Hello, everyone. I'm Makoto Nishimura from New York, from Kettering. I'm Takashi Toyonaga from Kobe University Hospital. We have a comment. Thank you so much. Okay, so I think you already know how to start the ESD, but today, maybe I'm repeating, but today we're going to do a pocket vibration method. And this is an anterior wall of the stomach, an anti-gravity cell. So today, now I'm injecting the water first. How large is this? This is a... How large is this? Oh, wait. So this is likely maybe three and a half or four centimeter region. And... Anti-gravity. Anti-gravity. Yes, so this is gravity, this is anti-gravity. Like an anterior wall with a patient in a supine position. Now I'm using the endocrine. Endocrine is made by Olympus, a very viscous solution. Needle out, please. So many times I start the injection from outside of the marking. Injection, please. And make sure the nice lifting. So this is... Okay, stop. And change to endocrine, please. And after... Confirm. The nice injection into the submucosal layer. Keep the needle out. And keep the needle in the submucosal layer. Injection, please. This is a... Rotate? Yes. More, more, more, more. And then inject. So because once such kind of... Again, stop. Such kind of viscous solution going inside to the muscle layer, it's very difficult to continue. Yes. Keep the needle out. The downside of the endocrine is a cloud. So it's very cloud. Injection, please. And in case of underwater ESD, it's very... Like this. Interrupt. Okay, interrupt. Thank you. And one more injection on here. So... Lifting very well. Which kind of solution is this? Endocrine. Yeah. So the... Injection. I think... Exactly, I lost it. They mentioned something like polymer. Absorbable polymer. I'm sorry. And they also have a powder type. Exactly the same. The product itself is completely the same. And we add the saline and also methylene blue into the powder type one and we can create the injection solution. Injection. So mountain-like lift is coming. Yes, so I'm sorry. Okay, needle in. Are you planning to open a fast conference, professional? Yes, so basically for pocket creation method, Dr. Yamamoto recommended to use a ST cap. And basically the way opening very small and going inside the ST hood and opening up. But I leave it modified, yes. So I'm cutting from here, the order side, and make it a little bit wider. And I don't want to change the cap. So that's why I'm putting a straight type cap. And then after the mucosal incision, I'm going inside to the submucosal layer. And hopefully this works. And as needed, we can open the end of the pocket, which is slightly similar to pondering. This kind of pondering... Sorry, the mode should change to the incision mode. Okay. Interval one, very quick. It's okay? Yeah, thank you. Tapping, that doesn't matter, okay. Ah. The good thing of the Pro-Knife is whenever we want, we can inject with needle-out. Needle-out. Yes. Are you injecting with the Pro-Knife? No, just saline. Yes, saline. Saline with... With the intercom and motor, yes. Motor. Hmm. Yes, so it depends. Like, if we cannot see the oral side well, I start incision from oral side and come back to anal side. But like a straight area or flat area, then sometimes I do such kind of thing. So it depends. Regarding the width of the opening, I also prefer to open wider. Almost the same width of the region. And then, next, I'm injecting by the... For me, even in the maneuver, in the pocket, become easier for me. So, the digging manner is difficult. The precise sector is conducting. Precise sector, no. No, no, no. Maybe we should increase the power. And also, this is a 3mm Pro-Knife. This is 3mm? 3mm, yes. Ah, ah, ah. I don't know. Usually, I use a 3mm. The current is coming. I don't see any spark. I've seen. What? Now working, yes. A bit longer conduction will be needed. Around there. You know, of course, if we cannot cut well, we can change to end cut more. That's it. Now I could make a nice cut, and now suction in the air. And suction and cut the air works. That's a good tip. If you inflate a lot, get into some cause that become very difficult, because straight situation create a narrow, some cause. It's a bit strange, isn't it? Maybe we should use the after electrolysis demonstration for this. Yeah, okay. What shall we change to? The swift, or? Increase the power a little bit, yeah? Or almost maximum. Oh, almost max. Swift. Yeah, maybe swift will work. Hmm. Is this... If the solution was water, dissection is very difficult. Saline is needed. No. Maybe this is saline, or water? Oh, saline. Which one? Saline? Okay. And also, end of flow must be made by saline. Okay. No, Makoto, if you're tapping the end of it very frequently, do you use a method open, or? Which one? You're tapping the end of it. Hmm, yeah. Do you just tap on the end of it? Yes. You just minimize the coagulation. Myself, I want to control the timing by myself. Interval longer, and one by one I'm cutting. But your multiple shot is... So it's also okay, small and multiple. Totally under control, the situation's okay. I want to control the direction, and cut it. I think that's important to know, that you have to know what you're cutting. It's a blood vessel, that's... Yeah, yeah, yeah. But here, the situation's totally different. Every single vessel should be treated. No, Makoto, you're changing direction often. It's very important to know the direction of muscle, right? And also, understanding the direction correctly. Right, so now we can see the muscle at six o'clock, and because I really want to cut the right side, but because it's close to the edge, I cannot cut the right side, and the channel is coming from the bottom. I rotate the stop, where I can cut from here to up. It doesn't look like a growth. So now I could open up about 50%, 40%. Sometimes I can make a small hole, and you need to push the knife in the injection, and it's coming back, and it's better to see the tip of the knife. Yeah, that's a good question. So this is a stomach, and basically, stomach, many times we are removing the gastric cancer. So basically, it's better to cut in the middle, or a little bit deeper. We think about the submucosal layer as SM 1, 2, 3. Usually, I cut SM 3, or SM 2. It depends on the current of the corner. But maybe we can... Like this? Yeah, so maybe we can use that, like this. It looks like there's water in it. In terms of the depth of the dissection, we can clearly define, of course, above most of the area is needed, and underneath the branch of the cell is the best. As a result, it could be SM 2 or 3. Can I have a 2mm filament? Frequently, what we see at the beginning of the dying period of the yeast, we tend to inject a lot for safety, and the submucosa expands so much that it loses the sense of direction. So, Shami, would you recommend going horizontally, or like tilting the spoke? Ah, yeah, it depends. The more easier direction should be selected. I agree, because if it comes up and down, it's a much easier movement. It's not always possible to determine the direction. Then the spoke is steady. Also, I'm checking which is better, anti-friction or retrofriction. In this moment, now he's performing the forward view, but maybe I prefer doing this in the retroflex. But in the Poker technique, retroflex doesn't lead to the, sometimes doesn't lead to the end, so both are coming to the same point. Much better. Yes, these are much better. Also, I try to teach people who start learning ESTs that this direction, the muscle up, tend to go towards the muscle, because the neck comes from the bottom. You have to be careful how you approach the direction. And also, you should consider about the direction. So, knife angle is coming like this. In this moment, this is okay. Upwards, upwards stroke. It's safer, it's okay. But this is dangerous, downwards. Towards the muscle. Same movement, but if the target is here, this is okay, but the target's located here, up, downward. That's why, but downward is not avoidable. I'm waiting, after grasping the target, I'm waiting until the knife pass the deepest part. Then cut this. Now, maybe downward. Just capture it, just slightly the scoop. Capture it, and scoop up, then cut. Now, now, now, level. Down to straight, it's getting longer. So, you have to consider the distance. Okay. Some of them, I just saw, as I was saying, there's a bunch of them. Yeah, there's a bunch of them. Okay, and that would be, this is a population parameter, either precise step or scoop value. Precise step didn't work, that's why. I don't know why. More, drier? So, when do you confirm the length of the dissection? Maybe we have a good point. We have a dissection. I think this is about four centimeter, about four centimeter. Open up a little wider. Many times, we need to double check from the outside. But the injection doesn't reach to this end. That's why more dissection we needed. And also, many times, we can see the blue injection solution at the end. Yeah, almost. Right, and we did not inject here, but still, it's elevating right now. So, maybe it's getting closer. I think we need to open up a little. In this, yeah, Pro9 has a very strong function. So, we can make a small hole and going to the subunit layer, we can inject. So, that's why I like this one. Oh, nice. Okay. Yeah, of course, there is no bleeding for this maxillofacial stomach. It seems to be relatively easy. But in the DR patient, we have so many, not so many, but depending on the patient, we have some bleeding. It's better to identify the vessels before cutting by the endocrine. So, with this pocket maceration method, do you go over the lesion first? Yes, usually I go over the lesion. I'm curious how you do the distance incision. Inside out or outside? Occasionally, I come in. From outside, yeah? Mm-hmm, outside. Because you cannot see from inside, right? Yeah, yeah. Because from the outside, more precise distance can be kept to give it a good margin. Mm-hmm. And many times, endoscopy staff can recognize if my sound is continuously going well. But they are just imagining, oh, if I'm missing that, yes, it's going well. You are- And it's silent. You are all rhythm. Maybe we have reached to this side, no, not yet? Yes, so I'm thinking, so maybe you have the timing to open up on this side. So it's actually side to side, ah. Right, sometimes I'm going to. Mm-hmm. And in the meantime, I'm holding a scope and opening. Ah, I see. I think many Japanese use the mode like this. I myself in the upper GI, I'm putting the shaft onto the table. Oh, the table. Table can hold the scope. The rotation can be provided by the left hand side, left hand. Then now I think we already passed through the digital marking area. So now I'm opening. So this is kind of a combination of. Well, still you're performing the forward view. Yeah. Because in the United States, the JS scope is not available. Ah. So I'm Americanized. Ah, okay. Even the junction region, I'm using the kind of forward view. Also, you don't have, I've heard you can limit the access to the service as if the bending is weakened. That's why many Western doctors only perform the forward view procedure. Okay. So you might as well make a tunnel at this point. Or tunnel. Yes, I'm now tunneling this. And for the side, I'm intentionally starting from, not from here, but from here to keep the function. Ah, just a little. Ah, I see. I see. I'm so Americanized. Ah. Do you count the fast movement too? Did you hear the rhythm? This one? Is this your rhythm? Yeah, this is my, yeah, kind of rhythm. Much faster than interval one. Yes. Interval 0.8. And especially if I have a fright. Ah, okay. I'm making that, I am. And of course, I need to keep the nice distance from the marking. Ah, I understood. So you're, how do you say, superficially, is it? This is a two millimeter pro knife. Oh, that's right. Right. And usually two, yes, I think. Is it two or three? Ah, two. Ah, two. We changed to two millimeter pro knife. I was wondering if you're purposefully playing shallow because you don't know if you still have a semi-coarse of that or not. Ah, not on purpose. I did it once to open up. You see, this is shallow, but this is two millimeter, not so small. Short one. Actually, opening up the pocket is kind of fun. Now, traditionally, pocket is open from the side, right? Yes. So I get it when I open up from the side, then sometimes the flap interrupts. Ah, that's right, that's right. So that's why. Maybe I saw somebody's ears, and I changed my ears. Could you explain to us how you ensure that there is a semi-coarse of cushion and not touching the muscle here? Right, so right now, I opened up the pocket, and this region is anti-gravity zone, and we have a bunch of space underneath. Of course, we shouldn't push too much because if we push too much, you can make vibration. Right, but here, you can see, it's just open up, so that's why. Even though I'm pushing like this, but my tip of the knife will not touch the muscle for this situation. So the Mikoto bridge is intentional. Yes, I'm making Mikoto bridge. Now I'm cutting a little deeper, and also, I don't want to make any muscle damage from here. That's why, yeah, last time, that's true, I intentionally cut a little short. Originally, for example, I'm not remaining such tiny Mikoto at this side, both of this side, because to open up from some Koza is safer because you can see the muscle surface. And now, we don't see any muscle surface from here. That's why, if you cut deeper in this moment, a vibration might happen. That's why, original pocket technique, so they are opening from the other side. But tiny Mikoto tension, intentionally kept before finish. Yes, still I cannot see well. Using a prohibition cutter right now. Supposed to be. Supposed to be. I'm just saying. Yeah. You have to use a new cutter. Yeah. Real life, that's it. Prohibition. So let's go inside one more time, and I think we have all the most up there. Usually we can't see something. Hmm. Uh-huh. Over here. Hmm. Yeah, yeah, yeah. So... Big difference. Yeah, I think maybe that's it. Uh-huh. Uh-huh. Oh, sorry. Yeah. Hmm. So usually we can see something from inside, and we can just... Once you've created the tunnel, just extending the exit, that's all. Hmm. Oh, here. Now this is an opening tunnel. When do you decide to go to the sides? Yes, so usually... Wait, so usually I open up the Advanced Passport from the inside. There I need a lot of data. I need to cut here. There's a line to cut. It's very easy to work with. Usually we can see, so this is a very thick mucosa. See this is a thickness of the mucosa. So at this point, usually I open up the end of the pocket as much as possible. Then I start opening from the side, from outside to in, or sometimes inside to out. Let me see where the gravity is. This is almost opposite of the gravity. It doesn't matter which side. Let me open up the amount of data. I think you should choose right or left, depending on how accessible the scope is. So one first. And also let me cut here. And then grab this side first. Anti-gravity should be kept until the end. In this case it's even. Yeah, this is it. I'm going to do this first. This is very easy to open. And I think I need to open it more. First access to the mucosa doesn't contribute if it's difficult. Early traction works. Okay, now I'm cutting this side. So it's much different than the last one. Using ST food, the opening is easier because you can keep the connecting part. Otherwise, straight food has such quick motions coming. For me, this pocket opening step is most difficult. By using such straight food. Some people change the knife with scissors. Yeah, just cut the opening. Cost-effectiveness is very poor. I think once we're used to using a needle-type knife, we don't need to open another knife. Sometimes I use an IT knife to open up the pocket. Like here. Usually, humans' stomach is not soft. The jumping to the mucosa is super painful. Then here. Then here. Better. It's still difficult. Just a moment. Could you please make a retroflexion through the pocket tunnel? Through the tunnel? Before doing that, please suck the mist. Because we don't see it so well. Please observe the scope shaft here. In the retroflex, the scope shaft always pushes up the mucosa. That's why this technique can provide a good counter-traction to the edge. I never tried, but it's a nice idea. This is another way of traction. Right. So I named this technique the retroflex traction technique. But just before submitting the video, Terry's group has already published it. I missed the opportunity. But it was published three years earlier than us. I just never submitted it. Yeah, this is a nice idea. But be careful. Very strong traction can be provided. Sometimes we can tear or lacerate. Yes. I also recommend you to remain in the last part of the mucosa until the end. To keep the dome shape. I found it much easier if you leave the stomach mucosa, but cut the mucosa. Then the final cut is so much easier. That's my method. If you want to leave the stomach mucosa, you can leave the mucosa. Ah, good idea. Otherwise, you need to cut the mucosa. Quiet. 99.9. Okay. Congratulations. Sorry, I cut a little bit too deep, but not so bad. And I damaged the muscle here. So I can just... So it was our discussion point. That's right. This is my patient. I'd like to deploy the clip. Ah, clip. Including the mucosa. Then I will watch the whole receptor area. And if there's no damage, usually I just leave it. Or I can do some minimal. Thank you so much. Congratulations.

pocket vibration method

endoscopic submucosal dissection

ESD

anti-gravity position

2mm pro knife

tunnel technique

retroflexion