Thank you very much, Norya and Hiza, for inviting me and assigning me this wonderful talk. And all of us were watching Dr. Yahagi talk, and it was overwhelming. But each time when I watch movies of ESD done by Dr. Yahagi or Dr. Tayanaga, I get very depressed. They give an impression that ESD can be done with such ease and beauty, and this is a very deceiving impression. I don't know Dr. Tayanaga long enough, but I know Dr. Yahagi for 20 years when he just started to do ESD, and believe me, it's not a learned skill. Already then he was moving endoscope the way he shows now, so I don't think that no matter how much you try, you cannot reproduce what he is doing. So you either born this way, or you will not be able to do it with ease and beauty that they do. So please, don't believe that you can learn skills like that. And for the rest of us, we have to compensate that we were not born that way with some additional devices, and that will be the topic of my talk. How to do it with relative ease and with kind of condition close to Dr. Yahagi. So I have only 15 minutes, so I will try to go fast. And the first new device which I want to say is Prodigy Multi-Knife. So this knife has two position, and one position when it goes as a knife to cut, and then you extend, you pull it back and you extend this isolated portion, and then it becomes IT knife. So in reality, it is a dual knife, but Dr. Yahagi took already that name, so they cannot call it dual knife. But the truth is that that's the real dual knife. So the way it works is like this. So you can either extend that active electrode out, and that's how you do marking, or that's how you do initial incision, and then you change it to the isolated tip, and that's how it started to work, similar to the IT Nano or IT 2 knife, and that's what it is. The second device is a traction device, also from Metronix, and it's Prodigy Traction Wire. It's a very simple concept. So they have a pre-formed nitinol wire, which is attached to the first clip. You put that first clip to the tissue, and first you have to obviously do a circumferential incision around the tissue, and then after you put that first clip, you attach it to the raised margin of the incision, and after that, you put the second clip to the opposite wall of the colon or stomach or esophagus, and that will pull the margin away and expose the submucosal space, making ideal position for the dissection. So this knife has a good future, and there is a latest modification where the same knife can also inject, so it will be a truly combinational dual knife. Now, the problem with that device is that it is static retraction, meaning it is retraction in one direction, and it's very difficult to do it. I'm not really supportive of static retraction. I prefer a multi-directional dynamic retraction. And for that, we now have a device which is coming from Fuji. It's called Track Motion Device, and it requires a double-channel endoscope. So you put it through the larger channel of the endoscope, and then there is only one handle. When you close that handle, it close the branches to grab the tissue, and then if you continue to close the handle, then it started to bend, and you can bend it in direction you want. So for example, this is a movie, and you can see that I have a polyp, which is an extremely difficult position involving the ileocecal valve. So in situation like that, when you do ESD, you have to start inside the small bowel, because after the incision, then the polyp will move away from the small bowel. If you start cutting on the opposite side, then the polyp will move into the terminal ileum, and it will be much more difficult to retrieve it from there. So I'm using regular colonoscope to do initial incision. And after initial incision circumferential completed, I do just minimal dissection, and then switch to the track motion device. As you can see, track motion device is mounted on a double channel endoscope, so to operate it in the cecum is not easy. That's why I'm using Lumendi as a conduit to the cecum, to deliver any devices into the cecum. So here you can see track motion device in action. You grab the tissue, and you can see that I don't need anybody to help me. All you do it yourself. You can grab and re-grab as many times as you want to, and you can change direction of your traction. That's what make it multidirectional. You can pull more, or you can pull less, and that's what make it dynamic. So here you can see I want to cut on this side, and I'm pulling it away, and then it is ideal position to use isolated tip knife. And the procedure becomes very, very simple. And once again, it is a difficult polyp located in a difficult place, but using the track motion device make it palatable. It may not look as easy ESD as Dr. Yahagi example, but still it's manageable, and it doesn't require much time to complete procedure like that if you have a dynamic multidirectional retraction. The problem with this device is that the device is married to the endoscope. It goes through the larger channel of the endoscope. So practically when you move endoscope, then you move a device. Ideally, you would like to have a traction device which is not related to the endoscope, which is working independently from the endoscope. And I will show it in a second. Just for the sake of time, I will cut short the movie. And so this is the end of the procedure. We are cutting out the polyp. And as I said, I close every defect with endoscopic suturing device, especially the defect which involve ileocecal valve. When you do ESD in a narrow space, then you are risking that there will be a stricture formation, and with that stricture formation, you can close ileocecal valve. So I do a full reconstruction of the rectum, full reconstruction of esophagus, full reconstruction of the ileocecal valve. And here you can see we are grabbing the small bowel, and then we're pulling it from the small bowel and attaching it to the cecum. And at the end of this one continuous suture, we are switching back to colonoscope to make sure that ileocecal valve is reconstructed fully and patented. And here you see there is no defect, there is no exposed submucosa, there is no exposed muscularis tissue, and everything will heal properly. Now, as I said that the disadvantage of the tract motion device is that it's fully dependable on the position of the tip of the endoscope. And you probably know that for the long time I'm using Lumendi. And Lumendi is a big overtube which you put on top of the endoscope and it gives you option to do traction. It's also help you to create a conduit from rectum to cecum. It help you to exchange the endoscope and switch, for example, from colonoscope to a short gastroscope and so forth. It allows suturing in the colon and additional benefit it allows stabilization of the colonoscope when you are doing ESD. Also when you are using balloons and you distend those balloons and you pull back, then you shorten the colon. Dr. Ryahagi said that how important to have a straight colonoscope and Lumendi allows you to make it straight and to facilitate ESD dramatically. So when you use Lumendi, then you can build in sutures on top of the four balloon. And for example, this is the sickle lesion. And you can do traction and it will be dynamic and it will be multidirectional. You can pull towards yourself and you can push lesion away from yourself. And this is a very flat lesion located in the sickle. And after I do initial dissection, then I just grab one of those suture which already sitting on the four balloon of the Lumendi device and attach it to the polyp. It's extremely simple. It's very easy to do. And now I have traction which is independent from the colonoscope. So here, look at this. I pull back. I have a good exposure and I can move endoscope without moving my traction device, which make procedure very fast and very efficient. So another example, the polyp located in the ascending colon. So the first polyp was in the sickle. So I cannot push the balloon with traction in oral direction. I have to pull it back. But this polyp located in the sickle. And look at this. We started procedure two minutes to seven, very flat lesion. Circumferential incision took probably 10 minutes. And after that, deploying the four balloon and attaching the loop. But now attaching it to the anal part of the polyp. So it will be traction, but not towards me. It will be traction away from me. And look how well it is exposing submucosal space. So, we attach it at 1910, so 12 minutes it took for circumferential incision, and then now procedure is very easy and very simple. Again, the traction is dynamic. I can do as much traction or as little as I want. And if you look into the picture here, you will see my right hand from time to time goes down to push that balloon further to increase the traction. And after that, there is no need for help, and the movement of the endoscope completely independent from the traction. And look how fast it is progressing. We started dissection itself of the submucosa at 10 minutes, so it's only three minutes into dissection, and we're almost done with that. Good traction, good exposure of the submucosal space. You can clearly see all the blood vessels, and this is the margin of the incision. And that polyp is approximately four centimeter big, but the whole cutting out the polyp took less than 20 minutes. And after that, I have a conduit from rectum to the astringent colon. So after the polyp is cut off, I just pull out colonoscope, switch to the suturing device, deliver it into the right colon in no time, and then close the incision. So you can see that the whole procedure, removal of the four centimeter, very flat, difficult polyp, and it took 47 minutes, including the suturing closure. So this is the end of the procedure. And that's how easy endoscopic submucosal dissection when you have traction devices. Now, for those people who still prefer to have grasping forceps instead of the clips, Lumendia did a modification. It's less expensive, and it doesn't have two balloons. It called C1. It's only one channel, and it's only one balloon. So the way it works, there is a second channel next to the main channel through which endoscope goes. There is only balloon attached to the overtube, which you will use for shortening colon for stabilization. And then there are special grasping forceps, which are multidirectional, rotating. And those forceps are going through that balloon, and they come in parallel to the endoscope. So it will be also traction independent from the endoscope. And this is the example how it works. So you can see that this is a big lesion located somewhere in transverse colon. So we do an initial incision, circumferential incision, around the polyp. And when circumferential incision is completed, then we switch to the traction device. So here you can see this was circumferential incision, and the forceps are coming right here in that viewpoint. And I'm grabbing the margin of the polyp. And after it is grabbed with the grasping forceps, you can see that I can pull it in any direction I want to. Again, dynamic, multidirectional retraction independent from the tip of the colonoscope. And that makes procedure very simple and very manageable. Yeah. Definitely. So, with your excellent traction, how do you take care of the vessels? I mean, in the same way that we do, or? Yeah, exactly the same way, but it's much more controlled, because I can pull, and if I pull, then the blood vessel, which started to, let's say, you're not completely transacting blood vessel, you just nicked the blood vessel. If I pull, I stretch the blood vessel, and it will stop the bleeding. So, today, we saw a movie when, in order to see the actual vessel, there was need to do more dissection, because the specimen was obscured in the site of the bleeding. Here, if I have a bleeding, I can just pull away the specimen and have a good access to the place where the bleeding originate. So it makes, so here, you see, we finish in no time, and then I can remove the polyp and go back with the suturing device to close that big defect after that procedure. So, the bleeding control is much easier when you have traction as well. And this is the suturing. You can see that we are switching to the Fujiscope. This is just minor bleeding, because you are cutting through the tissue with the needle. But when you have bleeding like that, I don't waste time to stop it. You drop the needle, and then when you tighten it, it completely stops the bleeding. And this is the end of the procedure. So, Noria, I think I used my 15 minutes, so we can switch to whatever you want to continue. Okay. All right. So, the one last thing which I wanted to talk about is the visualization with the use of spacer devices. So, those are traditional spacer devices. Those are two spacer devices which we have. One of them is distal attachment from Olympus. Another one is ST-HUD from Fuji. And you can see that both of those devices, they kind of narrow your view field, so you need to get used to see them. Another problem is that you need to have significant amount of dissection before you can enter the submucosal space with those devices. With Fuji, it's a little less dissection. With Olympus, it's a little more dissection. So, here is a new device which is called EnderCage. So, you can see this EnderCage doesn't obscure any view at all. And the way it works, you don't need to do big dissection. You just do small circumferential incision around the lesion, and then you pull the margin with the EnderCage to get access to the submucosal space. You will see it in a second. So, you push it in. You don't have to go all the way into the submucosal space. You just go like this, you grab it, and you are not only exposing the submucosal space. You also put the fiber under the tension. So, from that point, it's much easier to cut. When the fiber is under the tension, it's much easier to cut it. You just touch it and it is gone. And that's the way this device is working. No obscure view. And you can grab and re-grab. Let's say you separated some, then you go deeper, and you come and you pull back, and you expose more of those fibers. And you cut only fiber which are under the traction. Thank you. All right, Noli. Any questions from participants? Is EnderCage already commercially available? Not yet, but close. Close. But I can give you some. Great, Sergei. Thank you. So, the key point is traction. Traction really reduces the time to complete the ESD. Multiple studies say about 30% reduction. And risk of bleeding or complications, adverse events, are lower. Depending on the location, an easy location doesn't have so much of a benefit once you get used to it. Typically, gastric body, antrum, those are areas that are really easy. So you couldn't show any benefit out of using routine traction. Now, I want to ask around the Japanese faculty, senior faculty, and U.S. faculty. Traction is one thing that we tend to just hold back. Things goes well, okay, I don't have to use traction. Then in the middle of the tours, and we regret, I should have done it earlier. So what is your approach nowadays? Do you do it all the time, or in certain cases, well, let's see from seniors. Maybe you don't need the traction. I sometimes use traction device, but only for the difficult cases or very large case which requires longer procedure time. We can certainly shorten the procedure time by giving traction. So you pre-plan for difficult cases. Yeah, yeah, yeah. And also, the water pressure method can give some traction to the target tissue. But you don't have difficult cases, you have to use traction. That's true, Dr. Terinaga. In esophagus, universally, I'm using the traction, just the line works well. And in the stomach, relatively difficult case, I'm using the traction, push-and-pull one, named N-traction. And in the colon, deep colon, I'm using the small rubber band, internal traction. Easy to provide. But in the rectum, sometimes I'm using the push-and-pull. Push-and-pull, and sort of yo-yo technique. But I'd like to mention about conventional method. If it depends on the traction, so you need to put so many traction devices, or sometimes you fail. So a basic, conventional technique should be achieved when you perform the ESD, as if you are familiar with a traction device. So sometimes, it is better to start from the conventional method, otherwise you have some problem. Yeah, I think it's a pre-planning, and tailored to your skill level, and location is really key. Dr. Saito? Yeah, same as Professor Terinaga or Yahagi, but for the C-curl region, especially including the appendicolifice, I routinely use esoclip traction. So I'm going to, unless you have specifically a comment, for Japanese faculty, how many are using routine traction? None, okay. On-demand traction? Okay. So on-demand, this is universal. U.S. faculty, who's doing the routine traction? Sergei, because of your research. Amrita, too? For upper and lower both? Yep, that's what it is. All right, so on-demand most of the time, right? Otherwise, yep, Adnan? Are there any situation where the use of traction can backfire, meaning it can help you in that stage in the procedure, and then at a later stage, it actually gets in your way? It does. The traction is not only one directional. I mean, let's say if you use internal traction, depending on the location you put the traction to, once your dissection is moving forward, the traction changes. The air control is important as well, but sometimes you want to take it out. So that removability is one of the features of the Prodigy. It can just reposition as needed. I think there's other traction devices as well. I was going to say, when you're doing more kind of tubular dissection, esophagus or tunnel, sometimes leaving mucosa, submucosa, like little traction points, you know, not cutting the whole tissue, but using it strategically, can be similar to using CLIP. Absolutely. There's multiple ways to create traction, but once the device is introduced, that can be in your way sometimes. You have to be mindful of that.

traction devices

endoscopic submucosal dissection

ESD procedures

Prodigy Multi-Knife

Prodigy Traction Wire

Track Motion Device