This is a case I was referred to with the history of gastric adenoma, and the previous physician tried several EMR. Every time they go back, biopsy come back as still positive for adenoma. I do not have any images, so we decided to just take a look and see what's happening. I do not have any information, so when I went back in, this is what I see. So what's going on? Push button. Speak up. There's scar there. Yes, scar. The location-wise, we have to see the location of the lesion, right? So taking a look at here, you can see the pulse style. Oh, that's not the plan. So I omitted some of the video. But here is the G-junction. And this is a fundus, anterior wall, upper gastric body extending to the fundus. So basically, you are observing the lesion in a retroflex position. That's correct. It's a really difficult position. And its extension is going to the fundus. This is known to be a very difficult location. And there's a paleness inside. What are those? It's a little paler than compared to normal lesion. I mean, normal mucosa. What's that? Atrophic and metaplegia, both atrophic gastritis, probably. What's that? Atrophic. Oh, atrophic? Could be. It's atrophic? No, the plant one. Huh? Metaplegia. Metaplegia? Any other? OK, granulation, adenoma. With the? Dr. Toyonaga. We're categorizing to mucosal cancer in Japan. I'm sorry? Mucosal cancer. Mucosal cancer. Because of the concern of here or here? Definitely this will be the tumor. So, Norio, this is reoccurrence from previous resections. There's a question. Is this a recurrence or not getting a whole picture and getting the center only? I think this is remnant region. And this kind of whitish, flat region is a typical appearance of gastric adenoma. But in case of having bigger size, it usually turn to mucosal cancer. The risk of having cancerous component for the gastric adenoma getting higher as the size of the region getting bigger. Usually, whitish, flat region, less than 1 centimeter, has only 1% risk for having cancerous component. But in case of having 1 to 2 centimeter region, it has risk around 10%. But in case of having region more than 2 centimeter, it already have more than 40% risk of having cancerous component. That's why we should remove this kind of region completely. Great. Would you do mapping biopsy first? I know this is the center looks a little modified, probably because of previous EMRs. And there's some unusual feature. Probably that was why Dr. Toyonaga was suspecting maybe there's more than adenoma. Is that correct? Yes. There are no obvious sign for the deep submucosal invasion. So that's why endoscopic resection was the best choice. Great. So how many would proceed with the ESD or EMR? EMR failed a couple of times, but ESD? Okay. All right. Half of them want to do. If this is a surgery, what kind of surgery will it be? Right. Because of the location, it's going to be total gastrectomy, right? So we're looking at two totally different pathways. Would you take a biopsy first? We usually don't take any biopsy from this kind of lesion. So that was exactly what I was thinking. Looking at it, these surrounding dysplasia, I assume this is dysplasia, was probably overlooked over time. This is just too small area to be scarred with recurrence. This is probably present before, and it was not recognized properly. So referring physician was trying to get rid of the dysplasia, not knowing what the extent of disease was. So would it be easy ESD? We kind of talked about it. This location is extremely challenging. And any anticipated issues? Go ahead. Yeah, it's going to be retroflex throughout. And sometimes you may be able to do straight view, but it's going to be very difficult to access in straight view. And especially the gastroscope, at least the Olympus gastroscope that we have, is so difficult to retroflex in that area. Right. We have to have a really fresh. New scope. New scope to retroflex. Otherwise, you can use multibending endoscope. At least in Japan, we definitely use multibending endoscope for this kind of procedure. Great. So multibending scope. Go ahead. What would be yours? Would you, if you saw this patient, would you do colonoscopy before and when? What would your strategy be going forward? Absolutely. So before showing the video, I wanted to discuss how we're going to approach. This is a key discussion we want to have. Yes, I did advanced imaging. I did NBI. I didn't do chromoendoscopy because the center looks pretty benign scar. There's no abnormal vessels. Pattern looks pretty uniform. I just omitted the evaluation on advanced imaging. So there's no concerning feature. Everything was nice and soft, including scar, so I didn't think it was advanced pathology. Do you guys know about multibending scope, by the way? Multibending scope is only available in Japan and some other country, right? Some other Asian country. So in addition to the retroflexion, there's additional bending area so that it can bend like this. It's developed to just access difficult location in stomach. So in this case, if you do additional bending, it's going to go much more closer like a crane. We don't have it. I wanted to ask, just looking at the picture here, because we have probably some of the world's experts on early gastric cancer here. I mean, when I look at this picture, the convergence of these folds don't look very concerning to me because I think this is all from scar tissue and previous manipulation. But that flattish area more around that 6 o'clock is more concerning for me. Is that how you would look at this lesion and sort of think about it? Or are those folds? Those folds don't look very concerning to me. I think that's just puckering from scarring. I just want to know what the world's experts would think of this lesion like that. Actually, fold convergence of this region is relatively smooth, and there is no sickening at the central part. Therefore, this is usually caused by the scar formation due to the previous endoscopy resection. And in case of having much severe fold convergence and with sickening of the fold at the central part, it is really a good sign of having invasive cancer. And on the 6 o'clock, you can see the relatively flat whitish area. This is typical appearance of the gastric adenoma. But as I mentioned, if the lesion size is getting bigger, more than 2 centimeters, it has some risk of having cancerous component. Taking out one piece is important. What he's explaining is this is relatively straight. If there's a cancer, there's a little thickening towards the center, which is supposedly the cancer area. It looks like really thick and straight. That's one of the signs. Irregularity on the edge is one of the signs. It's relatively smoothly going down to the scar. There's no caliber change. That's exactly what he's suggesting. More benign feature than malignancy. If we're going to do this, which side should we tackle? How are we going to do? Hiro, how would you approach this one? I was thinking, because it's very close to the gastric cardia, I always think if it's something we could do tunneling from somewhere. I usually see this lesion from the anterograde to see if this lesion is parallel to the esophagus and just tunnel down to the stomach. It looks like this is a little difficult area for the tunneling. Because we probably need to approach in retroflex, I would consider doing it because we need to place the scope parallel to the lesion so we can go underneath the lesion. So I think the 6 o'clock area would be the most tangential area for the scope. So I would create some C-shaped mucosal incision there and then start the ESD. I want to know how the other faculty thinks. If my upper scope is not bending very well in a situation like that, I switch to Pitt's colonoscope. It's longer, so you can retroflex in the pyloric area or pre-pyloric area and then you get to this area much easier with a big loop of the Pitt's colonoscope. The drawback is that exchange becomes more difficult because the scope is longer and you need to use colonic lens devices, which are usually smaller. For example, if you started to work with Pitt's colonoscope in the stomach, then you switch to the dual knife of the colonic lens, which has very small active portion compared to the gastric mucosa. So to get the incision through the gastric mucosa, you have to cut several times. Incision doesn't look very pretty after that. And if you run into the big vessel bleeding, then coag grasper for colon, that's the only one which will feed through the colonoscope. It has smaller branches, more difficult to control the blood vessels in the stomach, but that's the choice I have if the bending is not adequate. Thank you. Just to let you know that the IT2 that you have really works well for gastric ESD. It's not available in colon length. So the colon length is going to be IT nano. Go ahead. Would you use a therapeutic EGD scope because it's a little bit more stiffer and stable as compared to regular H190 because sometimes it could be very floppy? Or would you use a 1T? Would you use a 1T or a regular H190 EGD? I probably would not use a 1T because the retroflexion capability is less. It can suction stuff much easier. But would you use a 1T? Sometimes I use a 1T because of the larger working channel. So first of all, I think this is a very, very difficult location to perform ESD. Not only technically difficult, but it's also got a high risk of perforation. I would actually probably do the proximal mucosal incision first. And my fear would be if I did the distal mucosal incision first, would the lesion move up away from that incision and be much harder to get to that area. There's also two questions from online. So there's a question from Venkata who says, Will MBI examination of the lesion differentiate scarring from invasive cancer? Now he's done. It's a little bit difficult, but probably scarred area looks homogeneous and we can nicely recognize the regularly arranged surface structure and vascular network. Then we can say that this is just a benign scar, not caused by a deep submucosal invasion. So those kind of differentiation would be possible by using MBI and magnification. Do you focus on abnormal vessels as well? Yes, of course. Usually neoplastic lesion has much tortuous vascular network and sometimes it becomes really uneven. Another question? It's along the same lines. Ulceration and irregular vascular pattern, will that signify cancer? All right. Who would think about use of traction? Yes. Great. Yeah. That's absolutely necessary. So in the interest of time, I'm going to start doing. The thinking is that I'm going to start working with the distal end, strip up towards the cardia and then use the traction to complete. This is marking throughout so that I know exactly where it ends to get the negative margin. I was trying to feel how I can access the fundus area and it's important to control the air distension because if you put too much air, there's no way you can reach the fundus. So to control the air, I get the sense how I can access. The injection was relatively smooth. I couldn't really get close to it most of the time, so working a little way out. This is a long video, so I'm going to get kind of. What kind of injection solution did you use for this case? This is supposed to be CME, so I cannot really disclose. Okay. Part of the fluid that I used is artificial tear. So methyl cellulose. It works well. The idea was to get the entry to put the IT2. For gastric ESD, IT insulated tip knife really facilitate the dissection and because the incision even in difficult location. So once I created NIDUS to insert the knife, I started out from the top part moving towards you. That's a theory. It works much better. At this point, it was really difficult, so I pushed it out to get the knife shaft contacting the mucosa. And IT2, you have to really trust the knife to protect the muscle and cut the mucosa to the submucosal layer. So as expected, some of the pumping bleeding occurs, and all you need is just identify the location, grasp with the coagulation forceps, and coagulate. You cannot let this bleeding go for a long time. You can open up the mucosa to the submucosa to expose the bleeding site, but as soon as you can recognize, you have to stop the bleeding. Lyle, is Haru on? Okay, so let's continue. Okay. I tried to get close to it with the dual knife. And as you can see, the control was extremely difficult. The problem is the muscle layer is becoming unfuzz. You can see the muscle layer... It doesn't work. here at the bottom. So I changed back to the IT. At least this perpendicular direction IT is much more safer. And it pushed the muscle away. And try to continue on semicolon dissection. Let's move along. I started traction method. And I can see, okay, this is going to work. Injected. Once the traction is in, you have to start incising mucosa so that everything is going to keep lifting up. And injection of the fluid identified or facilitated identification of semicolon layer. Nouriel, what did you use for traction? Is this overstitch or... Similar to that. Wait for publication. Oh, top secret. Okay. So with the traction, I was able to get to the area much better. Luckily I didn't encounter with humongous vessel. Do you see the muscle layer just in and out kind of scene? Do you identify the muscle layer? See these are the muscle layers, right? And you have to identify this layer so that you can just get the semicolon line. If you cut here, you're gonna perforate. I'm planning to finish by nine, so I'm gonna just skip through. Always just inject more fluid so that you can see the muscle layers, semicolon layer, mucosa. So you separate them. I pull back to the little more slanted angle. As I dissect more, the access will get much more difficult. So from the retroflex to the partial retroflex, I tried everything. Reduces air, more air. Just have to find out how to best access. And IT was really my friend throughout until the torso end so that I can push the muscle at bottom and go into the semicolon layer. Remember, the higher the gastric body to the fundus, the thinner the muscle layer becomes. So the perforation risk increases more and more. I wanted to show some of the difference between the insulated tip versus the tip knife. If you can direct this knife well, tip knife works beautifully. But here, I'm getting really close to the muscle. I'm trying to do more left to the right, kind of twisting the scope direction. But again, I was going onto the muscle direction. So this is a shallow muscle injury. And at the bottom, you can see the muscle layer here. And I just couldn't get to it over here. So in that situation, I pushed the knife to the right and go back to the lumen, away from muscle. So throughout the EST, you have to be really creative how best to avoid perforation and how best to access the semicolon layer. Any suggestion, question? Am I doing okay? If I would do this case, probably I would dissect some causal tissue from the upper side, utilizing the gravity, and the rest of the procedure I definitely use the traction method. Because the greater curvature side is very difficult to approach, but in case of using traction technique, it becomes easy. Much easier. I think now Hisa has a similar idea as Hiro. But whatever works, it was welcome. So I was keep going with this retroflexion. And then I turn my attention to more cardiac to the fundus. Inject the fluid. Here is extremely difficult to access, so the IT was the only way to cut the mycosis side. Any bleeding you have to take care of immediately. Okay, let's go. Continue on. It's almost your idea that I was going to the cardiac towards the greater curvature from here. But the traction, on traction off, you have to really find a way to just expose the semicolon layer. And at this point I was feeling so great, just keep going on and on. But I created some of the muscle injuries somewhere. In this case, without traction I was not able to do it. So that's the take home message. Nouriel, to me the most difficult area is when looking in retroflex is from 12 o'clock to 9 o'clock, basically towards the fundus. I would have considered doing the circumferential incision there first to open that up and that will move things towards more accessible because now the gravity is pulling there and it will be very difficult to access. Yeah, absolutely. So on and off I was just checking. This is actually I'm intentionally doing muscle dissection because I couldn't really get to the semicolon layer. I did confirm that I can access the fundus site, the mucosal incision on and off. And I just kind of went with this while I can. I just dissected as much as I can. Then went to the mucosal incision. But you're right, once the traction is on probably I should have just done mucosal incision throughout. So Haru's with us. Haru? Lyle, could you show him? Hello, Umami. How are you? Hey, good. How are you doing? Thanks for joining us. Yeah. I know it's late at night. Yeah, it's okay. There you go. Have you been watching the video? Yes. Now I can see the video. One thing I thought about is it would be much nicer if I have a push and pull method. One time this is only the pull. So potentially multi-point traction, snare traction may have been better because you have a capability to push. I think a crane method is similar way. Yes. So at this moment, the specimen becomes very floppy. So without traction, sometimes it's difficult to cut it out. So I prefer to use some traction. As you mentioned, can we use yellow snare, not the blue snare? So regular snare, we can push the specimen and also pull the specimen as well. That is a very good additional feature of the different type of traction method. So let's press on. As Peter suggested, I should have probably incised the mycosis much earlier, but now towards the end, I was able to access and use the IT knife to complete the mycosis incision. Frequently, we have to just let the bleeding go until we go down to the submucosal layer and expose the bleeding site before you coagulate. Remember, coagulation makes the tissue shrink. So when you try to control the bleeding with a coagulator, coagulasper, without opening up, it shuts down again. So it becomes much more difficult to access. There's some muscle injury here. And now, it's just wide open. I'm ready to coagulate, not let it bleed. Okay, almost towards the end. So Nori, so now you're dissecting very nicely. So what's your energy setting? Energy is actually with IT2, I'm using a swift coag. I think 40 watts. I think effect for 40 watts, something like that. Okay, good. Because of the blood vessels, I didn't want to do the more cutting forward current. The coagulation is important here. Dr. Fukami, can you talk a little bit more about, I know, traction in general? Because it's like there's so many things out there, but using when, where, and how, that is something, I mean, I definitely struggle. And if you guys could guide on that. That's a good question. So there's no standardized method to apply when. I asked yesterday about the on-demand versus universal traction. So for the beginner, I think universal traction really works well as a training and understanding the dissection. When one becomes expert, like our experts, Japanese experts, Sergey, everybody else, when it's working, we feel like we don't need traction. So we wait until we got into trouble. But as this case, you have to plan ahead when to use the traction. Especially the difficult location, traction is really necessary and really helpful. You can see some of the muscle injury and getting close to the cirrhosis, but you can see the organ behind it. Actually, this is the diaphragm and the heart was just above it. So the traction method, there are multiple traction methods. The major thing is external, internal, or push-pull. And those are things that you have to think. When to apply different things, you have to know the features of different traction methods. I think we're going to hear more and more about traction methods today and tomorrow. And you can practice in the lab as well. In this image that you're showing, right up top around that 12 o'clock position, is that where you came very close to the muscle? Just a little below. Yeah, right there. Some of the muscle was stripped off here. So it's very thin. Haru, would you close this defect? Yeah, yeah. So in this image, this 10 to 2 o'clock, the muscle layer is exposed. That is a circular muscle layer is exposed. Inner circular muscle. So I think no problem. Great. Particularly in this area, upper part of the stomach. Even if we make a full-thickness injury to the muscle layer, just a quick closure works well. Great. But in this case, it's nicely deflected. Thank you. Dr. Fukami? So closing this, obviously, there's a bunch of options. Doing an Apollo suit's enclosure retroflex would be very, very challenging. Do you think X-TAC versus just close the muscle defects with CLIP and let the rest of the lesion be open, would that be something? That's one option. The X-TAC can approximate the edges and then do the work with the CLIPs. That's one way. I want to hear Dr. Toyonaga, how would you close this one? I think we should close this one. Such large defects in the band, complete closure would be very difficult. But one choice would be the roll-on. Open-close CLIPs, such as the small CLIP with the small hole at the blade part. Then, by using a thread, then something like the overstitch, you can also close this defect. You're going to close with the overstitch, right? Yes. With overstitch, it would not be difficult to close it. And you have to work. I would probably grab it first with the overstitch to create kind of point of fixation and then pull out of the fundus, and then it will be overstitch in direct position. So, I don't think there would be much difficulties. If you would close this, where would you take the first bite? Wherever I can reach it. And then after that, I will put first bite, I would drop the needle, and I will use it as a pulley. And then the second bite, the second suture will be a continuous suture to close it. Doctors, don't you worry about, like, neighboring organs when you, because this is a thin film and you're already close to the chest organs. I don't take muscle into the suture. The strongest layer of the GI tract is submucosa. So, I will take submucosa and mucosa, and I will not go through the muscle. The needle will move in parallel to the muscle, so there is no chance to damage anything outside. Sergei, I think he's talking about the helix. No, no, I'm not using helix. I will not be using helix. Are you using the forceps? Yes. Grasping forceps to grab the edges if I need to. The idea is that I will try to go with the needle from inside right into submucosa, and the needle will come out at the mucosal side, and then rotate the endoscope and grab the opposite again from the wound towards mucosa, and keep going like this, so the chance of damage in muscle will be minimal. Sergei, how would you close it? I usually don't close this kind of wound, unless we actually made a perforation. I had a chance to do this kind of aggressive gastric resection many times before, and surprisingly, most of the large opening decreased the size within one week. Actually, one of my cases, which I really surprised, that the ulcer bed shrinks probably around 70% within one week. It becomes really close, because this ulcer bed looks very large because of the fully distended situation with a lot of CO2 gas, but after sucking the CO2 gas, emptying the stomach, it shrinks a lot. Then, ulcer formation completed, it becomes a really small ulcer. If it isn't necessary, we sometimes cover the ulcer bed with biodegradable material, which is polyglycolic acid seed, works very well. Thanks for the information. Just for your information, artificial ulcer that we create tend to heal much quicker, as he alluded to. One of the Korean studies showed that four weeks of PPI was adequate to heal the artificial ESD ulcer, compared to the pathologic gastric ulcer that you need eight weeks. Hey, Nori. Just a few questions about it. I'll let you see. I sutured it. I sutured close it. It's not as easy as Sergei said, but I was able to access the top part and just suture it all the way down. I adopted Sergei's technique of using hot biopsy forceps to pull this up. As exactly he said, my goal is to get the mycosis and mycosis only to cover it up. You see, it was not perfect, so I just added with the clips with a small defect, and the patient did well. Thank you so much. Thanks for the great discussion. Let's move on to... Can I put a word of caution? I realize this is advanced course, but kids, don't do this at home. This is not a case that you should be doing over the next year, 203. This is super expert type of case. Very, very challenging. What is the final path for this? I'd know my own name.

physician

gastric adenoma recurrence

EMR attempts

endoscopic submucosal dissection

cancerous components

traction methods

closing the defect