrate is how it's already turned into a gel. So I'll just kind of demonstrate it with this part. Yeah, it's adhesive. Well, it depends on what the indication is, right? But it's better to keep the patient NPO if it's a gastric, like let's say this was a gastric ESD. You know, you're going to keep the patient, you know, esophageal ESD. Absolutely. Pretty much how you would normally do it. The thing that's interesting about this is it creates a barrier. So it's acid resistant as well. So what I like to do is if I have a gastric lesion, maybe it's not fully closed, or we were even talking about duodenal ESD, it's a barrier function. And so what it'll do is it'll protect the stomach from either acid, protect the mucosa from acid or bile juice or pancreatic juices. Until, like, for example, in the stomach, until you get your PPI fully on board, it'll protect that area from any acid exposure. But see, it's, you can see it's already kind of adherent. I'll go up here. And I just added the water up here. So you can see that it doesn't dissipate. It's in here. And then you can take that out. We can put, turn the pump up a little bit, and we can just show you even with the pump. So this is, it doesn't come off with the irrigation. So it's still there. Now you can, you know, get it to peel off if I come in underneath here, but it's basically formed an adhesive gel over this lesion and should protect it for one to two days. All right. Wonderful. Thank you for it. Very much.

multi-knife

Medtronic

O-knife

gastric lesions

submucosal dissection

retraction device