Well, I would like to show you a similar case, like Norio's case, but I just want to show what I did for my own case by using multi-bending endoscope. This is a very big region. Can you recognize this region, by the way? This is, again, very flat, whitish area spreading to the gastric pharynx. This is the region, and taken biopsy revealed well-differentiated adenocarcinoma. And of course, this is a very difficult procedure because of the perpendicular approach and the large region size. In this kind of situation, we usually use multi-bending endoscope, which is only available in Japan and some of the Asian countries. It has second bending part. As a result, we can approach to the gastric pharynx or caldia by using second bending part very easily and very effectively. And as I mentioned during Norio's talk, I started procedure from the upper side and utilizing the gravity, I dissected most of the region from the upper side. It was quite smooth, even though the approach was completely perpendicular. But I tried to approach from the lateral side in a retroflex position, approaching to the submucosal layer at the posterior side and make a pocket and extend the submucosal dissection to the upper side. And using a multi-bending function, I dissected the submucosal tissue from the upper side to the lower side. But the rest of the procedure becomes very difficult because dissected area comes down and it becomes almost impossible to open the submucosal space. This is the situation which we should use traction method. There are many traction methods already reported by our Japanese colleagues. And Dr. Toyonaga invented the end track and Dr. Oyama reported the clip-and-line traction. And I made an end lifter. But I selected the most simple and cheap traction technique, which is clip-and-line traction. And I catch the edge at the bottom side and just pull the string. Then submucosal layer widely opens. As a result, the rest of the procedure becomes quite easy and safe. And as a result, I could make a nice resection. Yes, that's all. But I have another interesting case. Yes, this one. This is really a challenging case. This patient originally recommended surgical resection because taken biopsy already revealed adenocarcinoma. But he refused because colostomy was recommended by the surgeon. What would you recommend for this patient? Surgery or challenging ESD or piecemeal resection? What would you do? Sergei? First of all, I want to say that it was very cruel to show multibanding scope to us because we definitely don't have it. But I guess that you probably feel the same looking at my demonstration with overstitch. So I think that we are in par on that one because overstitch is not available in Japan. Definitely not piecemeal resection because then you may not be able to assess if everything removed or not. And it looks like the polyp is going up to dentate line, right? Very close to the dentate line. This is the anal barge but the dentate line was intact. So it's a little bit better because when the polyp involves dentate line after resection they have a lot of pain and so this may not be in pain. But clearly only one option you have. All the other options are not applicable. Only one option to try to remove it in one piece. And I would schedule it as the last procedure of the day so that you can go as long as you want to. It would be a big mistake to schedule patients like this as the first procedure of the day and then you ruin the whole schedule. But we can schedule as a first procedure and only have one procedure. Probably that is the right answer. Yeah. Now I want to question the big nodule within this lateral spraying tumor is the risk for having invasive cancer. That's right. That is the main question. So therefore I carefully checked the mucosal surface using NBI and magnification and we did crystal barotraining and magnification. But fortunately or unfortunately I couldn't find any invasive sign which presents Kudos type 5I or type 5N. So I decided to perform ESD. But probably it's a really challenging situation. What kind of challenging do you anticipate in this case? Dr. Toyonaga? Severe fibrosis underneath the big nodule. As if it wasn't caused by the deep submucosal invasion but barosterosis causes the severe fibrosis. That's right. Usually this kind of bulky mass moves a lot within the colonic lumen that induces a lot of fibrosis and sometimes it causes the muscle traction. This makes it really challenging when we conduct ESD. And do you have any opinion regarding the difficulties of this case? So yeah, I think that the biggest difficulty will be that there is no space. You cannot remove a case like this with traditional ESD. It has to be tunnel technique. There is no other options here. I think that that's the only option to get into it. And I agree with both Dr. Toyonaga and Dr. Yehar that there will be a lot of fibrosis and the tissue will actually look like a muscle. You will not be able to separate. You will not be able to understand if it is still muscle or is it just a fibrotic area. So it's a very tough case. Norio. Additionally, if there's any nodular component, there's the feeding artery, feeding vessels. And at the same time, this is a low rectum, so there's abundance of the vascular network. So it's going to be a bloody procedure. Yeah, that's right. That's right. So we should anticipate lots of vascular network and the severe fibrosis. And we should carefully plan the treatment strategy. It's a really important factor to get a successful result. Well, as Norio mentioned, usually there are rich vascular network and the chance of having severe bleeding is very high. But we can manage it if we carefully prepare all the bleeding situations. Actually, for the minor bleeding, we can stop it very easily just applying closed tip of dual knife. I usually use Bio3 Spray Coag 1.2. This is really helpful and a very quick procedure. This is a really tiny minor bleeding. Just apply closed tip of dual knife and step the coagulation current. It's a really simple procedure. And for major bleeding, we should use Coagulaspar, of course. And in this situation, I usually use SoftCoag 6.0. This is major bleeding from the thick artery. It's a very common situation when we conduct the ESD for this kind of big region. But once we capture the bleeding point using Coagulaspar, it is a really easy situation. But sometimes, bleeding becomes really severe. I sometimes switch to the gastric Coagulaspar, which has much bigger jaw. And sometimes, I use heart biopsy process, which has much bigger jaw. It depends on the situation of the bleeding. And for the thick blood vessel perforating through the muscle layer, if luckily, we find this kind of thick blood vessel without cutting muscle blood vessel, we can abrade it by using open tip of dual knife. I usually use SoftCoag 0.3. This is what we call vessel sealing technique, which was originally developed by Dr. Toyonaga. He will talk about this technique a little bit later. So this is one of the very thick bundle of the blood vessels. I exposed this bundle of blood vessels on both side, then catch it with the open tip of dual knife and applied 0.3 of SoftCoag. It is very, very helpful. And there was no bleeding at all, but I could nicely dissect here. This kind of management is really necessary during the procedure. I would like to show you actual procedure of this case. I used the multi-bending endoscope for this case, because it has 7 o'clock working channel as well as 5 o'clock working channel. I can use both working channel depending on the situation. Initially, I injected glycerol solution to the serbum causal layer to lift up the lesion. Glycerol is a very simple solution, which is consisted of 10% glycerin, 5% fructose and 0.9% sodium chloride, which was originally developed for the treatment of brain edema in case of cerebral infarction. But it has higher osmolarity, that's why it stays a little bit longer. Therefore, I usually use this solution for most of the standard ESD cases. It's a very cheap solution. It costs just $2 for 200 milliliter package in our country. Just to add, it's not available in the United States. Unfortunately not. I usually include small amount of indigo carmine to the solution to give some blue color to the serbum causal layer. And initially, I started my procedure from the oral side in a retroreflex position, because we can keep the stable condition by using retroreflex position and dissecting the serbum causal tissue. And I realized that there was a really sick blood vessel, therefore, avoid cutting here and try to dissect the surrounding tissue first in order to expose the bundle of sick blood vessels. Now, you can see the bundle of the very sick blood vessels. Therefore, I applied the open tip of dual knife and used 0.3 of first quark Bio3. It is very, very effective. In case of using Bio300, you can use Effect-1 5W for this technique. And if you are using much sicker ESD device, such as brush knife or hybrid knife, you should increase the power of the setting, such as Effect-1 10W. That will work very well. So after dissecting tissue from the oral side in a retroflex position and dissecting nearly half of the serbum causal layer, I put back the endoscope and approached to the remaining target lesion from the anal side in a straight position. And again, I injected glycerol solution to the serbum causal layer and carefully conducted mucosal incision and the serbum causal dissection. And as Sergei already mentioned, working space was quite limited. Therefore, it is quite important to have transparent food. By utilizing the transparent food, we can open the serbum causal space even within the very limited working space. After conducting some serbum causal dissection, I extended the mucosal incision to the lateral side and also connecting the incision line and start serbum causal dissection in a straight position by pushing manner. Of course, it is really tough situation, but by utilizing the rim of the transparent food, we can keep the stable position. It is really important to have a nice view of the operating field. Therefore, I washed the lumen again and again using the water irrigation. Please use normal saline for the water irrigation, otherwise it doesn't cut well. Please don't use distilled water. So the initial part of the serbum causal dissection from the anal side was fantastic. There was no problem. It was quite smooth. But in the middle of the serbum causal layer, I recognized a muscle traction sign. I couldn't find the dissection plane at all. It looks like just a muscle fiber. But there was no way, therefore I decided to cut through here. But as Norio mentioned, usually there is a really sick blood vessel within the tracted muscle. Therefore, we should be careful not to cut deeply. It suddenly causes severe bleeding during the procedure. It happens. But I already prepared multiple coagulation forceps. Initially, I tried to stop severe bleeding using 4 mm coagulant forceps, but it didn't work. Therefore, I switched to the much bigger coagulant forceps, which has a 5 mm jaw. Finally, I could stop it, then restart the dissection of the retracted muscle fiber very carefully, identifying both sides of the dissection plane and connecting the edge of the dissection plane. Again, I had bleeding, but it was okay. This is 5 mm gastric coagulant forceps, and I carefully caught the bleeding point and stopped the bleeding using soft coagulation. Of course, it was a really tough situation. We should carefully check the dissection plane, especially after coagulation. It turns very dirty, and sometimes it becomes very difficult to find the right dissection plane. Then, you should pull back the endoscope and clean the lens and check both sides and connect the edge of the dissection plane. That's only the way in which we can get a successful result. Now, I'm cutting the middle of the scalp tissue, and it gradually opens. And this is the final step. And finally, I completed the procedure. It was really tough. I spent nearly six hours for this single case. There was certain irregularity on the surface, but it was okay. And I coagulated the exposed blood vessels after the resection, and this is a resected specimen. And because of the bulky mass, it was very difficult to retrieve this resected specimen through the anus. That's why I introduced the ova tube. And through the ova tube, I introduced the scope again. And I used the six-centimeter net and also grasping forceps. Because multi-bending endoscope has two channels. From one channel, I introduced the net, and from the other channel, I introduced grasping forceps and captured the target lesion and put it back together with the ova tube. And fortunately, this was just a mucosal cancer, even though the lesion size was really big and also there was severe fibrosis. And the clinical course was quite good. This patient didn't complain anything about defecation or pain. Of course, it was more than 80% of circumferential resection. I usually prescribe steroids, supposedly, after extensive rectal resection. Then we can avoid strict deformation. Thank you very much. Any other questions? Yes. Yeah, I prescribe those patients who have a lesion, especially if it involves a dented line. I ask at the end of the procedure for anesthesia to give them IV Toradol. It will hold them for six, seven hours, and that's the most painful kind of period. After that, the pain subsides a little bit, at least become tolerable. I don't want them to take narcotics, anything with opioids because it can cause severe constipation. And then when they finally... And plus there is a predisposition for constipation because they are clean for colonoscopy. So it will take several days to accumulate stool. If they take narcotics all these several days, the stool becomes very hard. And then when it goes through, it will damage and cause a bleeding or tear my suture. So I try not to do that. And also I found it useful to dilate rectum with my fingers. So go with one finger, two, three. And then in case of such a big lesion, I would just grab it with fingers and pull it out. It works. I have a long and big hand, so it works for me. With your finger. Thank you. Thank you. Since, Haru, it's getting really late, can you stay on or you need to go? Yeah, yeah, I really enjoyed. Great. So, yeah, it was a great lecture. I really enjoyed it. Oh, thank you very much. It was really a change of life. It was nice to be with you. Better than watching Netflix, right? Could you go back to the fundus? Haru, I wanted to ask you a question. So with your traction, multi-point snare traction. Yes. You have a capability to push it as well. Would you have placed... Yes, yes. I have a very important point, Norio. So when we use the regular stiffness clip snare, so we can push it. So when we use a thin snare, so it's too much flexible, so it's difficult to push the specimen. So, anyway, so when we anchor the snare by a multi-clip and anchor tightly, then we can push the specimen if necessary. Great. Would you comment on the location of the attachment, if you were to be doing this case, and when? Yeah, yeah. So traction, it should be placed, for example, in this light image. So any time, so proximal edge of the endoscopic view. That is the best position to place. Then we can go behind the mucosa. So anyway, so at this moment, so Yahagi-sensei already mobilized most of the specimen. So just place the clips, the proximal end in this image. Close to you. Yeah. How about Dr. Toyonaga? If you try to remove this region using your own device, which is end track pair, do you prefer to apply it? I put the traction device mostly gravity side. Oh, gravity side, the same as me. Yeah, yeah. And I try to push. I guess everybody agreed to just strip off half of it before you apply traction? I myself would love to, but how about Dr. Aihara? Do you try to dissect without traction at the beginning? Recently, I started to use the traction for all cases, so from the beginning. From the beginning. Yes, correct. Amit, how about you? I sort of go back and forth on this. I think I talked to Norio about it before. Do you wait until you get into a difficult situation and then do retraction? Yeah. Or do you use it from the beginning and then the whole procedure goes easier? Yeah, yeah. Be careful. Please try to identify the muscle layer during the procedure. In case of using traction device, sometimes muscle layer easily retracted, especially in the gastric pharynx because of the very thin muscle layer. It usually lifts up. Then if you don't recognize the muscle layer, you will suddenly make a big perforation. Please be careful. I had a comment about your coloniosity. You mentioned muscle retraction sign. I think that's not something that's very well described in U.S. literature, but I think it's one of the biggest limiting factors when we do big bulky tumors. Do you mind giving a little explanation of what muscle retraction sign is? Muscle retraction is a kind of retracted muscle caused by the movement of the bulky mass. Usually, movement of the bulky mass causes lots of fibrosis, and when it becomes a bigger mass, it usually retracts the muscle itself. Fibrotic bundle becomes a very thick muscle fiber. We cannot distinguish the dissection plane at all because it looks like exactly the muscle layer. If we see the forward convergence towards the bulky mass, it usually has muscle retraction. We should be very careful. Dr. Toyonaga's group nicely described the muscle dissection technique. It was the lower rectum, myectomy technique. Myectomy. Wow. Great. Two questions from virtual audience. One, for rectal case, would you have given antibiotics? Oh, no. Because there was no perforation, I didn't give any antibiotics. The same? Dr. Toyonaga? We are routinely still using the antibiotics. No evidence. No, okay. No antibiotics. Was the ESC defect closed for the rectal case? Oh, no. I didn't close. I'm not Sergey. Sergey, have you closed it? Yes, I would have closed it, but the defect was not circumferential, so the chance of stricture is much, much less, obviously. The one which I tried to close is more than 90%. There, the chance of stricture is much higher. Okay, so it was not full circumferential. You may not have closed it? Yeah. Okay. Sounds great. Thank you so much. Thank you very much.

endoscopic submucosal dissection

ESD procedure

gastric pharynx

multi-bending endoscope

clip-and-line traction technique

pain management strategies