So, I'm going to talk briefly about other technologies and then hand it off to Peter. The Overtube system is available in the United States, and this can be really helpful in the United States because we have the big body habitats. We heard about the 200-pound patients. Even bigger patients are present, and colon does not be straightforward. If you can shorten it, great, it's one-to-one. But once you have a longer procedure, colon can be, again, distended. The endoscope can be looping again. There are several technologies available. First, Dr. Yamamoto invented double-balloon endoscope, which can be used for colonic ESD in difficult situation. However, we have newer modalities available, so I wanted to introduce those technologies. One is the balloon-assisted with the single or double balloon. This can create traction. The other is shape-locking. So, let's go over this. The main problem is sigmoid, or splenic pressure goes up when you push, and in addition, the loop creation creates a much longer loop in the transverse colon, so we want to avoid this loop creation so that we can continue on the smooth ESD. The one thing is two balloon-based technologies called dilumen. You can independently insufflate the proximal balloon and the rear balloon, and then you can create what's called therapeutic zone. This is another example. You detach this balloon system, there's the aft balloon and the fore balloon, and once you insufflate those balloon, this area can be the therapeutic area. So I push the fore balloon away and visualize the lesion, and it's at the bottom, and it's a stabilized system that you can perform the treatment you intended to do. Now the modified system has the loop, suture loop at the top, and that can be attached to the lesion to create counter traction. The initial tube was a little more cumbersome to use, it's a little sticky, and we needed some maneuver to make it smoother. Now newer generation is much smoother to pass the scope and modify it. Some institutions use this pretty regularly. Sergey has his own method to use it really effectively, and he uses it to save time, which is an amazing thing to do. And counter traction is really always beneficial. You can make it a one-to-one movement within the scope, Sergey. If you insufflate the balloon, you can pull this whole system to make the colon straight. So that's a benefit, making it looped colon into the straight position. And this can be the access, probably Sergey was telling certain attendees, this covering is actually some sort of plastic or some other membrane. You can disrupt the one side to insert additional tools, such as overstitch. So that's how he access to the right side to introduce overstitch to suture up any defect or perforation into the right side effectively and consistently. The other generation that is coming out is the C2 version, it has more of a robotic feature. It has the side-by-side, the accessory channel delivered to the area of the therapeutic zone. In this way, you can introduce the more articulated device for even cutting or grasping to create counter traction, doing more robotic maneuvers, or potentially continue on with the EST with the traction. This device may be somewhat game-changer. The way it works is a little more not as expected. If you remember robotics, the view is simply the view, it's a camera, a static view provided to perform the surgery. But this one is more of a little flexible, you have to adapt to the movement of the endoscope. And if you can make it stationary, this device seems to be very promising. But when you go into the patient, there's a lot of the factors that can affect the mobility of the scope and the devices as well. So we have to see how we're going to adapt this technology to the clinical practice, but just watch out, these are available technologies. The other thing is it's called a rigidizable overtube. This is simply applying the negative pressure, make it really stiff. It has various diameter to prevent the leakage of the air. So you can insert a colonoscope, adult colonoscope, pediatric colonoscope. There's a certain variable length. You can have a shorter or longer version. And you can insert all the way to the ascending colon to stabilize this tube. The amazing part is the rigidization. This is a regular soft, flexible portion, it's going over the pediatric colonoscope. With the turn of the knob, with this applying suction, it gets so stiff. So it actually keeps the shape, it's anti-gravity. And then you can move the scope one-to-one, push in and out. This doesn't have any availability for accessory channel. It may come in in the future, but this is an additional welcome addition to our portfolio to help navigating difficult colon to stabilize the field of the ESD area. Any questions about those technologies? Have you used them, either of them? Nouriel, I have a question. The company recommends specialized, very high-power suction. Have you ever tried it with wall-off suction and does it still work? I have not tried the wall suction, but the small suction system is pretty cheap and it provides adequate suction. So we have this separate suction, the canister and the suction pump, which is mobile. Thank you. You have a handy device. Could you push the button? Passing through sigmoid, if it's a little bit narrowed, it's a little bit tricky. We've been able to get it most of the time, but sometimes I have to push both of them together or sometimes it doesn't go and scope is gone and it's looping. It's not going ahead. Any tips to maneuver the sigmoid with it? Sergey, I would love for you to answer the question. Multiple, multiple conditions can affect the performance of the device. There is no one answer to that. And if anybody interested, we can make it into a separate talk to eliminate or how to get out of the situation. But the easiest way I think, and it's almost universal way, if you have problem, you slightly distend the four balloon. Then the four balloon kind of open up the lumen. You push it closer to the tip of the endoscope and you can get through even narrow places like this. If you feel a lot of resistance, then the main thing which you want, you want to stop. Then even regular colonoscopy, even regular colonoscope sometimes cannot go through the stricture or very torturous colon, especially if the patient had a hysterectomy and everything is fixed. So the main rule is you don't force, you take what you get there. So if the force is excessive, don't try to push it through. I think talking can be a little challenging. Do you try not to talk the system? I talk it and I actually talk the endoscope inside. So when colonoscopy was invented in Japan, all colonoscopy were done with the overtube on top of it. I remember that time when I was a student in medical school, very long time ago, another century by the way. And I remember they demonstrated how it was used. The patient had the overtube on top of colonoscope and when they were going through sigmoid colon, they used that overtube to straighten the colon. Dr. Yamamoto, I don't know, Dr. Yahagi, if you ever saw that. But that's similar to this. I have no problem rotating it and it was probably a problem when there was no hydrophilic coating inside. But now with hydrophilic coating, it's just easily moving in any direction.

Overtube system

endoscopic submucosal dissection

double-balloon endoscope

balloon-assisted

dilumen