So the truth is that I'm trying to make endoscopic intervention as simple as possible, and I'm not a big fan to use and to change parameters while you are going. So what I do during endoscopic submucosal dissection, I'm practically using very, very few changes. And if you think about it, there are too many parameters to keep in mind when you are doing dissection. First of all, the parameters will even call differently if you use Urbe as a generator or if you use Olympus generator or if you use any other company generator. And there is no way to memorize what is caused, for example, dry cut or endo cut and things how they vary if you go from one institution to another. Important what kind of knife you use in the sense of the thickness, because, for example, if you use Urbe knife, it's very thick, so it will create more charring even if you use the same generator parameters compared to, for example, dual knife, which is very small and very narrow. The surface area which is in contact with electrode will also depend. If you are using one of the protruding knives, such as the IT knife, then the surface area of the contact is bigger than, again, if you are comparing, for example, with the dual knife. And the speed of your movement is extremely important. If you are moving fast, you don't spend enough time on calculating of the blood vessels. You expect to have more bleeding. If you are moving slow, then it will be more charring, more smoke, and the area will look very calculated. The pressure with which you are touching with your electrode to the tissue is also important. So when you take all the... And finally, very important thing is that how clean is your knife is making a big difference. Because if you did not realize that the knife is dirty, and you don't see the effect which you are expecting, and you go up on the voltage of the generator, it is pointless. In that situation, you need to take out the knife and change it. And quality of the tissue definitely put into consideration as well. So there is no way to keep all this in mind, and that's why my idea is to keep it as simple as possible. So when I do initial incision, I use as little calculation as possible. I want it to be clean, and I don't want to hear from pathologists that my margins are so cauterized that they cannot say if the margin is clean or not clean. So one of the pure cut modalities, depending on the generator that you use, that's what I will do. And for this section, whether you are doing it traditional way or you go through the tunnel, I will use a spray clog. I'm not suggesting that everybody should use that modality. What I'm suggesting, you get used, try several of them when you are in training, choose one modality and then stick to it, at least in the beginning of your ASD career. And for me, spray clog work the best because it is fast, it's cauterizing small vessel, I feel that I have less bleeding with that. So just a few short examples. This is the dry cut, and you can see that I'm moving pretty quickly, but I don't create much of the cautery there. And then when the initial circumferential incision is completed and I'm going in, then I'm switching to spray. You can see that burning because of the high voltage, but it's much less bleeding. When you get into the area which is vascular, then you close the knife and you stay there a little longer, trying to cauterize the blood vessel like Dr. Tayanaga demonstrated. Unfortunately, not always work that way. And if you get into the bleeding, if you underestimated the size of the blood vessels, or if you got into the bleeding which you cannot control by just with the tip of the knife, then do not hesitate to take a coag grasper. It's very important that this is the third setting which I use. So dry cut or endo cut or anything like that for incision. Then I use spray to do the dissection itself. And finally, when I press on the middle black pedal in my generator control, then it's switching to the soft coagulation. That's what I use with coag grasper. So basically, I limit myself to three parameters. And very rarely I need to go up on voltage or effect. If I feel that something is not working, most likely you need to pull out the electrode, clean it, or switch from the water to the normal saline to get better conduction. And that's basically what is working for me. Great. Any questions? Any questions? Go ahead. Thank you. Your soft coag settings were a bit lower than what the usual is. Is there any specific reason for that? For soft coag? No. The soft coag is you are using with coag grasper, and it's a big device. All you need to do, just stay there long enough to cauterize it, and you trust your generator. You have to see that the tissue is getting white. If it is not getting white, then you need to use soft coag. You have to see that the tissue is getting white. If it is not getting white, then it's too early to stop. The important part when you are using soft coag is that it has a lot of collateral damage. That's why you cannot just touch the tissue with coag grasper. You grasp it, and then you pull it away from the muscle. Because you want to apply soft coag only to the blood vessel, you don't want to cauterize muscle around the blood vessel. That's the only precaution which I have. Just to add, the wattage setting is a limit. We talked about it yesterday as well, but if you say 80 watts, that's a maximum delivery. Once the tissue desiccates, resistance goes up, and energy goes down. They call it auto-dosing. If you set it higher, it just allows higher wattage to deliver at the beginning, so it's much quicker to complete the hemostasis. In some way, it is favorable because you don't give the thermal injury deeper. But if it works well, 60 watts is more than adequate. There are two types of coag grasper. One is 4mm coag grasper, good for chronic ESD procedure. I usually use it with Effect 5, 50 watts, which is exactly the same as Dr. Kanzaboi. But in case of using 5mm coag grasper, which is good for gastric ESD procedure, which has much bigger jaw, I usually use Effect 5, 80 watts. I usually increase the setting in order to have much more rapid effect. There's a question from a virtual audience. Is there a difference between EndoCut I and EndoCut Q for doing the mucosal incision? Probably there is, but I don't know what exactly it is. It's not the generator which I use. What I heard is the simple difference is the voltage. The EndoCut I has a lower voltage because you're using only a small, sharp knife-type needle or sphincter tone. The Q is for a larger area like a snare that you need a higher voltage to perform the task. You can do it either way. The setting is pretty much the internal application is the same. The EndoCut Q allows higher voltage or performing with a higher voltage. But the EndoCut Q consists of starting from the lower voltage than the EndoCut I. So, continuous conduction is needed. Gradually, voltage is coming up to be higher than that. For snares, if you go slower, lower voltage, middle, high, then cut it. So, continuous conduction is needed. But for I, tapping conduction is possible because always voltage is the same, 700 volts. Q is starting from 600. Thank you so much.

endoscopic submucosal dissection

parameters

generator

knife cleanliness

modality