So, I have a few cases, but this is the first one. So, this is from last year. It was a very large LSD granulotype lesion located at the hepatic flexure. So, this is actually the lesion. You can see like white-ish lesion over the, like, small hysterema fold. So, approximately 10 centimeter laterally spreading tumor granulotype in the ascending corner. And J-net, I did the NMVI J-net type 2A, and the pit was type 3L. And I usually evaluate, sorry, evaluate three factors before studying ESD. One is the gravity, and then the lesion stability, and then the scope access. So, I usually, like, push and pull the scope to see if I have the good access to the target area. It's quite large lesion. So, now we have a few techniques in terms of to, like, facilitate those kind of difficult ESD. So, one is the traction. And then the other one is the pocket creation method, as the Dr. Yamamoto explained yesterday. So, which technique would you do for this kind of large lesion at the hepatic flexure? Traction or pocket method? Please raise your hand. Traction? Okay. And the pocket. Any other? Probably EMR. It's very flat and easy to do EMR. But the thing is that the biopsy had shown some, at least, high-grade type of dysplasia, so we would not like to have any local recurrence after the piece marrow. So, I prefer doing, like, unblock resection for this kind of lesions. Okay. So, what I did was I started with the pocket creation method. Usually the pocket method is good for very large lesions. So, basically, we can dissect, like, underneath the lesion, like, all of the area first, and then finish the mucosal incision later. So, I started with the pocket creation. So, I made a two-centimeter mucosal incision. And then I am using this Fuji new magnifying coronaloscope, which has magnification capability. So, I prefer – I think Dr. Toyonaga is doing the same thing. I usually do, like, a little of the magnification to see the fibers better. So, as you can see, the focus is, like, targeting the fiber itself. So, you can see each fibers very clearly. And then the issue here – this is the middle of the pocket creation. The issue was that the lesion became, like, just in front of me. And then it was very hard to go, like, keep tangential angle to the lesion, so some mucosal area. So, as you can see here, I tried to go underneath the lesion all the way up to the right side, but it was very difficult because of the angle. So, what would you consider at this moment? Traction. Yeah. I found for myself that pocket and tunnel technique work much better in sigmoid colon and rectum. And on the right side of the colon, I really tried to do that because when the colon make all these germs, difficult to stay inside the pocket. And you also think that you push forward and you kind of tear it. So, on the right side of the colon, anything proximal to hepatic flexure, I would rather do it with the traction. On anything distal to the hepatic flexure, towards the anus, I would do with the pocket if necessary. Thank you. Any other comments from faculty? So, the traction is very helpful in this situation, but you have to think what kind of traction, right? It's in the right colon, so we have to think about how to apply internal traction. That's good. Yeah, thank you very much. So, because this is in the right colon, so usually we cannot use the clip and suture method because we have to come out and then place the clip and suture and go back. And there will be some friction between the suture itself with the scope. So, I will show what type of traction I use in this case. So, what I did was I stopped doing pocket at this moment because I was not able to go all the way up to the right side. So, what I did at this moment, instead of starting the traction right away, I opened up the bottom side of the pocket to be able to access the semi-ocular layer to the right side. So, I opened the bottom like 6 o'clock side, and you can see the house right here. And then, I'm still dissecting right above the housetrap to separate the result. Right now, the region is on the 3 o'clock side, and I'm dissecting. So, on the left side, you see the housetrap. And then, as you can see, it's still a little difficult to keep going to the right side. And then, what would you consider at this moment? So, I think the traction would be the best way. And what's the other consideration? Dr. Drogonov? I mean, you can retroflex on the lesion and see what access that gives you. Sometimes, that may help. It's hard to judge just by looking at the video, but I would consider doing retroflex just to see what access do I get. Perfect. That's great. Water pressure. Sorry? Water pressure. Water pressure. Okay. Yeah, that's the other way. Yes? So, right now, it's left lateral. So, patient was 300 pounds. It was very difficult to do a body position, so I tried to keep the same body position. But at this moment, I have to change my mind, and I asked for the nurse to give a help to me. So, I actually did the retroflexion, but this is actually at the hepatic flexure. So, it was very difficult to get an access to the oral side of the lesion. So, what I did was I changed the body position of this patient. So, I did the left lateral to right lateral. So, I kept the scope inside the patient, so you can see how the situation changes. Is the patient intubated? Yes, it's a general anesthesia. So, for the patient with a big body habitus, it's better to intubate. Sometimes the patient gets sleep apnea, and it becomes very difficult to continue anesthesia. So, now you can see that the scope is like a tangential to the lesion, but the issue is that it became a bottom of the gravity. So, for the access side, it's better, but now the gravity is poor. So, all the blood and fluid collects in this area. So, you can see here. So, now what you can see is that... So, I dissected the right side on this lesion, and then I think we need to dissect in this area. But there is a very large mucosal flap here. So, this is the time when we consider the attraction. So, what I did was I put the small rubber band with the small dual clip at the center of the backside of the lesion. And then grab the other clip, and then brought it to the opposite wall, probably like 12 o'clock, like above yourself. How did you bring this rubber band into the room, and just capture with the reposition of our end clip and bring it through the working channel? It's a very small, like five millimeter diameter rubber band. So, it can go through with the clip. Is it specially designed for endoscopic resection? No, I asked the nurses to buy it from Amazon. Basically, it's orthodontics. That's what your kids use it for. Because at Mayo, they always say, this is medical grade. Medical grade, yeah, that's right. It's not available. And then you can see the big difference. So, the issue is that when you do traction, sometimes the muscle layer also is pulled up. So, you have to make sure that you're not cutting into the muscle when you're doing traction. As you can see here, after the traction, here, so all of this is a big house ruffle. So, you don't want to cut into this house ruffle. Instead, you can see the real dissection pain right here. So, in this situation, you should use the injection between the lesion and this big house ruffle. Here. Here. And then, usually you see massive fibers on the house ruffle. And also, the submucosal tissue comes out of the muscle surface, and usually it's perpendicular running. So, that's the way to differentiate the submucosal tissue. You can appreciate how the traction works at this moment. So, I'm resting my knife on the top of the house ruffle to avoid any muscle injury. And then this is the last cut. You can see that the lesion has just peeled off from the muscle, and it's a quite large lesion with the two Haussler involvement, but in this case, the traction pocket and the body position changing, so all of three factors worked to finish this case. Because this defect was quite large, I did not close the defect, but I took time to cauterize all the blood vessels. And then I usually just pull the clip off, and then because this was a quite large lesion, I used a snare, but I want to ask for any advice for these, like a retrieval of these large lesions, and we have only like 3 centimeter retrieval net in my hospital, so any other options? Usually, this kind of very flat, laterally spreading tumor is very thin, even though the size of the lesion is quite big, we can easily retrieve it by just using suction with a cap. But we should be careful not to tear the resected specimen when we remove it through the anus. I see, so just ask the nurse to gently cut through. And sometimes I use the overtube inserting from the anus in order to protect the specimen. That is the best way to retrieve the big resected specimen. Thank you very much. If suction doesn't work so well, alligator forceps works very well, but you need to grasp the edge of the lesion from the submucosal side so that you don't make some damage to the lesion. I had another case where I removed like 3 to 4 centimeter gist, and they didn't go through the G-junction, so I wanted to ask you, what's the best approach? Would you like dilate the GEJ? We put the lesion into the plastic bag. Plastic bag? Then pull back. Got it. The collapse or something? Yeah, from the GEJ. I see. It becomes slippery. Oh, I see. Oh, that's good to know. Thank you very much. Any questions? I just wanted to mention that in the United States there is an 80 millimeter retrieval net available. 80 millimeter. 80, yeah. 80. Yeah, I find it to be okay, but I like the snare quite well, and the other option is you can use a stone extraction basket, like ERCP type of basket to grab the lesion with less chance to tear it because you don't want to break it, that's for sure. I see. Thank you very much. The problem with the snare, which Peter mentioned, it's called foot bolus snare, so it's a gastric length, so you have to switch to the gastroscope in order to use it. It's too short to use through the colon. I see. In pulmonology, they have a rotatable net that we use for some of our larger lesions. Thank you. Sometimes we take like one hour to do the ESD and another one hour to retrieve the specimen. I find retrieving those three to four centimeter jets through a geo-junction very dangerous. Okay. Got it. Thank you. This is the 10 centimeter specimen with the multiple intramucosal cancer. Yep. Oh, so we stopped at the supine, but I found that it didn't work well, so I further went to the right lateral, so probably like supine first and then the other side, and sometimes we do like prone if necessary, so as long as the patient is easy to maneuver, that's Yeah, so basically, Hugh's struggle with the access to the lesion and also, as I showed, there are three factors. One is a scoping, like stability, and also the lesion stability, and also the pulling. So as long as the lesion is located at the six circles, like to the dependent side to the gravity, you should consider repositioning the patient right away. And then if you struggle in terms of the access to the lesion, sometimes it's perpendicular, but it's very hard to predict the outcomes of repositioning. So usually we try different positions. If it's easy to predict, I would consider it. But sometimes it's very challenging to predict the outcomes. So we usually try everything not to delay, like prolong the procedure time. Does that make sense? Let me add to that. Absolutely. The fixed area is more predictable, but the transverse colon sigmoid, the rotation doesn't really translate to the rotation of the lesion. It kind of moves along. So you have to try and see. If it doesn't work, you have to go back to the original. I usually adjust the air amount. So if the lesion is in front of you, sometimes we suck the air. Sometimes the lesion gets tangential to yourself. But in this case, it didn't work. So that's why I asked everybody to help us change the approach position. Thank you. Hiro, just the online question. Just confirm. It was 85 minutes? 85 minutes. Great. Thank you.

hepatic flexure

endoscopic submucosal dissection

traction

retrieving specimen

post-resection strategies