And thank you for having me here. First of all, so I'd like to speak about endoscopic sub-mucosal dissection tool and knife. ESD involves several steps to complete the ESD. And so I'm going to talk to you about the basic knife and the tool section. Usually, it's 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 include marking, injection, incision, and dissection. Prophylactic steps manage your complication, including hemostasis and suture. I will show you some tools and knives that are completed in each step. First thing we need to do is marking the 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 APC 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 the 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. You have a choice of the two things. One of that is a clip-based closure. 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. OK, now we are focused on the knives. What knife we use is so important, depending on the region you're cutting. I will show the several types of knives. So this is a simple type of 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 knife. This is just applied to the retracted and cuts the fibrotic tissue in a proper and safe direction. Inserted tip type, it's called an IT knife. It's designed for better cutting performance in vertically and horizontally direction. This approximate side is equipped with 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 the knife for working a smaller lumen, like a colon or SYG lumen. This knife is a different type of the ESA knife. You are very familiar to 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 the improved ESD safety and a good acquisition of the tissue. A good control of the hemostasis, always you can do that by grasping the bleeding vessel. Last knife I'm showing is a hybrid knife. This is relatively new. It's developed now in the market. Some of the knives is all inclusive from the marking, injection, incision, dissection, the coagulation. You can skip the asking your technician exchange any accessories of forceps or injection needle. I added two slides to help you perform ESD. First thing is a distal attachment. If we use them, you can pinpoint your view on the spot. You are cutting and coagulating. Also, you get a better visualization of some cause of plane, placing the cap against the region. Other things is very important thing is a traction device. Now they are available in the market in Japan, in the United States. Especially, it's becoming and developing in the market. No need to adjust the position, body position, and instead of being aware of gravity. Traction always helps you get the wider window plane for cutting on the coagulation. Now I show you some of the case we are doing. So first case is a stomach antler arm 10 millimeter depressed region. We selected to use an insulated tip of the knife. The region is very subtle. So we start with marking with a needle knife. So this kind of the knives 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. After the initial incision, you can start with using your IT knife to hook up to the incision. The circumferential incisions are being performed. So actually, this kind of a needle is very useful in almost all of the gastric region because the stomach is a large working space. So you can do the dynamic, speedy movement. Usually, in Japan, we use a clip-on thread to make up good traction after the incision. They're putting a thread. Now you see the submucosal plane for cutting. So I moved the knife left and right, and right and left, cutting the submucosal plane. This is repeated movements that establish the ESD dissection. After the rejection, I watch carefully the submucosal defect, any bleeding or any vessels. If I see something, I operate it with using the metal part of the knife. Next 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 perform the marking. Now you can see the region is downsloping into the stomach lumen. So we inject the distal edge of the region to make it flat. After the injections, we start it 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 the distal attachment. If you see the minor bleeding, just apply the 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. It's just applied for a needle 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 millimeter, deep breast region. It's a very subtle finding. So we applied the chemodyne endoscopy to identify the region. So after the injection, we selected to use a hybrid knife. This knife is all-in-one ESD knife uh it's including injection, marking, dissection. Everything is this knife. So actually this is a retroflex view. Now you can see that the mucosal plane is going to the gravity side. Now you place on the distal attachment on the region. Then you focus on the spot you are cutting. It's a kind of the pocket creation method. If I feel satisfactorily, then back to the proximal side. Then a little bit of incision and injection with ESD knife. After that, we start to the incision proximal side to connect to a distal attachment. 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 sub-mucosal plane using a distal attachment, so placing on the region. We repeated the same movement to accomplish the ESD. The next case is an esophageal region, 10 mm SCC. We use a different type of ESD knife. This is a scissor type of knife. So we focus on the brownish area. After the chemoendoscopy, we place the marking using an APC. I think this scissor type of the needle is very good for beginners to start with because actually before cutting, you can make sure you are grasping the mucosa or sub-mucosa, not the muscle layer. So after injecting, you just grab the mucosa, the whole surface. And raising the mucosa away from the muscle layer, then you feel safety in the cutting. Same thing, we have to repeat, and a little bit advanced forward with the ESD knife. Now you see the sub-mucosal plane. We grasp the sub-mucosal plane and getting away from the muscle layer. Then I ask you to repeat the same movement Then I ask you to rotate the knife vertically. Then we focus on the sub-mucosal plane, the horizontal cutting, and getting away from the muscle layer. It takes time actually, rather than other knife, but it's very safe because always you can confirm what are you cutting. Also, you can use for coagulate the small vessel. Okay, last case is a colon sigmoid, three centimeter LSTG. So actually this tumor is being performed by a hydraulic knife. I show you the case three already. And also I use a multiple device using maximum traction. So after injection, we start with a incision using this knife. The same thing that we are doing, just as a 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. After placing the multitube traction, we put air to get a wide range of the mucosal view. Now you see the fibrotic tissues. Also blue line has to be the cutting here. You see has to be the cutting here. Now I'm doing the same movements. And so I'm moving the needle, knife, up and down. Because the multitube traction gives you the 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 area. Now you see the broad window for cutting. Just moving the hybrid knife up and down. So actually this technique is very useful beginner to learn ESD. Because wide range of the mucosal view helps you the 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 though for the beginners, we can do that. But the selection of the knives and tools adds more operator dependence. 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? Actually, the National Cancer Center, we are using the IT knife for gastric regions and the dual knife with this attachment is used for coronary, early neoplasma and the superficial SOG 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 to, yeah. Okay, thank you very much. Don't you have any other question?

endoscopic sub-mucosal dissection

ESD tools

knives

hemostasis

distal attachment

traction devices