Thank you very much. It's my great honor to be here. I'm a little bit nervous because this is the first time to attend this hands-on session. My topic is esophageal ESD. This is the agenda of my presentation. First of all, I will talk about the basic strategy of the ESD, and I will introduce two methods, useful techniques for the esophageal ESD. And how to manage the structure of the esophageal ESD is quite important, so I will introduce the management. As Dr. Shimamura and Dr. Amit mentioned, the basic strategy of ESD in their previous presentation, ESD procedure is divided into four phases, marking, injection, mucosal incision, and submucosal dissection. The basic strategy of ESD is similar regardless of the organ. However, there are some differences, and I will explain mainly the point to be careful about in the esophageal ESD. During the marking for the squamous cell carcinoma, we spray iodine staining. The concentration of the iodine staining is important. We use 1% or less than 1% of the iodine staining. And after spraying the iodine staining, we sometimes experience this situation. There are so many iodine-stained area, and we are confused which one is cancer and which one is not cancer. In this situation, pink color sign is quite useful. Pink color sign is defined as color changing after spraying about one minute. The region is located at the right side of the esophagus. The coloration of the iodine-stained area is changing to the pink. This is a very good indicator of the squamous cell carcinoma. And during the marking, please store the tip of the knife. If you use a dual knife, like this, the setting of the electrical current is very important. I prefer to use the soft coagulation mode, effect 4.5, if I use the BIOS 3, and we are making the marking dot around the region, about two millimeters outside of the region. And finally, we make additional marking dot to know which is the oral side and which is the anal side. And in the barrett esophageal cancer, situation is a little bit different. Barrett esophageal cancer in the long segment barrett esophagus is quite difficult to make diagnosis, and maybe this issue will be discussed in the advanced course. I will explain the barrett cancer located in the short segment barrett esophagus. The barrett esophageal cancer located in the short segment barrett esophagus, the location is quite unique. About 60 to 70 percent of the barrett cancer is located at the 2 o'clock, and the coloration is also unique. Most of the region is reddish. So if you find some reddish area at the 2 o'clock direction at the squamous SC junction, please be careful to observe. And the amount of the air is quite important. If the amount of the air is not adequate, the region is easily hidden, and it is very easy to overlook the region. So if you observe the squamous columnar junction, please inflate using the adequate amount of the air. And using NBI, the region can be recognized as brownish area, and it is much more easier to detect the region. And if you use NBI magnification in the region, irregular micro surface pattern and irregular micro vessel pattern can be recognized, and we can make diagnosis this is a cancer. And sometimes we experience the sub-epithelial invasion to the squamous epithelium, and we usually make oral side of the marking dot about 1 centimeter to 1.5 centimeter, a little bit oral side. The next step is the injection. First injection point should be placed at the most anal side. And I usually inject about 3 millimeter outside of the marking dot. And during the injection, please pull back the needle slowly and slowly and slowly. Don't obstruct the elevation. And this puncture hole is a very good landmark of the incision line, and I usually make incision to connect this puncture hole. And additional injection using the tip of the knife is quite useful for safety procedure. And the next step is the mucosal incision. During the side mucosal incision, I make the incision line about 3 millimeter outside of the marking. And during the incision, please check the tip of the knife, this white ceramic tip. If you observe, if you can see this white ceramic tip during the incision or dissection, it is very safety procedure because the tip of the knife is only 1.5 millimeter. And I usually make oral incision a little bit far from the marking dot, about 5 millimeter outside of the marking, because I usually use the clip with line method, and I apply the clip at the oral side, and I make incision a little bit far from the oral side. And the setting is also important. I prefer to use end cut eye effect 3 or dry cut effect 4. And the incision line, I make incision as shallow as possible, because this is a muscular mucosa, and there is a vascular network just below the muscular mucosa, and during the incision, don't damage such vascular network. And I prefer to make incision as shallow as possible. And the next step is the submucosal dissection. I think it is most important how to use the transparent food during the submucosal dissection. And I think there are two phases. One phase is before entering to the submucosal space. And in this situation, please use the lower part of the transparent food to push down the oral mucosa, like this. And the length of the knife should be a little bit longer to approach the submucosal space horizontally. And I dissect the lower one third of the submucosal layer. And after entering to the submucosal space, please use the upper part of the transparent food to pull up the specimen. And maybe you can directly have a very clear vision. For the setting, I prefer to use the swift coagulation mode effect 5.5 by 3. OK, I will show you one video clip. This is the same case. This region is located at the right side of the esophagus. And this is a reddish area. And if you spray the iodine staining, please spray the iodine staining all over the esophagus because we have to detect the metachronous cancer. And during the marking, please store the tip of the dual knife. And I make marking dot about 2 millimeter outside of the region, like this. And finally, I make additional marking at the oral side. And the next step is injection. In the esophageal ESD, please make injection at the most anal side. And please inject as gently as possible. And during the injection, please pull back the needle slowly and slowly and slowly. Don't obstruct the elevation of the submucosal layer. And next is mucosal incision. As I told you, please check this white ceramic chip during the incision. And please make the incision line as shallow as possible, especially in the esophageal ESD. And we don't damage the vascular network during the incision. And if you find such muscular mucosa, please dissect very carefully. Don't damage the vascular network. During the esophageal ESD, such motion, such as because of the heartbeat or peristalsis or respiratory movement, is very obstructive for the procedure. And the next step is oral incision. And as I told you, oral incision setting a little bit too far from the marking dot. And using the DualKnifeJ, additional injection using the tip of the knife is a quite useful technique for safety procedure. And the circumferential incision was made. And the next step is the submucosal dissection. And before entering to the submucosal space, please use the lower part of the transparent hood to push down the normal mucosa. And dissect the lower one third of the submucosal layer. And please add the injection using the DualKnifeJ. And be careful during the dissection. And the additional fluid cushion is very useful. And from now, I will enter to the submucosal space. And after entering to the submucosal space, please use the upper part of the transparent hood to pull up the specimen. And sometimes we observe such a white tissue nodule during the dissection. I'm sorry. I'm sorry. Oh. Yeah. This is a esophageal gland. So please include to the specimen. And the region can be resected in a block fashion without perforation, like this. Please dissect carefully, carefully, carefully. And the region can be resected. OK. This is the final step. And the region can be resected. Yeah. And pathologically speaking, this region is cancerous cell is embedding to the lamina propilia. But the region can be resected in a block fashion without margin free. So this is a curative resection. And I will talk about the useful technique during the esophageal ESD2 method. Dr. Shimamura mentioned in his presentation, a clip with line method is quite useful. After circumferential incision, please apply the clip with line at the oral side. And the next step is, please enter just below the clip. And after entering to the space, please pull back the line slowly and slowly. OK. I will show you one video. Yeah. I applied the clip to the target region. Yeah. After circumferential incision, I apply the clip with line at the oral side. And I confirm not to hang the muscle layer. And I enter to the submucosal space. But before entering to the submucosal space, I inject using the needle. And this is a very big point. Please enter under the clip. And after entering, please pull back the line carefully. So dissection layer can be recognized very easily. And dissection can be performed very safely, like this. In this method, please enter to the space. And after entering, please pull back the line carefully. The second useful method is pocket creation method. This method is proposed by Professor Yamamoto. And this is the region. And in the esophageal ESD, endoscopic manipulation is easily influenced by the movement, such as heartbeat, and peristalsis, and the respiratory movement. To overcome this situation, we sometimes make pocket of the submucosal space. After entering the submucosal space, endoscopic maneuverability, endoscopic manipulation is completely stabilized. This is a very big advantage. I will show you one video clip. We developed transnasal endoscopic ESD knife and transparent food with a Japanese company. But unfortunately, this device is only available in Japan. And this patient has severe structure after chemoradiotherapy for the pharyngeal cancer. And we decided to use the ultrathin transnasal endoscopy to do the ESD procedure. And before entering to the pocket, the endoscopic maneuverability is a little bit unstable. But after entering to the submucosal space, endoscopic maneuverability is quite stabilized. So it is very easy to make pocket like this. For pocket creation method, ESD procedure by ultrathin endoscopy is quite useful. I make pocket. It took about two minutes or three minutes to make the two centimeter pocket. And if you master the ESD technique, you can reject large region, regardless of the size. But in the esophageal ESD, the stricture after large rejection is a very big clinical issue. There are two methods to prevent the stricture. One method is oral steroid intake. This method is proposed by Dr. Yamaguchi in Nagasaki, Japan. And we prescribed prednisolone, 30 milligrams per day, two weeks. Next two weeks, 25. And 20, 15, 10, 5. Totally eight weeks, we prescribed oral prednisolone. And the stricture rate is significantly lower compared to the conventional method. It's a very good method. However, if the patient is suffering from diabetes meritus, or if the patient has infection such as the HIV virus, oral steroid intake is contraindicated for such patient. And in this situation, we sometimes use injection steroid solution to the ESD ulcer. This is a circumferential ESD procedure. And we inject the torium-synuron acetone about 100 milligrams to 150 milligrams to the ulcer bed. And according to this manuscript, the stricture rate is significantly lower. OK, thank you very much. And in the esophageal ESD, you should master the basic strategy. And you should get knowledge of the various methods, such as pocket creation method or clip with line method. And how to manage the stricture is very important for the esophageal ESD. And in the esophageal ESD, endoscopic maneuver is easily influenced by the heartbeat or palpitation or respiratory movement. So good manipulation of the endoscopy is essential for the esophageal ESD. Let's learn the basic strategy and the endoscopic manipulation method in this hands-on session with us. Thank you very much for your kind attention. Thank you very much for your wonderful presentation. Do you have any question regarding esophageal ESD? For your information, there is certain difference between Japan and the United States, because our targets for esophageal ESD is mostly scleromastoidal cancer. Probably more than 95% of esophageal cancer is still scleromastoidal cancer in our country. And we don't have so much case for long segment barrette esophagus. That's why there's huge difference between Japan and the Western countries. By the way, in case of having long segment barrette esophagus, do you sometimes do circumferential resection for the 10 centimeter? Yeah, most of the time. It's possible, but the severe stricture is very severe. But maybe about half a year, we dilate. And maybe stricture can be resolved, I believe. And is there any technical difference between the ESD procedure for the scleromastoidal cancer and the barrette cancer? Most of the technique is similar. But as I told you, marking or making the diagnosis of the tumor border is different, because the scleromastoidal carcinoma is very easy after spraining the iodine staining. But barrette cancer is very difficult to make diagnosis of the tumor border, especially in the long segment barrette esophagus. I had a question. So first of all, thank you for showing that beautiful ESD. One of those procedures, were you using a neonatal x-ray scope, like a small scope that goes through the nose? Oh, yes. Sometimes I do. So you have an endocap that goes onto that small scope and a knife that goes through that small accessory channel? Yes. Do you mean during the trans-nasal ultrathin endoscopy of the ESD? Yeah. Most of the procedure is similar to conventional ESD. But sometimes the maneuverability of the endoscopy is a little bit unstable. So it is important to enter to the submucosal space as soon as possible, I think. Thank you. I think you have equipment maybe in Japan that we don't have access to. We have cases where people have severe esophageal strictures but have gastric cancers that need resecting. This technique is very useful. The region is located after the stricture or region with fibrosis because of the previous ESD. In this situation, it is very easy to enter to the submucosal space if we use the trans-nasal ultrathin endoscopy. Thank you very much. Could you use the microphone? Because there is a virtual audience through the website. Please press the button. Yes. Now it's working. What is the diameter of the biopsy channel for that ultrathin scope that you have in Japan? Yeah. The ultrathin endoscope produced by Fujifilm is the diameter of the channel is 2.4 millimeters. But unfortunately, ultrathin endoscopy proposed by Olympus company is 2.2 millimeters. But this knife is only 1.95 millimeters. So both of the companies' endoscopies are available. OK, thank you. Thank you very much. Still, there is one more question. Yeah. Could you use microphone? Yes. Fantastic talk. Thank you very much. So it is very useful not to cut deep initially. And as you elegantly showed, would you explain further step for the attendees? Now you exposed muscular semicozal, some superficial semicozal vessels. How do you dissect down to the semicozal? Do you change the electrosurgical unit setting, use more coagulation? And how do you do the trimming? Setting of the electric current is similar. But how should I say? It's a little bit difficult to in English. But it's emotion. Emotion. Don't damage to the vasculature. Don't damage, don't damage. Yeah, it's my passion. Well, you have to coagulate the vessel at some point. Do you use forceps or going with a knife? I don't use forceps before entering to the submucosal space. You do? I don't use. Oh, you don't? OK. Usually, we can coagulate sick blood vessel without using coagulator. Probably, Dr. Toyonaga will explain detail about how to coagulate, how to deal with sick blood vessel using open-tip of devices. Well, we will accept the question even from the virtual audience. Please, free to ask us during the talk. Norio is carefully checking the question

esophageal ESD

endoscopic submucosal dissection

marking

injection

mucosal incision

submucosal dissection