Good afternoon, ladies and gentlemen, I'm Takashi Tono from Kobe University Hospital and Professor Yamamoto from Jitsuhi Music School. He is kindly commenting me and later on he is performing the other procedure. Today will be a bit advanced course, so I have created the region almost at the same location as yesterday, but a little bit more wider and more greater curve side. It means the approach to some causal layer will be much more perpendicular. And also today's big curve is much more forward, so maybe a bit difficult than yesterday. So the strategy will be the same. I'm creating the J-shape or C-shape incision at the beginning, then if some causal entrance was difficult, I will try to use the traction device. So please, can I use the injection? We are starting. So Dr. Sakaguchi is assisting me from Kobe University Hospital as well. If you have questions, please ask us anytime. We will try to answer your questions as much as possible. So in the stomach I'm using only a pure saline, without color, without anything. So now lifting is coming. Okay, stop. Also the basement should be punctured, okay. Okay, stop. Around 2-3 mm to the injection point is plenty enough. But the pig has a thicker mucosa, that's why we need a punch, but much harder than human. Okay. Okay, probably we can perform additional injection by knife itself, but a bit time-consuming. Time is limited, that's why I'm injecting as much as possible now. Okay, then we shall start. So again, by using the torque of the scope, I'm controlling the direction. And also up and down, the right and left, especially right and left adjustment is very much helpful to confirm the direction to the left-hand side. Let's start from the most distant side of the region. Okay, this is a 2.5 mm flash knife BDS. BDS means the slimmer sheath, so that's why you can suck the air much more efficiently, as if I'm using a 2.8 mm working channel. Because the knife grows, the tip part of 3 cm is 2.7 mm thickness, but the proximal side, with the endoscopy view, it is difficult to confirm, but from here to proximal, 2.2 mm in diameter. That's why suction comes much faster. Then we can control the region location and also the approaching angle. So controlling the suction volume is very important to create an easier approach to the target. Then I'm also just a little bit adjusting the focus to see the surface of the target very clearly. Then at the beginning, I'm controlling the movement by fixing the cap on to the mucosa. Then I'm creating a starting point by conducting the end cut mode, for the human, one or two times is plenty enough, but it was three times needed for the pig model. Then you can confirm we have already breakthrough the mucosa by injecting the saline through the knife. Okay. I want to confirm again. Here you can see the mark. So by tracing the mark, you can confirm the direction. Also you can simulate which maneuver is needed. So both, just practice and also confirm the direction. Then same thing can be done inside the starting point, step one, control the knife, step two, then conduct the current one or two times, then two and three, two and three, two, three, two and three. Now knife is dropping out easily. That's why I'm capturing the mucosa by the backside of the ball. By shifting the cap, I'm holding the mucosa. Then also by scooping up the knife, mucosa, by using the backside of the ball, you can control the incision depth just underneath the mucous mucosa. That's why bleeding less likely happen. So in this location, there are so many branched vessels. That's why shallower incision is better to prevent the bleeding during the incision. So control and cut, control and cut, just a little bit scooping up. Then additional injection will be needed. Okay. So where is the mucosa? Today region is relatively large, that's why we can cut the mucosa much more than yesterday. Small region, you need to consider about how far you cut to create a good mucosa to utilize the gravity. Okay. So greater carp's eye is very much easy to bleed in the human. A live pig or a real patient. Then again, just a little bit scoop up. But if you hold it too much, current density coming down, that's why just control the knife toward the aiming part a bit, then cut it. Don't twist during the conduction, because the knife will be easy to slip out. Just a little tension, then conduct it. Knife can be proceeded by itself. If backflow has come, it is better to close the knife and push the sheath harder to block the backflow. Okay. So same thing, just control and cut, control and cut, control and cut. Now again, the knife will slip out very easily, but by holding the mucosa using the backside of the ball, sometimes mark between, mark gap is wider, sometimes you will be coming in wrong direction. So this is a very good, bad example. Okay. But then, step by step, it is better to perform the mucosal incision. Also to stretch the mucosa, it is very important to confirm the border of the region and the mark. Also by stretching the mucosa, incision situation coming better, because the current density is coming higher. Because now mucosa is folded, that's why it is difficult to cut. Then by using a cap, I'm stretching the mucosa, then by using the blade part, efficient incision can be done. So please try to control the current density as much as possible at any time. Then tip of the sheath has the flat tip, that's why knife doesn't go deeper easily, so it is very safe. Okay. I have changed my mind. So because the region is falling down to the gravity side, that's why I use the traction from the beginning, then I will complete the incision first. Also the region is relatively large, that's why as if I cut to the outer side of the mucosa, region doesn't shift down to the greater curve side so much, I guess, or I believe. Another injection. Coming closer, needle in, please. Then push harder, then please confirm injection is coming. Then now channel have opened to be injected, then continuous injection can be done. At the beginning, I'm just tapping injection, then channel has opened, I'll continuously inject. If I want to inject large amount of volume, tap, tap, then efficient injection can be done. Back side of bow. I have twisted a bit more hard, that's why mucosa has folded, that's why efficient cut didn't come. Just slight contact, then twist the scope a bit, then very easy, efficient incision can be done. Now I will place the traction. Here you see very nice vessels. So because many vessels here, you can see, whitish vessel, here is the shallower incision, that's why, but just behind, underneath here, large vessel exist, that's why by scooping up the mucosa, I'm controlling the depth of the incision. Now, okay, once more, set the knife and scoop up, then cut it. Okay, by reducing tension of the musculoskeletal mucosa, incision is very open, but there are so many vessels. So if you cut directly, massive bleeding will occur. Okay, now we shall put the traction, because it's totally perpendicular now. But of course, by reducing the saturation volume, now more tangential approach can be done. But yesterday I have already shown you, so today I'm using the traction. Okay. Yeah, by changing the insufflation, the amount of the gas in the stomach, you can change the direction, approaching direction. But Dr. Toyonaga will show you how to use the traction, line and clip. Line and see tube. So in Japan, commercially available device named endotrack. Endotrack. I'm using the endotrack, but this was the self-made prototype of the endotrack. Oh, okay. But because of this experience, we have reached to the product. So I can show you. This is the tube of the snare, thin snare. And inside the tube, I have put the thread. This thread is very expensive because this thread came from the overstitch. But just nylon will work well. Well, I use this one. In the past, we have always made this one for the traction. The purpose of the sheath is for controlling the tension of this traction. By pushing pull, you can control the tension. And also by pushing the sheath, you can push. And also by pulling the device, of course, you can pull it. And close it. This is the open-close type clip. This is a short clip? Short clip, yes. Easy clip works well as well. But this one has the advantage. So I want to use this thread about 5 cm. So you use about 5 cm of the thread? Yes, 5 cm of the thread. If you push here, like the crane... So with this sheath, we can change the direction of the traction. Also, if you pull back, the tube will interfere in this situation. Okay. Then, this is the external traction. That's why we need to re-insert. Along with the endoscope, the outside endoscope is needed. Because of the single-channel endoscope. Also, if you have the double-channel outside, independent traction with the endoscope is better. Yes, even if you use a two-channel scope, the traction should be outside of the scope. Because you want to control the endoscope independent of the traction. If you use the traction inside the scope, then it moves together. Then, I guess it is better to put the line part to the sub-recausal side. Well, whatever. Yes, okay. Wait a minute. Well, anything is fine. So I'm grasping the edge of the region. I'm inserting the right-hand jaw underneath the region. Temporarily close, please. Up again. Okay, go ahead. Then, by checking the situation, if you grasp the muscle at this moment, that would be a disaster. Okay, now, very nice. Fire it, please. Yes, please. Okay. So, now, by pulling back, you can open up the sub-causal, as you see. Okay, just I'm starting the... Wait a minute. Let's go this way. Okay. Also, by pushing the tube, you can push it. It's short. It's okay, right? Okay. Just a little pulling back. If you pull back too much, the sub-recausal space becomes thinner. So just a little bit is plenty enough. Okay, now, very nice traction I've created. So, also in the human, we very much pay attention to the best cell, was there or not. I guess this will be the best cell. So, okay. Here, you don't see any best cell, that's why you can cut it. I change the duration of the endocut eye from 3 to 2. Without the best cell, you can conduct the cut mode. But here you see the best cell. So, if the best cell is there, we need to conduct the coagulation mode. Okay. So, but this is the branch best cell, so no need to cut in this moment. But in case of having the bleeding, I'm using the forced coagulation. Okay. This will be also the best cell, that's why I'm dissecting underneath the best cell. Also, current should be conducted tap-tapping fashion, tap-tap, to avoid excessive burn effect. Okay. So, which side is difficult? This time, usually greater curbside is difficult in the human, but this pulsine model, lesser curbside is much more difficult. I don't know why. Maybe just lay down, that's all. That's why shape is different. Okay. And I see some fibrosis here. That's why I'm conducting the cut mode. And just touching it, then emitting the cut mode, very precise dissection can be done. Just touch and slide the ball on the fibrotic subcausa, like polishing movement. Okay. I don't see any best cell, that's why I can conduct the cut mode. So, now I will disconnect the incision edge. So, this line, there are so many branched best cells. That's why I'm inserting the knife underneath the subcausa, then conducting the forced coagulation mode. And also, by scooping up, I'm disconnecting the incision edge. Also fibrosis. Okay, you see here fibrosis. Okay. Then by conducting cut mode, very short second. The duration is controlled by the setting, duration two. Okay. Okay, the left-hand side. If you have questions, please send us the questions. Okay. So, before proceeding the dissection, it's better to disconnect the edge first. But now, the region was... Traction is working very well. Yeah, but if you push, pull back, subcausa become very thinner. Yes. And also, edge of this incision was folded. So, the... Don't pull too much. Yeah, landing point is difficult to see. That's why I want to change the direction by pushing the tube. The underlying mucosa is elongating toward the endoscope side. Now... Yeah, better direction. Better traction has been created. Then a bit more. Then I push, the lifting has come. That's why I'm using this type of traction device. This is very easy to prepare. So, if you don't have the traction device, please make it by yourself. This is a medical product. Just combine each other, that's all. So, I guess no problem for the clinical use, too. Then, if you create a good tension, dissection becomes very, very efficient. Now, I have created subcausa groove. And it's totally disconnected to the greater calf side. You see? Right hand side should be also disconnected. But here, there are many fibrosis. That's why... With this image, you don't see where is the muscle, where is the subcausa, where is the fibers. But by adjusting the focus like this, now I'm very much confident about where we should dissect. Okay, now you see. Fibrotic, but here you see the surface of muscle and also the subcausas here. That's why I can selectively and effectively inject the saline through the knife. Again, I'm inserting the knife underneath the fibrotic subcausa. Then, conducting the current, I'm disconnecting the edge of the incision. Also, still some subcausa fibers remain here. That's why inserting the knife and scooping up. It's okay. It's a bit dangerous because the subcausa is very thin with fibrosis. Okay, when you observe from the distance, please come down the magnification to adjust the focus. Also, again, I want to demonstrate. If you pull back too much, the subcausa becomes thinner. Also, the target is coming far from the endoscope. The usual situation would be this, without traction, or with traction. This is different by pushing the tube. You see here, the line is here. The tube tends to come straight, and the line is pulling up to this side and the other side of the wound. It's much different. Very good traction. That's why the easier dissection and efficient dissection can be done. When you dissect, you need to pay attention to the penetrating vessel. I can see here the vessel, as if the color is white, because this is the X-Plant model. In this moment, I'm seeking the penetrating site by dissecting underneath the vessel. I missed to adjust the focus. That's why I was not so confident. Now I'm very confident about the dissection plane. You see here, this is the penetrating site. Beside the vessel, I'm dissecting to expose the penetrating vessel. Also, a bit of push is needed. Okay. The space of some causes here is a bit thinner. That's why I'm scooping up and cut it. Inside the knife, don't conduct in this moment. If you conduct here, you are damaging the muscle. At the backside of the ball, please scoop up it. Then conduct it. Also here, you see the fibrosis. That's why I conduct the cut. This will also be a vessel. That's why the coagulation model is better. I'd like to demonstrate the pre-coagulation technique with the low power setting. 604 means 600 volt, 8 watts. Please observe what is coming. Just a bubble. This is not a spark. Just a bubble. It means I'm coagulating with heat less than 100 degrees Celsius. It means totally the same with the soft coagulation model. Not burning, but boiling. White coagulation. By pushing the knife against the vessel, we can see the vessel. You see a very shrunk vessel can be seen. Now, pre-coagulation has been completed. That's why I'm cutting with the higher setting of the voltage. You can see the yellow. This is spark. Spark is always cutting or coagulating, burning the target. Then, in such a manner, you don't create so much bleeding. This is the cut end of the vessel. Already, this patient has blood-frozen wound. That's why I can cut it directly. If you are treating the real patient, every single penetrating vessel should be treated carefully. Also, by pushing, the force was weakened. That's why traction was not so well. The right-hand side is fibrotic. That's why it's a bit difficult. But the target is soft fibrosis. That's why such a scooping technique works very well. You can see here the edge. That's why I'm scooping up. I don't see that by coming closer. Now, you see the edge very well. Then, by capturing the edge with a blade and the backside of the ball, I'm scooping up. Then, efficient dissection can be done. Now, we need to disconnect the overside completely. Also, in this moment, by pushing the target, you can open up the remaining fibrotic. Already disconnected. Then, here, the target is behind the region. That's why it is very difficult to confirm the landing point. That's why I'm opening the starting point. But it's still the landing point behind the region. That's why I'm coming back to the lumen side. Then, I have confirmed the edge. Then, by scooping up and aiming the overside helicium causa, I'm disconnecting the incision edge. Where is it? It's a bit fibrotic. I can see the landing point very well now. Just dissect it right to left and left to right. This is a forward view. Then, coming back to the forward stroke. This is a pseudo-perforation. Some cause a hole. Then, this is a backhand stroke. Backhand stroke can be scooped up very efficiently. Also, by using this type of foot, please create a better view and a better tension. Here is fibrotic. That's why I'm conducting the cut mode. But also, this tapping technique works very well. You see, as if some cause fibrosis quite severely. By using this tapping technique, you can dissect anything you want. Totally different from right and left. Left-hand side is very much soft without fibrosis. But this is the best cell. Penetrating side will be here. But I will skip the pre-coagulation technique because I have shown you very carefully. Also, there is no risk of bleeding in this moment. But when you are treating a real patient, please take care of every single penetrating vessel very much. Also, fibrotic. That's why I'm performing the tapping technique. By sliding the tip of the ball onto the fibrotic, some cause a polishing movement. Very, very precise and safe dissection can be done. Also, if you can capture it, please try the scooping technique. Almost already, just a little fibrotic part is remaining. Also, by injecting, I'm confirming the border of the muscle and some cause. Almost done. So, I'm always observing the tip of the knife. Then, if you dissect from here much more, maybe you are creating the tunnel to the outside. That's why it's better to... Dr. Toyonaga, we have one question. What settings do you use while cutting the fibrosis? This is the end-cut eye, duration 2 or 1. Yes, I use the same. I use end-cut eye, duration 1. So, if you increase the duration, a longer cut is coming. It means it's very dangerous. Yes, cutting current can cut more than you expected. So, we control the cutting by the duration of the cutting current, the time. Time is very short. But if you conduct the coagulation mode, just creating a channel, that's all. So, for the severe fibrosis, such a cut mode is better. Yes. So, you see very, very clean alisabeth. Yes, very good. This is the penetrating vessel. So, please take care of every single penetrating vessel and fibrosis as much as possible by using the proper setting and technique. Thank you very much. Beautiful technique.

endoscopic procedure

incision

traction device

saline

mucosa

cautious dissection

pre-coagulation techniques

fibrotic tissue