Thank you very much, Dr. Yahagi and ASG, Dr. Fukami, and thank you for having me here. First of all, so I'd like to speak about endoscopic submucosal dissection tool and knife. ESD involves several steps to complete the ESD. So I'm going to talk about the basic knife and the tool section. It's usually operator-dependent, but I show you some different types of the needle and the tool that helps you perform ESD. I'd like to share the illustration slides. They are showing the several steps to perform ESD, therapeutic steps including marking, injection, incision, and dissection, prophylactic steps that manage your complication, including hemostasis and suture. I will show you some tools and knives that complete each step. First thing we need to do is marking region. It is not always necessary if you see the regions clearly, but if you see the region is obscure, you need to do the marking around the region. You have a choice of the markings using the FBC or ESD knife. To prevent bleeding during and after the procedure, we needed to achieve the hemostasis with a coagulation forceps. But usually I use an ESD knife. If I see minor bleeding or minor vessel, just apply the ESD knife on the spot of the hemostasis. Last step to finish a procedure is closing the defect for prevention post-procedure bleeding or perforation. We have a choice of the two of things. One of that is a clip-based closure, so another thing is a suture-based closure. It's sometimes a difficult procedure. You need to get a good running to apply the ESD, closing the defect. Before doing the ESD cutting, we need to lift the region, then proceed to the cutting. We can maintain the lifting for a while, a new special solution used. Okay, now we focus on the knives. What knife we use is so important, depending on the region you're cutting. I will show the several types of knife. So this is a simple type of the knife. The structure is very simple, it's a needle type, and you can just apply it on the regions and precise cutting a dissection in any dissection. The right picture I'm showing is a hook type of the knife. This is just applied to the retracted and cuts the fibrotic tissue in a proper and safe direction. This type is called an IT knife. It's designed for better cutting performance in a vertical and horizontal direction. The approximate size of the equipment is a tip. And also, you can cut the surface with the metal part of the knife. It enables a speedy cutting and a broad cutting surface. This is also applied for many locations of the gastric region. You can also do the hemostasis, but need other knives for incision cutting. The right picture I'm showing is another type of the IT type. This is designed for working a smaller lumen, like a colon or esophageal lumen. This knife is a different type of the ESD knife. You are very familiar with the forceps, right? So actually, you just grasp the mucosa or some mucosa getting away from the muscle layer. You always can check the position before cutting. That gives you improved ESD safety and good acquisition of the tissue. A good control of the hemostasis, always you can do that by grasping the bleeding vessel. The last knife I'm showing is a hybrid knife. This is relatively new. It's developed now in the market. Some of the knives are all inclusive from the marking, injection, incision, dissection, and coagulation. You can skip asking your technician to exchange any accessories, forceps, or injection needle. I added two slides to help you perform ESD. First thing is the distal attachment. If you use them, you can pinpoint your view on the spot you are cutting and coagulating. Also, you get a better visualization of the mucosal plane, placing the cap against the region. Another very important thing is the traction device. Now they are available in the market in Japan and the United States. Especially, it's becoming and developing in the market. No need to adjust the body position instead of being aware of gravity. Traction always helps you get the wider window plane for cutting and coagulation. Now I show you some of the cases we are doing. So first case is a stomach antler arm 10 millimeter depressed region. We selected to use an insulated tip on the knife. The region is very subtle, so we start with marking with a needle knife. So this kind of knife cannot do the incision first. So that's why we start with a needle knife. After injection, initial part of the incision was performed by a needle knife. Then you can, after the initial incision, you can start with using the IT knife to hook it up to the incision, the circumferential incision being performed. So actually this kind of needle is very useful in most of the gastric region because the stomach is a large working space. So you can do the dynamic speedy movement. Actually in Japan, we use a clip on the thread to make up good traction after the incision. They're putting a thread. Now you see the samokoza plane for cutting. So I moved the knife left and right, and right and left, cutting the samokoza plane. This repeated the movements as established with the ESD dissection. After the dissection, I watch carefully the samokoza defect, any bleeding or any vessels. If I see something, I operate it with using the metal part of the knife. This case is a EG junction, 10 millimeter small nodule, adenocarcinoma. So actually the esophageal region is performed in the small working space. So we prefer using the dual knife, it's a kind of a needle type. So using this, we performed the marking. Now you can see the region is downsloping into the stomach lumen. So we injected the distal edge of the region to make it flat. After the injections, we started with incision in the distal margin of the region. So distal attachment is very important to place the region to fix your view. Even though the bleeding happens, you can fix the view using distal attachment. If you see the minor bleeding just applied for needle on the spot, you are coagulating. Then followed by a circumferential incision, moving to the proximal side. Just to focus on the view, using a distal attachment is very useful to pinpoint the spot you are cutting. It's a subtle movement, but step-by-step you are advancing the dissection. Now you see the vessel here, just applied for a needle and knife on the spot. You can coagulate. It's not a big pain. Actually, it's not an artery that you can coagulate first. The third case is a sigmoid, 15 mm, deep breast region. It's a very subtle finding. So we applied chemodyne endoscopy to identify the region. After the injection, we selected to use a hybrid knife. This knife is an all-in-one ESD knife. It includes injection, marking, dissection. Everything is this knife. Actually, this is a retroflex view. Now you can see that the mucosal plane is going to the gravity side. Now you place the distal attachment on the region. Then you focus on the spot you are cutting. It's a kind of pocket creation method. If I feel satisfactory, then back to the proximal side. Then a little bit of incision and injection with the ESD knife. After that, we start the incision on the proximal side to connect to the distal side of the incision. Now you are connecting the incision. Then we finish the circumferential incision. Now you see the mucosal region is going to the gravity side. We can focus on the submucosal plane using a distal attachment, placing on the region. We repeat the same movement to accomplish the ESD. The next case is an S42 region, 10mm SCC. We use a different type of ESD knife. This is a scissor type of knife. We focus on the brownish area. After the chemoendoscopy, we place the marking using an APC. I think this scissor type of needle is very good for beginners to start with. Before cutting, you can make sure you are grasping the mucosa or submucosa, not the muscle layer. After injecting, you just grab the mucosa, the whole ceps. Raising the mucosa away from the muscle layer, then you feel safety in the cutting. Same thing we have to repeat. A little bit advanced forward with the ESD knife. Now you see the submucosal plane. We grasp the submucosal plane and getting away from the muscle layer. Then I ask to rotate the knife vertically. Then we focus on the submucosal plane, the horizontal cutting. Getting away from the muscle layer. It takes time actually, rather than as a knife. But it's very safe because always you can confirm what are you cutting. Also, you can use forward to coagulate the small vessel. OK, last case is a coronal sigmoid, 3 centimeter LSTG. So actually, this tumor is being performed by a hydraulic knife. I show you the case 3 already. And also, I use a multiple device using maximum traction. After injection, we start with an incision using this knife. The same thing we are doing, just as an incision, is to make a mucosal flap. Now we are injecting with a needle. So different things is, after the circumferential incision, we applied for multitube loop traction. So first loop is a fixed distal to the region. The third loop is a fixed distal margin of the region. So after placing the multitube traction, we put air to get a more wide range of the mucosal view. Now you see the fibrotic tissues. Also, blue line has to be the cutting here. Now I'm doing the same movement. So I'm moving the needle, knife, up and down. Because the multitube traction gives you a nice view of the cutting surface. Apply the second loop is a fixed distal to the region to make more view available. Almost the mucosa is peeling off the muscular layer. Now you see the broad window for cutting. Just moving the hybrid knife up and down. So actually, this technique is very useful for beginner to learn ESD because wide range of the view helps you to guide where to cut. that throughout the procedure, traction is working for you. Okay, let me summarize. So actually the ESD is advanced techniques with multiple technical challenges. But now we have a wide range of the knives and the tools. So actually when we are using the tractions, actually the ESD is much easier for, even for the beginners, we can do that. But the selection of the knives and tools are more operator-dependent. So when you use these kind of knives, you need to be familiar to these. Also you get more information from the mentors or companies. Thank you very much. Thank you very much, Dr. Hashimoto, for your great presentation. Do you have any questions? I clearly understand that the device is completely depending on the preference of the operator. But what is your most favorite device for ESD? So what kind of situation do you select another device? So. Actually the National Cancer Center, we are using the IT knife for gastric regions and the dual knife with this attachment is used for chronic early neoplasma and superficial SVG neoplasma, yeah. And what is the reason why the operator at the National Cancer Center prefer to use IT knife for gastric ESD cases? Is it the more safe and fast or, yeah? When I show you in the case one, it's very speedy, actually. So the surfaces of the cutting is very bold. So actually the speed is very important. Thank you very much. Don't you have any other question? Okay, thank you very much.

endoscopic submucosal dissection

ESD tool

ESD knife

complications management

knife selection

mentorship