to you. And honestly speaking, I felt a little bit worried about coming here because I was really worried about getting infected during the course and after the course, and maybe bring the Japanese virus here. But fortunately or unfortunately, three weeks ago, I got the best, strongest vaccine and isolated for 10 days and fully recovered and coming here now. There is no risk. Okay. Okay. So let's move on to my topics. My topic is a procedure setup and technique for colorectal ESD. Here are my disclosures. First of all, I'd like to share with you why we need to perform the colorectal ESD. About 20 years ago, we used to perform the piecemeal EMR for large colorectal region, as you can see. This is my example performed by piecemeal EMR in our National Cancer Center Hospital. And we did the piecemeal EMR on over 10 piece, and histology showed high-grade dysplasia benign region. One and a half year, you can see the clear post-EMR scarred. That's okay. However, about 30 months later, you can see the SMT-like elevation with the reddened nodule on the top. This is invasive recurrence. This patient required salvage surgery. The histology showed a T3 invasion. Well, that's very terrible, but this disease is thought to be the rural disease in Japan, and most of the local recurrence can be treated, and that's true. But 10 years later, the same things could happen in the United States. My friend, Dr. Amit Gupta, investigated the data. The local recurrence with malignancy could occur in the United States. The local recurrence with malignancy is 2.4%. It's not so common, but the most serious and worst scenario for patient, as well as us. That's why we need to perform ESD. Here, outline of my presentation. First of all, I'd like to show you the procedure setup and basic procedure technique and traction technique. An anatomy of the colorectal in performing ESD, a colon is a thin, curved, and long bill. So, the bleeding is less occur compared with the stomach. On the other hand, owing to the thin wall of the colorectal, the risk of perforation is much higher than that of stomach. As Motohiko says, gastric ESD is a battle against bleeding. On the other hand, the colorectal ESD and esophageal ESD is a battle against perforation. Also, owing to the curved and long anatomical characteristics, it is very challenging to get a stable scope position during the procedure. And preoperative care before ESD, the most important point is adequate boil preparation. We highly recommend an excellent boil preparation. And also, we accept the good boil preparation if you can suck the all of the residue before the procedure. And we do not recommend poor and inadequate boil preparation because it is very much difficult to get the bleeding clean and operation due, and it is also very risky in case of perforation. And Japanese guideline recommend using the spasmolytic agent, I mean scopolamine. It is not so commonly used in the United States, but it is very helpful to stop peristalsis to get the stable scope position during colorectal ESD. And there is no specific care for sedation and antisobotic agent management, so you just follow the guideline. But it's better to share the information that you may change the patient position during the procedure while being intubated. Please ask your anesthesiologist to use scopolamine use and changing patient position during the procedure. And the scope selection. It's better to use the high-definition serine periatric colonoscope. Maybe many of you use a standard colonoscope for advanced endoscopy, but for colorectal ESD, it's really a rigid and bulky tip of the endoscope, so I think the periatric serine colonoscope is better. And hopefully, as a middle-length, short-length colonoscope is better to manipulate the scope. And also, the lesion located in the lectum and sigmoid colon, the therapeutic gastroscope 180J or T is a good option because the bending portion is very small and the scope shaft is small. And I would like to share with you how we insert the scope. It is a very basic technique, but a very important technique. So during the colorectal ESD, your scope manipulation and control should be directly transmitted to the tip of endoscope, so you need to insert the scope straight. Here you can see the axis-keeping shortening technique. This is originally developed and reported from Japanese experts. So if you pass the sigmoid colon, please torque right and pull back the endoscope slowly. By doing so, you can shorten and stretch the sigmoid colon. So please keep your colon straight. And I'd like to show you the device for colorectal ESD. As our previous presenter explained well, I briefly explain the devices. First, a needle-type device, a dual knife, a flash knife, and all right pro knife are commercially available. So all of the needle-type device has the water jet function. It is very helpful to continue the procedure while injecting the subliminal injection solution. And among the IT knife family, I would recommend using IT knife nano. An IT knife nano has a smaller insulated tip and a shorter blade. It is very helpful and suitable to enter the narrow working space in the colon and the esophagus. Of course, then the CO2 insufflation is must-have, and it is very helpful because CO2 is easily absorbed during the procedure, and it is very helpful to relieve the patient pain. Also, in case of emphysema during the perforation, an endoscopic cap is must-have. Particularly, the tapered endoscopic cap, a short-type ESD hood developed by Professor Yamamoto and Professor Saito is very helpful to enter the subliminal causes space, particularly in the colon with the fibrotic lesion. There are several kinds of the high-viscosity injection solution, sodium hyaluronate, and all right gel, and AW, and so on. You can select as you prefer. So recently, the needle-type device with water jet function is commonly used, so you can cover this water jet function. And I'd like to talk about the optimal patient position. So during the correct ESD, you need to always utilize the gravity-assisted traction. So it's better to position the lesion and opposite to the gravity-dependent side. If you are unsure of the gravity-dependent side, please flush water and make sure of the area of water pool. Area of water pool is the gravity side, so that you can place the lesion opposite to the area of water pool. And during the procedure, you can change the position of the lesion. You can change the position according to the situation. Let's move on to the basic technique of correct ESD. The first step is a mucosal flap creation using the needle-type device. Please gently apply the tip of the needle to the mucosa and create the mucosal incision like this. After that, please create the mucosal flap. It is very important to dissect the top of submucosa, i.e., bottom of mucosa. At this moment, you don't have to go deeper. Please focus on creating the flap. Like this, I dissect the superficial layer at the top of submucosa. By doing so, you can create a mucosal flap. At this moment, you can, of course, extend the mucosal incision as well. And the second technique is submucosal dissection using the needle-type device. The basic technique of submucosal dissection using needle-type device is dissecting forward from inside to outside. Before the procedure, please make sure of the muscle direction. In this case, the muscle direction is now the 8 to 2 o'clock position. And gently apply the tip of the needle knife and hook the submucosal tissue. And while lifting up the tissue, you can go slowly and carefully. By doing so, you can perform the safe and reliable submucosal dissection. And you can understand how deep you cut and where to cut next. I'd like to show you the mucosal incision using the IT knife nano. You can apply the long blade of the IT knife to the edge of the mucosal incision and extend the mucosal incision by pulling the device or pulling the scope. This technique can be done by retroflex position as well. And the ceramic tip can prevent the perforation, as you can see. So, our IT knife nano allows for the fast mucosal incision. Our next procedure is a submucosal dissection using the IT knife nano. So, you can manipulate the endoscope powerfully by pulling the device or pulling the scope. And parallel to the muscle layer, we hook the blade of the IT knife to the edge of the submucosal and pull back the device parallel to the muscle layer. And the big advantage of the IT knife nano, this device allows for fast submucosal dissection. And in case of bleeding, as the previous presenter said, please carefully find the bleeding source using the tip of the endcap. And here is the bleeding source. And gently apply the tip of the knife. Oh, sorry, stopped. But you can easily stop the bleeding using the tip of this device. And if you experience the muscle bleeding from a thick breast cell, it is impossible to do the hemostasis by the knife itself. So, you change to the hemostatic forceps and catch the bleeding source and apply the minimum electrocoagulation current like this. Once again, if you accurately grasp the bleeding source, now the bleeding is stopped. And then coagulate the breast cell. This is a very important procedure. And so far, I was invited to the several national and international hands-on course. During the course, I learned a lot from the training and procedure. So today, I'd like to share with you what I learned from the hands-on training as a trainer. So, probably sooner or later in this afternoon, most of the trainees are struggling with their ESD training. So, if you see this situation, I often ask the trainee to look at the stomach outside. Let's see what's happening. Now, oh, man. So, the stomach is fully inflated. Can you continue the procedure in the fully inflated balloon? No way. It's impossible. So, fully inflated stomach is a very bad situation. The trainee often says, oh, sorry, my pig. I will treat myself. So, most of the trainees are pressing down the stomach to deflate the air. That should be done by endoscope. So, this is a benefit of suction. The suction allows for the stable scope position, as you can see. And also, the suction makes the sub-mucosa thicker. And also, our suction facilitates entering the SCM dissection plane. So, I'd like to say the optimal air insufflation level is much, much, much less compared with a standard coronoscope. So, please focus on the suction during the procedure. And I'd like to say how to manipulate the endoscope. Not only the basic, but also the therapeutic procedures, we need to manipulate the endoscope, small wheel, larger wheel, and shaft push and torque. So, I experienced two inferior and superior training. First of all, I'd like to show you my inferior training. He said to me, oh, Dr. Abe, I have lots of experience of ELCP and other therapeutic endoscopy. Oh, I'm really so excited to demonstrate the ESD. Okay, please look. So, I'd like to show you the video. So, he manipulates the larger wheel and small wheel using both right and left hand. He rarely holds the endoscope. He never push and pull the scope and never torque the scope. This is not so good for ESD procedure. Honestly speaking, it took 15 minutes only for marking. The next superior training, oh, Dr. Abe, I have no experience of ESD. Please teach me. Okay. Unexpectedly, his scope manipulation is excellent. So, he manipulates both small wheel, large wheel using only his left hand, and he pull and push the scope shaft by his right hand. So, let's see his procedure. Of course, this is his first experience of ESD, but he completed ESD himself without any assistance. So, I believe the scope manipulation is very important step to do successful ESD. So, I would say the scope manipulation of the larger wheel and small wheel should be done only your left hand. Please don't use your right hand. Your right hand should be focusing on the shaft. This is very important point. Okay. Let me briefly explain the traction device. So far, several traction devices are commercially available. In Europe, a band-assisted ESD is commonly performed. And in Japan, an SO-clip is an endo-clip with ring-loaded spring. This is commercially available. And also, it is maybe the launch in the United States and other countries as a counter-traction clip. And multiple traction is available. And also, my friend, Dr. Amit Bhat, develops the traction wire. He will explain in detail later. And I'd like to show you one case of the ZL2A plus 2C. Laterally spreading team of 15mm in size. Not so large region, but you can see the five losses in the center of the region. The region is hepatic fracture, a little bit challenging location. And magnified endoscopy reveals a non-invasive pit pattern. So during the procedure, as expected, we see the severe five losses and the region sifted approximately. And it is very challenging to obtain the satisfactory traction during the procedure. So I decided to use SO-clip. The first endo-clip is deployed to the backside of the specimen and catch the ring and bring it distally using another endo-clip. And then anchor it to the opposite side of the lumen. By doing so, let's see now. So we can see the fibrotic area with satisfactory traction. We can continue with the procedure. The meticulous re-dissects the fibrotic tissue, fiber by fiber. Finally, the endo-clip section was done. And also finally note that the reason I'd like to briefly talk about the pocket creation method. Pocket creation method is developed by Professor Yamamoto. We are privileged to have the mastery of the PCM method here. As you can see, the first step is the creation of the mucosal entry. And if we can get into the sub-mucosal space, you can extend the pocket both laterally and proximally. And the pocket creation method allows for prevention of the injection leakage like this. And also we can get a stable scope position throughout the procedure, keeping the good traction. And the pocket creation method allows for tangential scope access, regardless of region location, even in the very challenging location, such as the hepatic fracture of the splenic fracture. This is a take-home message for successful corrective ESD. First, I would recommend that the optimal scope selection and device selection is a very important step. And in terms of the technical point of view, meticulous device control and satisfactory traction is very important. Once again, the corrective ESD is a battle against perforation. Please focus on the safe procedure. And finally, the practice makes your ESD perfect. This time, you are privileged to have four days or two days, a very wonderful intensive corrective ESD course. Please enjoy the course. Thank you so much for your kind attention. Thank you, Dr. Abe, for your great presentation. Are there any questions from the audience? I completely agree with your opinion. I think straight endoscope position is the key factor to have successful result. I had a chance to stay in the United States for two months before coming here and visited many institutions and observed their procedure. And I found that mostly they use wrong size endoscope and just pushing into the cecum under the strong sedation or intubated sedation. They don't care about the curved wrong size endoscope. But as a result of manipulating such a curved endoscope, they couldn't control the device properly. That's the major problem here in the United States. So please keep straight endoscope position as far as possible. Any questions from the audience? Yes, please. Okay, thank you for a nice lecture. As you both told, the endoscopic tip control is very important for successful corrective ESD. And the short scope, short and slim scope, is much better for ESD procedures. And nowadays, water exchange method is widespread. And I think the 130 centimeter scope is good enough in most of the cases. And I want to ask you as doctors, is there still a challenging situation or difficulty using a short scope for colonoscopy? Why do you use such a long scope? It's not necessary. I do think so. Nobuyo, what do you think? Well, the body habitus in the United States is really different from Japan. Everybody has, well not everybody, most of here doesn't have the big belly. But the people have really distended belly that gives too much of freedom. The transverse colon seem to be longer in United States than Japan. So once you go into this torturous transverse, it gets really difficult to get to the cecum with a short intermediate scope. We have one intermediate scope, but sometimes I fail to go to cecum with that. So that's probably the reason why we use a long scope. It's just a body habitus difference. I mean, also many people are really tall. So the colon length seem to be longer. But for ESD, a shorter scope is better and for some selected patients, it's good enough. And is that 130 centimeter scope available in the US? Yeah, it is available. If you wish to purchase, you can request intermediate length. But I believe that most of the institution doesn't have intermediate scope, mostly long size endoscope. Correct. So maybe with like Sergei uses additional overtube device. With that, we may be able to use a shorter scope and potentially additional different overtube can make it possible. But that's something we have to see. There's one question from virtual audience. If there's a perforation during colorectal ESD while doing ESD for SM1 cancer or any cancer, is there a risk for seeding into the peritoneum? Okay. Thank you so much. According to Japanese data, there are little risk of the peritoneal seeding after the perforation closure for gastric ESD. And also the long-term outcomes of ESD has been published in gastro this year. If I remember correctly, there is no perforation-oriented death in the United States. So we can close the perforation site. After that, they're going to be okay. Thank you. Is there any other question? Yes. Yes, please. Thank you, Professor. In what situation do you choose to do a pocket method of ESD versus a circumferential incision? For circumferential incision? No. Circumferential lesion? Okay. Incision, sorry. Okay. That really depends on the preference of endoscopies. So probably Professor Yamamoto routinely use a pocket creation method for all organ. And on the other hand, we prefer using the IT knife. It is not very challenging to complete the procedure using the IT knife to complete the PCM. So that really depends on the preference. But I'd like you to experience both of the methods and choose which one is best for you. Do you have any comment, Dr. Yamamoto? I think pocket creation method is very useful, especially for relatively large region, because we can have very stable condition within the submucosal area. Is that correct? Yes. In addition to that, lesion with fibrosis such as recurrent lesions, pocket creation method is very useful. If you make a circumferential mucosal incision, the mucosal elevation becomes very, very difficult. But using a pocket creation method, after going into the submucosal space, you can keep the good endoscopic operation period by applying the traction and counter-traction with the hood, transparent hood. So for submucosal fibrostic lesions, it's very useful. Yeah. Thank you very much. Any other? Okay. Thank you very much.

colorectal ESD

endoscopic submucosal dissection

procedure setup

preoperative care

scope selection

patient positioning