First, let me start the case, and then you're going to have a lot of different type of ESD and difficulties and how to cope with it. All right. This is my disclosure. It's more case-based. A 77-year-old lady who has no history of colon cancer had a colonoscopy just because there's a need for studying DOAC. She was found to have AFib, so anticoagulation is needed. On colonoscopy, there was a small ulcerated lesion that was described, was seen, and it was not removed. It couldn't be removed entirely. So it was biopsied, and a tattoo was placed in preparing for surgery. So the colonoscopy was done by a surgeon in a local area. A surgeon recommended surgery, and the biopsy came back high-grade dysplasia. And the patient gets really worried about surgery, so they decided to look for any alternatives. First, CT scan was done. There's no signs of metastasis, no lymphadenopathy. So asking the PCP and looking for internet, she decided, well, maybe ESD is the way to go. So she was referred for ESD. So here's the lesion. There's a big tattoo nearby. Usually it's not this close, but... By the way, this is a friendly session, so please speak up. What kind of lesion? Is it size? Paris classification? The location is the right colon, ascending colon. Please. Sorry. So, you mentioned about this. It is an SSA? Cessus serrated adenoma? Yeah. They call it small. Are you suspecting, or? No, no, no. I'm not suspecting. So, I think I read that there was an SSA with hydrate dysplasia, but the morphology doesn't look like an SSA. It looks like a, I don't know, it's like between KUDO 4, 5, PARIS 2AC lesion or not. Yeah, you're getting really close. It kind of went back and forth, but if you want to look close, KUDO classification is a PIP pattern, so you have to magnify and you have to talk about it after looking really close. How about Japanese faculty, not Dr. Saito? What do you think? Or should I? I personally think it looks like invasive cancer, so I really want to know the indication for ESD in the states. So could you walk us through? Why do you think it's cancer? What's the Paris classification, and that's the first, macroscopic? Macroscopic type is 0 to 2a plus 2c. We see deep depression with emerging elevation, and also this region has some thickness of the tumor, so I think it is invasive cancer. All right. Let me just get close to it. So, surrounding pit is surprisingly not that neoplastic appearance. It's more kind of ballooned up pit, do you agree? It's more like, it's not, I've known about this pit, but in type 3, it's not there. But there's, definitively, there's a clear demarcation on the depression. So, I think both Ricardo, right, Ricardo and Sage-Cho agreed it's 2A plus 2C. Central depression, unfortunately, this is a pediatric colonoscope, so I cannot really do magnification, but NBI-wise, it seemed to be some preservation of a pit inside. I cannot really suspect the 5N, but is there any opposite thinking? Basically, we cannot talk about the pit pattern without using crystal violet staining and magnification. It's really mandatory to stain the target region with crystal violet and use magnification. That's mandatory procedure when we talk about pit pattern. That's a great point. So the pit pattern is a magnification classification, so we can suspect if you're really familiar with the pit pattern, you can sort of guess, but you have to do magnification. So let's probably have to say it's a nice classification, right, OJNET? Who want to take the nice classification? Dan. So, I was going to start off with the KUDO. I thought it looked like it was multiple KUDO patterns. On initial look, it came up as KUDO2, and then when we sort of moved up to the left upper side of the lesion, it looked like 3L with some gyruses, but then in the center, it's like a 5N where it's completely distorted, like amorphous within the depression. And that part, looking at that, the JNET pattern would be, I'd say, like a 3, maybe? And then the center, especially. 9-3, JNET3. Yeah. Yeah, again, the KUDO pit pattern, you can speculate, but at this point, we cannot really talk about it because of the no magnification. Dr. Saito, what's the answer? Yeah, this is a typical NPG-type cancer, non-polyploid growth carcinoma. The microscope type could be 0-2A plus 2C. And as Dr. Abe mentioned, so maybe with the severe fold convergency and some thickened fold. So I also, and for the JNET, so without magnification, it's somewhat difficult, but we could see some dotted vessel in the center depressed, but nice classification could be type 3. So only from this image, so we suspect SMDP invasive cancer. Well, of course, if we could additionally perform the crystal vial staining, so we could evaluate the pit pattern more in detail, and we could evaluate the SM1 or SM2. Great. So Seichiro and Dr. Saito both kind of talk about bulk stiffness and the thickening of the fold convergence. Those are the signs that probably it's a little more invasive. Yeah, I think those are important points. And I typically change the configuration by changing this air insufflation, so suction air, to see if this folded down. If the configuration doesn't change, it really shows a stiffness. That's additional feature I look for. So should we do ESD? No? I can see it. No. Would you do ESD? Well, a patient came from New Mexico down to Arizona. The patient really wants to have it done. No. Is it Juha? It was Juha? Yeah. Okay. All right. So, okay. What would you do? Is there any role for EUS? In this location, there's only one thing you can do is probe EUS. We have no – well, we can change the adult colonoscope, do the near focus, which is, in my opinion, still suboptimal for zoom scope. We don't have crystal violet, but we can do more detailed pit pattern. So Dr. Saito, what would be the finding if you do the magnification? When would you choose to do it? When not to do it? In our institution, NCCH, we routinely use optical zoom colonoscopy. So we could perform additional pit pattern for any cases. In this case, of course, it's really important. Now, of course, in the conventional endoscopic images, we suspect some causal deep invasion. But still, the tumor size is very small, one centimeter in diameter. So we could perform additional pit pattern. If the pit pattern is non-invasive, there are some suspicious of non-invasive, so we could perform a diagnostic ESD. But of course, after an unblocked resection, the detailed histopathological evaluation is really important. Is there a downside of doing the diagnostic ESD? It depends on the diagnostic accuracy of SMD. Because if we diagnose high confidence SMD invasion, the diagnostic ESD, no meaning. So it's all depending on how well you train to see the lesion, how confident you are. So for participants, would you have done ESD or try it? Yes. Okay. All right. Go ahead. Would you consider full thickness resection, or is the lesion too large for full thickness? Yeah. So if you're really not so sure if it's deep invasion or not, then that's one option. This is a very small lesion. It's probably at most 12 to 15 millimeters. So it is a possibility to do FDRD. But would that be truly beneficial? That's a question, right? So are we doing service or not? As a former surgeon, I would say that full thickness resection is not a good idea if you suspect cancer. Because there is a theoretical risk that we can spread the tumor in the peritoneal cavity. If you want to do diagnostic step, it has to be ESD, not full thickness resection in that situation. Because if your margin, deep margin, come back positive, which that's what I expect, the patient is still eligible for radical surgical treatment. But if you do full thickness resection, then there is a risk that peritoneal cavity will be contaminated. And then you eliminated the chances for radical surgery in the future. I am strongly against it. And that's the same reason I'm strongly against transrectal resection of any lesion which surgeons are doing. Because there is a risk that they are converting resectable cancer into unresectable cancer by doing that. Only ESD is if you want to do something. Good point. So when you tackle on a difficult lesion, there's always a chance of perforation as well, right? So you have to choose the right lesion. That's the point of this case. So I had access to the EUS. I did a quick EUS. It doesn't take that long. And what you see is the submucosal invasion is clear. And it's actually touching the musculoskeletal propria. It's clearly it's deep SM. It's most likely T2. And of course, I didn't do endoscopy, I mean, the surgery, I mean, ESD. The interesting thing is I did limited biopsy, but I did re-biopsy. I couldn't show the cancer. I strongly insisted you have to have surgery. Then the result is T2N1. So the patient had the three lymph nodes positive already with the extensive lymph node invasion. So if you have done FDRD, probably you didn't do any service to the patient, so. So that's a start. We have to really look at the lesion first to look at the indication. That's really important part. So now let's go into the ESD. For next presenter, Dr. Dobashi. So I will show you gastric ESD. So the mucosal incision has already completed. And I do the submucosal dissection like this with the IT knife. So during the submucosal dissection, I saw a thick vessel like this, penetrating like vessel, like this. So if you see there is such kind of penetrating vessel, what do you do? Do you want to use the pre-coagulation or keep doing the submucosal dissection? Please raise your hand. If you use a pre-coagulation, please raise your hand. Yes. This is ideal. I tried to isolate the penetrating vessel more to do the pre-coagulation easily. But however, I missed to control the bleeding. So I proceed to do the submucosal dissection with the IT knife like this. So I want to use the coagulant spot before in advance, but bleeding occur like this. So I control the bleeding with the IT knife. It's possible, but I should use the coagulant spot because after the complete resection, the re-bleeding occurred in the stomach. It seemed that I could control the bleeding scope like this. But after that, the re-bleeding occurred. So this is a, yes. So you tried to strip the fibrous tissue and expose the vessel first. And unfortunately, one of the vessels is being cut. Exactly. So what did you do to change? What kind of coagulation setting or what kind of current did you use to cut through the vessel? If I have to change to the coagulant spot and with the soft coagulation mode. Before you cut it through with a knife. What did you do? But if you cut the region with the IT knife, I will coagulate more. I will dissect with the coagulation mode. Which coagulation mode? It's a swift coagulation mode. Swift. Yes. Do you typically slow down a little more? Exactly. Okay. So as I showed, I move the endoscopy very slowly like this. And the point is that there is a penetrating vessel. So we move the IT knife through this penetrating spot like this very carefully and very slowly like this. Don't move quickly. And the other thing is where you're going to dissect the vessel is another point, isn't it? If you're going to go too close to the muscle, then the penetrating vessel will retract. So it's going to be hard to coagulate. Yes. If I cannot control with the IT knife, I may switch to the coagulant spot. But this time, I successfully controlled the bleeding like this. Okay. Would you have done a coagulant spot before you cut through in retrospect? Yes. Okay. So after the conclusion... Norio, can I ask a question? You're sure. Yes. What about switching your coag mode, for example, to low-forced coag? That's a good question. I should do that. But once the bleeding occurs like this, it's very challenging to control the bleeding with a lower voltage of the coagulation mode. But perhaps in the beginning, as you're approaching it, instead of going with SWIFT, would you ever convert to low-forced in order to prevent the bleeding as you're cutting through? Ideally, I should have used the coagulant spot in advance. Yes. That's the first choice, but sometimes it occurs like this. Probably Dr. Toyonaga will be able to talk about the vessel sealing technique, which we usually use very low setting of phosphor. We can nicely seal the thick blood vessel before cutting there. So it is one of the very important techniques during the ESD procedure. Thank you very much for a great point. But once the machine bleeding occurs like this, it's challenging to identify the bleeding spot. At first I do the forward view, but it's very difficult to identify it. So I push the endoscope around the retroflection view. I tried. At first, it will be also challenging to identify the bleeding spot. So I changed to the RDI mode by Olympus. It's very useful to identify the bleeding spot like this. So I tried to grab the whole bleeding spot with the collagen spot like this, but it's still bleeding like this. We should not coagulate unless we can hold the whole, we can completely control the bleeding. Otherwise, it becomes more difficult to control the bleeding. So I tried to grab the bleeding spot like this. If you cannot keep the distance between the tip of the knife and the bleeding spot, I have to push the collagen spot like this. I finally hold the bleeding spot like this and I did the collagen. So I can control the bleeding like this. So I should pre-coagulate before in advance such kind of the thick vessel if you see the, if you see such kind of the ventilating vessel. This is my suggestion for you. Can I say something? So I think that these cases very clearly indicate the difference between ESD and EMR. With ESD, you have to move slowly. And if you cut blood vessel, it will be just one blood vessel. And you know where it happened. It's in the place where your last cut happened. So you stay in the place where you did your last cut and you can identify the blood vessel. But if you do EMR and you put snare around it and then you cut, you may be grasping two or three vessels like this. And suddenly the whole field is covered with blood. And I'm talking from experience. That was one of the reasons why I eventually abandoned EMR. And then when there are three blood vessels shooting in different direction, you will not be able to cauterize it like this. Because you grab the blood vessel and it stop bleeding and you know that you are in the right spot. But if there are two or three blood vessels going on, then you grab this vessel but bleeding will not stop. So you may think that you did not grab the right one. Plus when it is all covered with blood, you don't know how many vessels are there. So just to reiterate, EMR is dangerous. And from that point, I think that ESD is much safer procedure. But you have to move really slow. No zip cuts when you can damage more than one blood vessel. One millimeter at a time. You cut, you watch. No bleeding, you move further. Thank you very much for that comment. Great. Thank you so much. Any questions? Thank you. So looking at the blood vessel, I know it's the stomach. So the core grasper for upper GI is slightly wider. If you encounter the same blood vessel in the colon, the core grasper we use in the colon is much smaller. To me at least, the vessel looks much bigger to grasp it with the core grasper for the colon. How would you approach the same case if it happened in the colon? How would you approach if you're pre-coagulating? Yeah, if you have the, if you also have to see there's such kind of different vessels in the colon, I should use, we should use the core grasper in the difference with the smaller, smaller size of the core grasper. But we can grab the, if you cannot hold the, hold the vessel, we grab many times. And I think the vessel will shrink. So it's easier to do the, to hold. Can I add? So in this situation, if you have only colonic core grasper, and I'm in the same position, because when we started to do ESD and we were using both gastric lens devices and colon lens devices, the staff, especially in stressful situation like that, they will not look into the package and you are inside the colon, you have bleeding in the colon, you ask for core grasper and of course they will give you gastric lens core grasper. So you push it through the colonoscope and then you realize that it's too short and the bleeding continue, you wasted $250, but the bleeding is still there. So I had to eliminate all the gastric lens core grasper. And you're absolutely right, the colonic lens core grasper will not work for such a big blood vessel. So in situation like that, I would take hot biopsy forceps, which have much bigger branches, and then I would grab it with hot biopsy forceps. But you have to be careful because the branches of the hot biopsy forceps have teeth. So if you grab artery, which was not bleeding, preventatively with hot biopsy forceps, you can cause bleeding that way. So that was a desperate measure. So first I would try to stop it with core grasper, which is device intended for that use. But if it is not working because it's too small, then you have another choice, hot biopsy forceps, with much bigger branches. The same setting, soft coagulation mode, the same setting. And in case of finding this kind of bundle of thick blood vessels, you should observe the bundle very carefully. And this kind of reddish basculature is been, which is easily shrinks after giving some coagulation. Therefore, from the side, you can coagulate the reddish bean. Then final step is grab the remaining bundle of blood vessels, that is mostly artery, which has relatively whitish color. So carefully catch the artery, then coagulate it completely. It will become safe situation. If you completely expose the thick blood vessel, still we can use the open tip of the ESD devices and apply very low setting of forced coag. Probably, I will be able to show some of the case, and Professor Toyonaga also show some cases. And if you find out the large vessel, and you need to check, which is a bean, as Professor Yahara mentioned. And this is very larger than device forceps. Just close it and contact, and conduct the soft coagulation mode. Bean can shrink very easily. And the remaining artery should be grasped. That will be the other option. Would the underwater technique help you in any way? I know it's in the stomach, and I'm not sure where in the stomach, but would underwater help? Underwater technique, would it help? Coagulation. Well, visualize the vessel, and maybe preemptively coagulate it. I usually use the underwater method. Do you have anything to do with underwater? For vessel sealing, underwater condition usually not work well, especially when we use coagulant. But when we use the tip of dual knife or flash knife, underwater condition is very good, even for the vessel sealing. But in case of using coagulant, you should suck all the liquid before activating RF generator. Otherwise, it doesn't work well. So the soft coagulation works inside the water, under the water. It takes much more time. You have to keep applying. Maybe you have to increase the wattage. So those are the things you have to know. If it doesn't coagulate right away, you have to know that its energy will be sucked away because of the pooled water, blood. But that's why we try to dry out as much as possible so we can quickly coagulate the vessel. But it works. Notably, in the underwater condition, blood splits quickly, and we easily lose the visual field. So pre-coagulation is much more important than in the air condition. And also, I'd like to suggest to use 1T scope because in case of active breathing, we cannot suction well. So it's better to think about to change to 1T scope, stand by outside of the endoscopy room, and also change patient position. I think Dr. Dobash showed a very nice point about the gravity. Yes, actually this is the case of the wider channel of the endoscopy, 3.2. Thank you so much. We always have that oh, no moment, right? You're cursing yourself. I shouldn't have done that. Also, I'd like to present the massive hemorrhage in the stomach. This is my disclosure. Here, you can see the widespread superficial lesion in the middle or lower part of the lesser curve side of the stomach. Then, after the careful observation, I have marked around the lesion, and I started the incision dissection, and I created the mucosal flap. And by proceeding the dissection, I have found a very large vessel, but this vessel is blanched. This vessel is coming from here. The penetrating vessel is here. That's why I first coagulate by using the low dose of the fourth quark to be precise by 30.4 or 800, 600 volt, 8 watt, and cut it without massive bleeding. And also, such very large blanched vessel have already coagulated with the low dose of the fourth quark and succeeded to cut it. But we restarted the dissection. As you see, the other large vessel can be seen. This is a real procedure by conducting the low dose of the fourth quark and the pushing, compressing the vessel by using a knife itself. Blood flow can be stopped temporarily, and the heat can be focused onto the vessel. Then, after pre-coagulation, if you conduct the fourth coagulation mode, usual fourth coagulation mode, you can cut it without massive bleed, and such small bleeding can stop by the fourth coagulation. But you can see the other branch is there. And also, I missed to see the penetrating site of the vessel. Then, unexpected such massive bleeding has happened. But in this moment, the bleeding point is very difficult to see because it was hidden by the mucous region. So it is very, very difficult to stop bleeding. That's why I placed the traction device onto the edge of this side of the region and pulled back the region and opened up the bleeding point. And then, I found the bleeding point. I'm using the larger coagulation grasper named Coagulasper Z with teeth. That's why you can roughly grab the larger, wider area of the vessel and succeed to stop bleeding, as you can see. After stop bleeding, you don't see a sufficient dissection level. And also, during the hemostasis, such huge hematoma coagulant was created. In this situation, precise precision cannot be proceeded. That's why you need to remove it or suck it. Usually, a direct suction device works well. But in that moment, we didn't equip the device. That's why I directly connected the suction tube onto the channel. Then, by sealing this point, you can suck it without the device. And the channel will be 3.2. We don't have the 3.7. But if you connect the tube directly to the channel, so you can suck it with such a fresh, huge coagulant without so much difficulty. So for the further procedure, you need to completely clean up the lumen. Otherwise, you can't see the appropriate dissection level. Then, I wanted to start the dissection. But if you start from the chart coagulated area, dissection print cannot be seen. That's why by using this device, by pushing the tube, you can open up some causal and restart the fresh area. And minimize the unclear area. Then now, from here to there, precise dissection can be done. That's why it is ideal to prevent the death cell. But if you create a massive bleeding, such a modification will be needed. Thank you very much. The result was fantastic. Thank you very much. Any questions? Can I ask a question? Andy? So in the beginning, I started using dilute epinephrine. And then I stopped for many years. Oh, sorry. In the beginning, I had used some dilute epinephrine. And then I stopped using it for ESD for many years. And recently, I was watching our friend Professor Jung in Korea. And he uses dilute epinephrine. And it really increased some of the dissection speed. And I've noticed some people prefer, some don't. Is there guidance about this in Japan? No. Prospective control study is ongoing. But it can maybe really decrease the active bleeding. But this cell doesn't disappear. That's why still pre-coagulation will be needed. Or coagulation after ESD to prevent the delayed breathing will be needed. Would you use it for something for the intubation? Oh, for this case? For the stomach, I only use the serum without anything. No? No, Hisa? Yeah. Previously, I usually used epinephrine for the submucosal injection solution, but we also stopped using epinephrine because we can easily recognize the possible bleeding point. Then we can coagulate the blood vessel much better during the procedure. As a result, delayed complication, I mean, delayed breathing becomes less and less. Do you think the Pure Start can be effective for such massive breathing? In the UK, they are frequently using it in the colorectal case. Just put a Pure Start and take a cup of coffee. For the minor bleeding, and if we cannot find the bleeding point, Pure Start sometimes works very well. We can achieve spontaneous hemostasis. But in case of having massive bleeding from the sick artery, probably it's very difficult to stop it. I don't recommend to wait so long time because the patient create a shock. I have used Pure Start for bleeding during ESD, and I noticed that if the bleeding is severe, the flow of blood just flush Pure Start away. It just doesn't stay. And if the lesion is at the antigravity site, it doesn't even want to stay there because it's trying to move to the dependent site. That's my observation. Just to clarify for attendees, Pure Start is one of the medication approved by FDA for hemostasis and potentially used for intra-procedural clearance of the view. And we're going to talk about it a little later. Would you use Pure Start for Would you use Pure Start for after the ESD to prevent post-ESD bleed? So that's the question that we don't know. We don't have the answer yet. So maybe it's in a clinical study. We may be answer will be elucidated in the future. We won't endorse or we will say yes or no at this point. Can I add? I think that the best way to prevent delayed bleeding is to completely close that area. Because if you have exposed vessels, then no matter, Pure Start is not forever. Eventually, some tissue, some food will come and scratch that area. And so I don't think that this is a good idea, especially on the left side of the colon where the stool is formed. I think that you need to close it. Thank you very much. Next, Suwani. Yes, another bleeding case. So this is a three and a half, four centimeter lesion in the ascending colon. Semi-pedunculate, biopsieshow high-grade dysplasia, so we want to do ESD. Now this is in a retroflex position, so I'm just going to make it a little faster. Initially, so we perform ESD in a retroflex view. Because of incision and dissection, things went well. So we expect that we're going to encounter large blood vessels in a lesion like this. When you see polyploid, large plate lesions, there tend to be a lot of blood vessels. We normally don't see severe bleeding in the right colon, sometimes in the distal rectum, but not normally in the right colon. But this case is unique because of the lesion morphology. So you start to see big blood vessels, but we try to dissect slowly to try to not cause bleeding. So when you see these blood vessels, you usually try to calculate before you cut it. And you tend to also see fibrous tissue in the center, because you see some fibrous tissue there, but it's not severe. You can still do dissection. So things went well, and this is almost done. Okay, so what happened is we almost finished, and we see some more blood, right? We think it's not that big blood vessels, and we perform pre-coagulation using coagRASPR, and we cut that area. And after we cut that, it's slowly oozing. And then, oh, we thought we have to do a little bit more, but we don't. And after we cut that, it's slowly oozing. And then, oh, we thought we have time. We're going to try to dissect a little more submucosa, and we'll do pre-coagRASPR again. But then it becomes severely bleeding, much more faster than we expect. And this is what happened. It's almost done. We thought that we can stop that area. So initially, it's not that fast. So I tried to stop bleeding using the tip of the knife. But it becomes so severe. So switch to 4-millimeter coagRASPR, and it becomes like this, like blood everywhere. The bleeding is very fast, and the dependent part of the colon is at 6 o'clock. So it's already not pulling the blood. It shouldn't pull in that area. But when we try to position the scope to visualize the bleeding spot, we just keep losing view. I turned the patient slightly to change the direction of the blood. Still doesn't work. Do abdominal pressure to change it. Again, doesn't work. And the clip go bleeding like this. So I cut the remaining submucosa because it's almost the end of the procedure. And I use hemo spray. So we use hemo spray. I don't have that part of the video. But it's a lot of blood clots and clots from hemo spray. Once we slowed down the bleeding with hemo spray, I was able to find a bleeding site and follow the treatment with coagRASPR faucet. So not sure if anyone have any comment on maybe I should have done something different or any tips to do anything different. Luckily, this is toward the end of procedure. Because if we use hemo spray and you have more to dissect, you might not be able to continue the dissection. So it was a big blood vessel which was transected in the middle. And first, your endoscope was on the right side. And it was pressing that part of the vessel which was still coming through the wall. But the second part, which was in the polyp, that's where you saw the bleeding. But that was just transected part of the vessel, the real one. It's the same vessel. It was transected in the middle. So I think in that situation, what I would do, I would press the distal attachment into that area trying to compress. It started to bleed when you move farther with the endoscope. When you were staying there and endoscope was compressing it, it was not bleeding. But as soon as you moved a little bit, then it is released the compression and start. So I would press the endoscope into that area and ask for coagRASPR. I would not even try to stop it with the dual knife. So my general rule of thumb is that if the size of the vessel is comparable to the size of the active part of the dual knife, then I can stop it probably with dual knife. But if it is bigger than the dual knife, I would not even try. coagRASPR is the answer. We didn't try that long. Initially, it was like small, slow oozing. And we quickly changed to coagRASPR. I believe I also try hot faucet. Because I thought if I use the bigger cup of the coagRASPR faucet, it might work better. But it's still not. The main issue is the flow is fast. Let's just say artery and the visualization when we try to grab that area, we lost visualization. Yeah, Suwani, just a couple of comments. As soon as I notice pulsation, you know that that's an artery. Even if it's just oozing a little bit, if it's pulsating, I also wouldn't have attempted to do any coagulation with the knife. At that point, that's when I would immediately turn to coagRASPR. And then one comment about using hot biopsy forceps. You have to realize that the hot biopsy forceps do not have as much surface area as coagRASPRs do. And they actually have quite a thin surface area because they're designed for cutting and tearing tissue. And so you're getting a higher current density that is less effective at coagulation. And you don't have as much surface area. So I probably would have not done the hot biopsy forceps either and would have gone just straight to coagRASPRs. Yes, thank you. We tried that for some time. That's why I say, let me try something different. But it didn't work. Okay, thank you. Suwani, I think as Sergei's point is well taken, I think a cap to, I don't know how easy it was to get close to it. But putting a cap to tamponade temporarily is a really good technique. And as soon as you start seeing bleeding, you have to just, I tend to just change to coagRASPR and call for it. And you saw that the transsection of the vessels and start trickling the blood. So that's a time you have to really stop quickly. I wonder, I have an old setup of the coagRASPR with a separate foot split. Yeah, that's a time that you have to stop right now. Do you have a setup of the separate foot switch and be ready for coagRASPR right away? Yes, yes. We actually switched it quite quick. But yeah, maybe I should have changed to coagRASPR sooner. We did pre-coagulation with coagRASPR before we dissect this area. But probably not, lately we see that it's not adequate and it's bleeding again. Yep. So Anya, can I ask you with the HEMO spray? I have not used electrosurgical energy like ESD after it. Was there any difference with the metal or is there any sparking? There's not a lot of powder left at the site. It's just like enough to slow down the bleeding. And for us to be able to see where that spot is to treat. So yeah, I don't think it's going to be much difference setting than what we use. But I don't see difference effect in terms of like the coagulation or bubblings that I normally see. Not really difficult. I saw we can, when you do those HEMO spray, I don't just push the whole powder in. Maybe like you just do slowly. And once we see it stop, then you stop. Otherwise, everything's going to be white out. Yes, so a little bit more control delivery. Any questions from participants? When you had the bleeding there, you ended up deciding to complete your resection. And then go after the vessel. Is that what happened to you? I actually tried to stop first with correct grasper. But I thought that I couldn't stop it. Maybe because the tissue around is like obscure, the way I cannot get to the blood vessels. And then later on, I decide to just dissect the remaining tissue to hopefully open the area. And maybe I can get to the blood vessels easier. So my question is, by doing that, could the vessel have retracted and made it harder for you to identify? Yeah, I think that's possible. That's what happened. Yeah, that's possible. That's why if it pull like this, I believe it's like this area. I thought I got it. But after tricoagulation, many times it didn't work. I would say that actually that is something, though, that in POEM, for example, you frequently cut through a vessel and it immediately retracts behind the muscle during the tunneling. And the only way to really access it is to actually cut some of the surrounding muscle so you can get to it. So I think that's very reasonable to be able to see and visualize as opposed to blindly coagulating. And of course, it's not as exact in applying to ESD, but it is a good strategy if you can see that vessel retract immediately is to try to find a way to expose it. Someone suggests to do epinephrine injection. Do you think that would work? I'm not sure for severe bleeding like this and where exactly we're going to inject. I didn't try, but I wonder if anyone will try. Actually, in desperation, I have to inject epinephrine to just slow down. Identifying the bleeding point is a really key point. And if there's so much blood, I couldn't really see. So injection of epinephrine at 1 to 10,000 solution, the regular hemostasis, those actually helps. It doesn't stop it, but make it easier to identify. So I think if you didn't have a hemospray, you should have probably you would have done the epinephrine injection. My name is Sasaki. My presentation is ESD for remaining in lesion after EMR perforation. So this region is located at SECAM. This patient was planned for ESD, but my colleague determined EMR, so he changed therapy for EMR, ESD to EMR. Injection solution is glycerol, which makes angiocalamine and epinephrine. So my colleague performed EMR, snaring, and cut. Here, this region remain, this is a perforation. So the region remain here. So it is, we switch the operator and perform the ES remyelin in the region. So it is important to change, it is important to change the surgeon, of operator, it is important to change to operator. So we, unfortunately, the patient had no abdominal pain and so treatment was continued. First, perforation is area was closed with a clip and then localize the hyaluronic acid. We inject hyaluronic acid and we perform ESD to the remyelin region and close the perforation area and we used traction device, ESO clip. ESO clip is very useful to dissect the area and we changed the knife, hook knife, we, hook knife. Hook knife is very useful to narrow area dissection. Traction device is very useful in this case. And carefully, we dissect some cause area. Clip is disturbed to dissect, but we can do it. We could dissect. The region was remyelin and we perform EMR, additional EMR. And we performed additional clip and so he could not, need not surgery. That's all. Very intriguing. Open to question. Did you need to decompression of the abdomen after the procedure or during the procedure to change patient position to supine position and push angio-cat needle or something like that? How to monitor abdominal distension and the air leak and how do you cope with it? Gary? No, we need not to air out. Thank you so much. And also, you started antibiotics, right? Immediately after the perforation? Antibiotics. Antibiotics, yes, yeah, we use antibiotics and we stopped two days food. I have a question. Why not just do EMR of the remaining lesion and go to ESD instead? EMR the rest, clip close the perforation instead of going to ESD, changing operator. Changing operator. Why not just do EMR of the remaining lesion and go to ESD? The remainder region is bigger, so we thought we could not perform EMR, so we changed the ESD, okay? Probably location of the remaining tumor was the problem. In this particular case, it was located behind the hood. Therefore, probably snaring of those remaining tumor was quite difficult. That's why he selected to do ESD in this case, I guess. And I think the condition of the bowel preparation is very important when we conduct colonic ESD. In case of having perforation, we should avoid leakage of colonic luminal content. Only the air leaks out from the perforated area, nothing happens. But if colonic content leaks out from the perforated area, it will cause severe peritonitis. That's why we should clean the lumen beforehand as far as possible. And in case of making perforation, we should carefully check the perforation site. And if it is located at the lower side according to the gravity, we should change the patient position to avoid the leakage of colonic content. That's my suggestion. I think the timing of the clipping is also very important. So in this case, you clip close the defect perforate site immediately after you recognize the perforation. But I think sometimes it is not so good for continued dissection. As you mentioned, sometimes the deployed clip disturb the dissection. What do you think about this point? I think perforation, he have not abnormal pain. So we could, we thought we could continue ESDs because as you mentioned, I think you dissect from the opposite side of the clipping site. So then the direction is different. So you can continue dissection. And then after that, you use the traction device and making a tunnel and dissect the region. In my opinion, it's right? Yes, yes. But we could dissect the narrow area, I think. I would probably agree with Dan. And unless this is cancers, I would probably convert to piecemeal EMR and quickly finish because the closure, as you can see, the clip is going to be in your way. And then you have to avoid the thermal injury to the clip as well, so that it prevent another delayed perforation risk. So I think you have so much of comfort doing some of the gaps too, you can see. You have so much comfort doing the ESD in this situation. That's great. I mean, with expert hands, you could have done it. And I think there's an option of the piecemeal EMR as well, of course. And this is a great example that even perforation happens during the ESD. You dissect off the area, close the perforation and still keep going on to complete the ESD. That's just a take-home message. Perforation did not happen during ESD, it happened during EMR. That's right, it's much bigger. So most of the ESD perforation is much smaller, but that's a key point. One, you recognize perforation, take care of it and keep going. That's the key point on this piece. And carbon dioxide insufflation is a must. I'd like to hear thoughts on what maybe I'll call benign pneumoperitoneum. So let's say you do not have an obvious perforation during your ESD and then afterwards, the patient may feel uncomfortable after they wake up and maybe you discover error on imaging. What is the practice that in your centers, if the patient needs a percutaneous decompression, afterwards they feel better? Do we monitor them conservatively? Or let's say they don't need a decompression, do you monitor them conservatively? Or are these patients, even in that situation, does a surgeon get involved for laparoscopic examination? A patient that's not obviously unstable, of course, maybe just a little uncomfortable, or we see error, even a large amount of error in the peritoneum. I was a consultant surgeon, but we checked carefully patient abnormal pain every day, every morning. So, of course, we use CT colonoscopy and check blood test every day, so very close, close. Carefully, very carefully. I think in your patient, though, if you're getting an imaging, probably they have pain or some symptom, right? And so then, you know, you had a perforation. I think there are two things. I think in a case like this, if you have a definite perforation, you think you've closed it, but you wanna make sure, send them home, and you haven't sutured it up or whatever. It's been described, you could shoot some contrast and just get a stat non-con CT. You have to dilute it about one to three, one to four, but it's like a stroke protocol CT, really quick, and you don't see any contrast extra, but you see error, you're fine. But I think if you have a patient who's had ESD and then they have pain and you get imaging, I think letting a surgeon know is reasonable, but if you have the ability to go back in, like, you know, within a very short amount of time and close it if you haven't, that's probably reasonable as long as they're stable. You know, when the error is causing not just pain, but like vital sign instability because of decreased venous return of the heart from the pneumoperitoneum, then you should definitely decompress before you do anything else. Yeah, I would say just a few things. Yeah, yes, yes, yes. I think that, you know, it also depends on how confident you feel about your closure methods. If you have done a fair amount and you know suturing, for example, and you have confidence that when you do that it's closed, the patient's not, if you feel confident that it's closed after the procedure, I don't even know that you, you know, I would hope that you wouldn't reflexively get a CT scan because it will show error, but what do you do with that? And I think the other thing is that in terms of the surgeon, certainly for patients who are symptomatic or you have some still concern, maybe it wasn't quite closed that well or there's a lot of coagulation, it really helps to establish an alliance with a surgeon that you will consistently call who's aware of the procedures you're doing, who's perhaps even seen some cases where you were concerned about perforation, but they followed them with you and they saw that actually that was okay, or also saw in situations where, no, there's higher risk that there's still an ongoing perf and they might have to intervene. Because if you just say like consult surgery altogether, many of them don't know what you're doing. Many of them don't know the risks involved and will kind of just very reflexively send their resident and then all of a sudden the patient's in the OR and that's a disservice to the patient. Yeah, I think that's exactly right. At my center, we've had a series of, over the years, a series of pneumoperitoneums that reflexively, the patient received a laparoscopy and nothing was ever found, like a patient per year, maybe something like that. I think we have to work on our communications with our surgeons a little more. And they all definitely get antibiotics, I see. Is it recommended by everybody, the experts here, to completely close any colonic ESD on the proximal colon? Complete closure? We don't use any complete close, in another case. So, the surrogate would, I know his answer, but. There's a trend that we recognize a complete closure, benefits, reducing bleeding risk. And if you have any thermal injury to muscle, then there will be a benefit of preventing delayed perforation as well. So we have to think about cost benefit ratio. In Japan, that's gonna be prohibitive because you increase the cost, but here, again, you have to use your judgment. More than two centimeter, right-sided colon, closure, the high-quality closure, actually reduce the bleeding risk, for sure. And I have one case that I didn't close confidently and then came back with a delayed perforation. And those are the things that make you wonder if I should have closed or not. So I tend to close as much as possible, to prevent any of the post-procedure, delayed bleeding perforation, especially we have so many people coming from far away. So that's a benefit for us. Sergei? And I agree with Norya in the sense of closure. And I close every ESD defect, which is more than two centimeter. I think that we have convincing evidence that if it is less than two centimeter, then it's not a problem. We have convincing evidence that if it is less than two centimeter, you don't really get much of the benefit. But if it is two centimeter and more, I close all of them with endoscopic suturing device. Like Norya said, it's especially important if your patients are coming from a distance. In Japan, I guess it is not such a big issue because everybody gets admitted. But in my case, most of my patients are coming from long distance, some of them three hours away, some of them even another state. And so it's a big burden for the family to leave the patient in, then go out and then come back to pick up. And the cost of admission is astronomical. Norya said that yesterday from his own experience. So by closing every defect, I confidently send the patient home. And all you need, just one case of delayed perforation or delayed bleeding so that you get convinced and you will forget about economic benefits of not closing. And we have several people in the audience from Fuji, from Olympus, who were observing my cases and they will confirm to you that I suture close every defect, no matter right colon, left colon, esophagus, stomach, duodenum especially. Duodenum is especially difficult. And if you can avoid doing ESD in the duodenum, you should avoid it. Because even if when you do everything correctly and you do X-ray after procedure, most of the time you will see some extra-peritoneal air, some micro-perforation happen. And if I close it, it's not concern. If you don't close it, it is a concern. Sergio, can you expand? Because I know a lot of us can close disposable defects, but sometimes when you close Frank Corporation, you may do multiple layers and put a needle in it and press. I'm practically never use more than one suture. I close everything with one continuous suture. If there is a full sickness defect, intentional or unintentional, intentional meaning it was a full sickness free hand resection, unintentional meaning there was a perforation, then I will do a full sickness closure. Meaning that I will use a hot biopsy forceps to grab the margin of the perforation or full sickness incision, pull it into the lumen and do a full sickness bite with the suturing device. But you cannot do it inside the peritoneal cavity because then you may grab something which you did not intend to grab. So you pull it into the colon lumen. You suture, you grab it, and then you continue to do it till you completely close it. After I close it, I always do, if there was a full sickness defect in the colon, I always do a leak test. You want to make sure that it was a airtight closure, which means that I take a laparoscopic virus needle, we always have it in endoscopy unit, and puncture abdominal wall and connect it to syringe with water and remove the pusher from the syringe. Then you see how the air comes out. This way you decompress peritoneal cavity. And when you finish closure, I stay there with endoscope and I insufflate colon and see that there is no bubbles going through that water. Usually one suture, if you did it properly, is good enough.

colonoscopy

ulcerated lesion

high-grade dysplasia

surgery

endoscopic submucosal dissection

perforation

clip closure

resection

antibiotics

recovery monitoring

coagulation and traction devices