Hello. Hello, everybody. I'm Hironori Yamamoto from Jitsi Medical University in Japan, and today I want to show you how to perform ESD. And my technique is pocket creation method. And before starting the procedure, I want to explain a little bit about how to control the endoscope for ESD procedure. I control everything, the wheel, both the big wheel and small wheel, upright and right and left with the left hand. I don't use the right hand for the small wheel. And can we show the endoscope tip as well? Okay. And for rotation of the endoscope, I rotate like this, and making the loop outside of the body of the patient, and I can rotate to like this. And in this way, I can rotate on 360 degrees for the both side, like this. So it's easily rotated using the loop outside of the body. And then just a little bit of adjustment can be done by just rotation with the left hand. Okay. And I use a special cap, that's an ST hood. The tip of the hood is narrowed down to 7 millimeter in diameter. And when we use this one, we have to apply a lens cleaner to the hood, Q-tip and lens cleaner. By the way, my assistant is Dr. Mura from the same institution at Ditch Medical University. Apply the lens cleaner and ready to go. And turn on the light and insert the endoscope. And I have already made markings for the other region. And this is the water jet. This is the region marking. So when you perform ESD, you have to consider the direction of the gravity. Water is this side, so this is the downside of the gravity. And rotate the endoscope, and this is the upside of the gravity. So now, the region is on the upside of the gravity. Okay. So what I will do is inject and elevate and make a mucosal incision, and create a submucosal pocket. Step by step, I will explain. This is an injection needle. Okay. But before starting the procedure, I want you to teach how to practice the movement of the endoscope for ESD. For example, I can follow the line precisely like this. This kind of smooth movement is necessary for ESD. You can practice this kind of movement anytime like this. Just gently touching the surface of the mucosa and make a curve or line. This kind of movement is necessary, so you can practice that. Anyway, needle out, please, and flash a little bit. And I will inject, and for the injection, stick the needle and inject, and pull back the needle and elevate the mucosa. And after the first injection, then I stick the needle at the base of the protrusion like this, outside of the muc, outside of the muc, and inject. And for each injection, I inject 1.5 to 2 milliliters each, and base of the protrusion, and inject. Okay. And here. Yeah, sometimes there are two ways of the practice. This is now my assistant is controlling the device, and then I can concentrate on the endoscopic control with both right hand and left hand. And if the endoscopic control is stable, I control both the device and the wheel. Okay, this is good enough. Then let's start cutting. The cutting, the direction of the cutting is to the direction which you can see is better. That means in this way, in this way, if I start from here and going to this way, then I can see the direction I am cutting. But if I start from here and cut to this direction, then the knife covers the direction you will cut. So I prefer cutting from this side. Left to right means the forehand in this situation. Forehand, yes. Okay, and this is the end cut eye, and the tip of the knife, now I am using a flash knife, and the tip of the knife should be inside of the submucosa before moving. Then a little bit of direction, I make, then start cutting. At the beginning, you can cut a little bit, little by little, adjusting the direction, but then you can cut like this if you become good enough. Like this, and about two centimeters of the mucosal incision I made, then I start direct dissection. And for the dissection, at the beginning, I just use the tip of the knife, not the food yet. So right below the mucosa, I cut, dissect, using the, this is a swift quag, swift quag effect 4. And again, from the edge, and using the tip of the sheath, you can make a little bit longer, and using the tip of the sheath, you can elevate it. Like this, maybe one more, with the sheath. It's okay to touch the muscle layer as long as you don't press the pedal, but when you press the pedal, you have to make sure you are away from the muscle layer. And this is good enough. Now I can go into the submucosal space with the tip of the food, suck the air as much as possible, and use the water jet, and then go in, like this. And then I slowly dissect, coming closer to the muscle layer. Okay, and now I press down to the muscle side, and I can see through the muscle, and after I see through the muscle, I adjust the direction. In this way, we can come, I can come closer to the muscle layer. And for the dissection, I rotate it 90 degrees, and then now I can use just the up angle for the dissection. Like this. And after I can see through the muscle layer, I inject, I make additional injection. So you are using, usually injecting the hyaluronate? Yeah, usually I inject sodium hyaluronate solution, viscous substance, that stays much longer time than saline. Also do you put the color when you use that? Yes, I use a little bit of indiocharmine. Okay, inject. By injecting the fluid right above the muscle layer, I can make a very good, clear submucosal layer right above the muscle layer. But in this situation, I should not inject into the muscle. So what I will do is, in this situation it's not very clear, but to see the muscle layer and then change the direction parallel to the muscle layer, and then inject. Okay, good. Then sometimes come out and see the direction of the lesion, and make sure the direction of the pocket is the same as the direction of the lesion. like this. Over-insufflation should be avoided. Suck the air. And this is the muscle layer. So right above the muscle layer. I dissect. And when you apply the current, just for a short duration, like tapping. In this way you can avoid unintentional cutting to the muscle layer. And also the excessive burn effect to the... Yeah, excessive burn effect is avoided by just making the duration of the current for a short time. Now I can see the muscle layer and then adjust to parallel to the muscle layer and leaving a little bit of submucosal tissue on the muscle. When you are not comfortable with your dissecting to the right direction, just swing the tip of the endoscope, tip of the hood. Then you can see through the muscle and you can have a good imagination which way the muscle is going. Okay? Then this is to the muscle direction, so change the direction and keep dissecting. That's why if you put too much color, you don't see through the target. Yes. So shallow color is better. Yes, right. So I can see through the muscle. So coming close to the muscle and see through the muscle and then adjust the direction, that is much safer than without recognizing the muscle layer. So I try to leave about one third of the submucosa to the muscle side and two thirds on the specimen side. Okay? By swinging the tip, I can see. I can see through the muscle. Okay? Like this. And I guess a little bit this side I dissected to the right side and the left side is not good enough, so I will dissect a little bit left side more. So do you completely dissect underneath the region? Yes, almost. Almost. Then you will open up a pocket. Yes, right. I try to match the pocket, the width and the depth of the pocket to the size of the region as much as possible. Okay? From here. Okay, again. And now I will check the depth of the pocket. Depth of the pocket. When I check the depth of the pocket, this is the... I place the finger, I place my finger to the mouthpiece and pull back and the same depth I will insert. And this is good enough. This is a mark, so this is good enough. And also you can see the rid of cushion. The injection have already done from the pocket side. Oh, yes, yes. Keep the injection to the inner side. Already at the inner side, yes. Additional injection create the... Yes, right. Because the lifting, that's why injections reach to the inner side of the... I also check the width. This is the left side edge and the pocket is also about the same. And the right side edge here, good enough. Maybe a little bit too wide. Okay, and then I start opening the pocket and injection, additional injection to... Because I left the surrounding mucosa intact, I can make a good protrusion. Okay, needle out and I inject. Okay, inject please. Inject. Good protrusion. Stop. And... Okay, inject. Stop. Inject. Inject please. I guess it will be better to clean the lens and the cap. Okay, right. Yes, let's clean the cap. So, we are often re-cleaning the lens to see the target more clearly. Yes. This is a very important step. Yes, thank you. The opening of the cap is narrowed, so the outside of the pocket, the view is interfered with the cap. So maybe you see the dramatic change of the image. The outside of the pocket, you can't see very well, but inside the pocket, you see everything is clear. Because touching to the submucosal tissue with the cap, so the endoscopic view is maintained. Okay, then I will continue the mucosal incision for opening the pocket. Okay, so this time I consider the direction of the gravity, and the left side is a bit down side, so I open from the down side of the gravity, and place the knife here, and cut like this, and I check the marking, and a little bit outside of the mark, I cut. I don't need to apply a lot of tension. Flash knife can cut very nicely without tension, just a little bit of direction I make, and because I cut, it's by the electric cut, maybe it's a bit shallow, and the trimming is necessary. So, I cut the same line again. Because pig mukosa is much thicker than human. Yes, it's cut, but yes, a bit longer, yes, a little bit, yes. And if this approach is not that easy, but then you can make a retroflex view, like this, and place the knife, and I check the mark over there, the mark is over there, okay, like this. And then, I start opening. For opening of the region, this is a mukosa incision I made, and for opening the region, I place the knife inside of the pocket, and cut through to the incision, mukosa incision, to the direction of the luminal side, from inside of the pocket, like this, from inside of the pocket, from inside of the pocket. So, in the past, you remained a small part of the sub-mukosa. Yes, I'm leaving a little bit here, a small part of the sub-mukosa, to keep the natural traction. Then, you can see through the mukosa incision here. Let's see, here, here is the, maybe I need, I didn't cut a bit far, only a little bit, okay, then I will cut all the mukosa, yeah, circumferential mukosa incision should be completed, okay, and now, now, left-hand side, small sub-mukosa, and right-hand side, the sub-mukosa is remaining, yeah, so, actually, this was not ideal, the deepest part should be cut first, anyway, trimming was not complete, it's okay, but it's okay, but a little bit tricky, yeah, so, as long as you can control the endoscope precisely, slowly, but precisely, no problem, but at the end of the procedure, it becomes a little bit unstable, so you have to be very precise, that's it, okay, this is the pocket creation method, okay, and then, where is the, the water slide, maybe, here, here is it, so, as I have explained, a little bit of sub-mukosa is remained on the muscle layer, about one-third, and two-thirds of the sub-mukosa is on the specimen's side, that ideal level of the sub-mukosa dissection, so the sub-mukosa dissection plane should be selected properly, yeah, like this, okay, yeah, that's it, thank you, congratulations, thank you, can we continue, or we need a break, no, it's okay, so, I'd like to show you the other procedure, Takashi Kuroda from Kobe University Hospital, and Dr. Sakaguchi is kindly assisting me, so, you have seen the procedure with the ST-FU, so, from now on, I'd like to show you Now I have already placed the mark just a little bit until the side of the lesser curvature. So in this moment, in the left flip position, if you turn the scope to the left, image turning to the left, and turn to the right, image turning to the right, like a bicycle. But in the lower part of the elastic body, or the upper side, there you see, and your wall, if you rotate the endoscope to the left, image turns to the right, because down angle is needed. So if you turn to the right, image turns to the left. Very, very uncomfortable. Very difficult to control. That's why I, as much as possible, want to perform gastro-EPSD in the lateral flip position. Okay, then we are injecting just saline in the stomach, because we can inject the additional injection anytime you want, when you use a flash knife, or the wireless function end knife. Okay, so IPS is the same with Yamamoto's procedure, but the big mucosa is very, very thick. That's why a bit much force is needed to sting the mucosa. So, also, okay, you need to consider about the direction of the gravity. So water is falling down from here. It means gravity is coming from the right hand to the left hand side. Then, by rotating the scope and by pulling back the scope shaft, you can trace the outside of the mark, as you can see. So today I'd like to show you the conventional flap creation method. Also, I'm using the zoom scope. I don't want to perform the magnifying diagnosis during the dissection, but it is better to adjust the focus just a little bit. Only a bit magnification works very well to adjust the focus. Yeah, very focused. Then, this Fuji zoom scope is fantastic, because continuous zoom function is available. Also, by tapping the button, step-by-step, multi-step zoom up is available. So it is very efficient to control the focus depth. That's why I'm using this one. So, the tips are totally the same with Professor Momota's procedure, but I'm using the longer interval, because I want to control every single stroke by myself. First, of course, you should plan how to incise. I want to create a J-shape or a C-shape mucosal incision to create a mucosal flap, because gravity is coming from the right hand to the left hand. By remaining on the right hand side of the mucosa, I want to hang up the region. Then, it is better to come closer. Now, the cap is controlling the distance from the mucosa, and also, as if the pig is living, the palisades on the respiratory movement can be controlled as much as possible. But next, it is better to create a starting point. This time, I'm stopping. Then, a bit push, then conduct cut mode. Usually, in the human, only one or two times conduction is plenty enough. Then, inciting the knife, I'm injecting. It means the mucosal incision will be shallow. Now, it has lifted, that's why the incision depth was enough. Next, I'm controlling the knife to the left by rotating the scope. Also, I'm creating a starting point by inserting the tip of the knife into the mucosa. Then, I'm controlling the direction. Then, cut it a bit. Then, the knife can proceed by itself. Also, a very much important point is how to prevent the bleeding, because in the stomach or the lower rectum, there are so many thick breast cells, branched breast cells. It will be running just underneath the mucosal mucosa. That's why I'm inserting the knife tip and creating a starting point, step one. Then, controlling the direction, step two. Also, just a little bit pull back the knife, scooping the mucosa. Then, rotating the scope, I'm creating the shallower mucosal incision just underneath the musculoskeletal mucosa. Then, by holding the mucosa with the backside of the wall, such a tricky situation can be coped. Also, additional injection can be done by the knife itself. Then, it is better to store the knife, close the knife, and push the sheath a bit harder. Then, tap, tap. Then, nicely, injection can be done. I want to see much more clearly. So, in that moment, in this moment, already explant. That's why any breast can be seen. But if you see breast cells, it's better to treat beforehand. But beforehand, before that, I'm creating a much wider because incision. And you see a very nice injection can be done by knife itself. So such image doesn't work so well, but if you adjust the focus, everything can be seen. So we can simulate this will be the branch vessel. This will be the vessel, maybe. Then lift it, okay, I create a much more because incision to the left side. Then control it. Like this. I'm sliding the cap. Then you can control the incision level. And by just a bit scooping up the mucosa, you can control the incision depth as you want. Okay, now C-shaped mucosa, incision have done. And to get in some mucosa, it's better to incise a bit more to the right-hand side. Again, set the knife, step one. Control the knife, step two. Then conduct step three. Then two and three, two and three, two and three. Okay, so now by using the gravity, region will be falling down to the left. Also, by disconnecting the mucosa, disconnecting the mucosa, that the incision line has well opened. So now it is better to re-inject, additional injection. Then it was not efficient, so please seek some small pocket when you need to close it. Then push to the pocket a bit harder. Then inject it, okay, lift it. So now I'm disconnecting some mucosa. Do you use saline for the injection to the knife? Yes, yes, because anytime you want, I can add the injection. And also by injecting saline, you can clean up the image. And also, when you start the dissection, it's very important to control the insufflation volume. Now it is a bit too much insufflated. That's why mass layer is coming perpendicular. Then if you, oh, sorry, suck air, see, target's coming up. Then more tangential approach can be done. Then by scooping the sub-mucosal tissue, I'm disconnecting the mucosal edge from the healthy mucosa. If there are no vessels, you can also conduct the cut mode. But if you see the vessel, it is better to conduct the coagulation mode. Then here, there is small vessel or no vessel, that's why directly you can dissect it. But maybe this will be the vessel. This one is vessel. So vessel is mostly tough. Here, you see also vessel, doesn't open so well. That's why if you cut it, you can release the tension, but breathing will happen when the pig is alive. So pre-coagulation technique is very important. Change to the 0.4, very low output, eight watt, and 600 volt. By decreasing the watt set, the heating up speed coming very slow, and no spark is coming. This is almost totally same with this soft coagulation mode, but the voltage is higher. That's why you can coagulate much more deeply. Okay, then pause, please. Pause, please. By scooping up, I'm dissecting the vessel. So you have seen the movement of the specimen. By losing the tension of the vessel, the incisional edge have well opened. Now small vessel or some of the fiber is there. So now just also I'm adjusting the focus, then insert the knife behind the target, and just a little bit scooping up. Then by rotating the small wheel, you can a bit rotate the image, and then you can see the direction much more clearly. Then also step two, step two, three, two, three, two, three, mark. By dividing every single stroke into three, three step, one, two, three, you can control every single stroke very, very precisely. Also by scooping up. This will be similar with the pocket opening. We'll scoop up, then conduct coagulation mode because there are so many vessel. Then from muscle to the lumen, it's totally safe. So additional injection works very well. All right, gravity coming from here. Left to right, ah, here is what? Maybe by dissecting somehow situation is changing. That's why flexibly you need to change your strategy. Now U-shape incision will be better from now on. So set the knife and pull back the scope. Then duration of four, three. So, yeah, three, ah, duration, three. So just a little bit I show the differences. Duration two, please. Cut duration is shortened, you will cut smaller. Three, please. Three. Now more faster and more longer cut is coming. So cutting effect can be controlled very, very easily. Just enlarge the duration or decrease the duration, that's all. Now I also want to remain the small tension of the remaining recorder. Almost done, but just a little. I remain. So now I have already explained my greatest tips. That's why I'm just completing the dissection. Ah, no, no, I failed to comment about the dissection depth. Usually in the human, there are branch vessel in the middle of the sacrum causa. That's why dissecting underneath the branch vessel, I don't see any branch vessel now. You can keep the appropriate dissection level because if you dissect shallow, bleeding comes. Of course, above muscle layer is needed, but by controlling the incision dissection level between muscle layer and branch vessel network, it will be the one third, just about one third from the muscle layer. Same level. Yes, same. But more precise, of course, above muscle, but underneath branch vessel. Yes. Between branch vessel. Please simulate this will be a branch vessel. Then set the knife under the branch vessel and between branch vessel and muscle, we are dissecting. So selection of the level of the dissection plane is very important for good quality ESD and control of the bleeding. All right. If you can control the bleeding completely, procedure become much efficient and faster. But when you break through the branch vessel network here, incision edge, there are so many branch vessel there. That's why capture the vessel, and if the vessel is bigger, please pre-coagulate the vessel beforehand. But small one can be treated with a post-coagulation mode. So please aim apex when you disconnect the incision edge. Then by using the cap, by using cap, I'm dividing the edge as you see. So please use cap as much as possible and insert the knife underneath the vessel and scoop up to the apex. Then please dissect branch vessel network without. Do you prefer post-coagulation rather than swift coagulation? Yeah, because I want to control the bleeding. Bleeding better. As if you create the bleeding, soon, immediately by emitting such spark, you can stop it. Swift coagulation has a few lower coagulation ability. Yes, post-coagulation has a higher voltage. More coagulation power. Then if you use bio-3, the voltage of the post-coagulation is totally controlled. Totally controlled, yeah. That's why the feeling of the dissection efficiency will be almost same with the swift coagulation for me. That's why high quality of the dissection efficacy and also the higher coagulation ability, that's why I'm using the post-coagulation. But if you conduct longer, too much coagulation or too much thermal damage is coming. That's why to control the conduction duration. You want to have the same voltage level. Yeah. So that's the reason why you don't like precise sect. That's right. And also precise sect has a much higher incisibility. Dry cut to swift coagulation. Yes, the waveform itself changes automatically. It's fantastic, but if I can conduct it to the yellow pedal, I will use it. But I want to always equip the post-coagulation on the blue pedal because I want to stop breathing immediately when it happens. Yes, yes. If I always want to set the post-coagulation on the blue pedal. Yeah, blue pedal is for the control of the breathing. So you want to predict what happens. If you want to cut more faster, so you can use the cut mode when you dissect it. So if you feel uncomfortable for the dissection, but if you just use cut mode, anyone can. End cut. Yeah, end cut. Is that the same as the mucosal incision? Yeah, during the dissection, more show distance will be better to avoid excessive dissection or perforation. That's why I'm setting the cut duration one or two. Oh, yes. When I use the dissection. Yes, I agree. When I use the end cut for the dissection, I choose duration one. Yeah, I know. That is long enough for the dissection of the submucosa. Yes, I totally agree with you. Then before completing, before making final approach, it is better to completely disconnect to the oral side by dissecting any single branch of the cell. It is better to come from the lumen side because you can see through everything. From the submucosa side, target is hidden by the remaining submucosa. That's why. So you want to see the blood vessel. The blood vessel, yes. To complete the trimming, I'm coming back to the lumen side. Then I have already disconnected. Then you will make the final approach now. In that way, you can avoid bleeding. Also, you can see the final dissection point here. Oh, I see. The landing point can be seen, but if this one is connected, you don't see the landing point. So this connection is very, very important before making final approach. Now, only such a longitudinal submucosa remaining, then by twisting the endoscope right to left to right, right to left to right, and right to left. So please try both direction, forehand and backhand. Every endoscopist have the preference. So only forward or only back. So forward and back. Both should be trained. It will be very, very efficient if you achieve both hands, forehand and backhand. Backhand is mostly efficient to scoop up the target because the backside of the ball can capture the target very well. Then you can complete it. Now, I have utilized the gravity as much as possible. Okay. Very good. Thank you very much. Okay, any question or comment? Very nice. Okay, so pocket and pocket technique and conventional way, both it is, I guess, better to achieve. Yes. Especially final step in the pocket correction method, totally same with conventional way. And to get into some koza, also a conventional method. But if you have some difficulty to get into some koza to create a pocket, traction, early traction works very well. So we have three options. So according to the region or the situation, we can choose it. Okay, thank you very much. Good. Thank you.

Endoscopic submucosal dissection

Pocket creation method

Controlling the endoscope

Rotating and adjusting the endoscope

ST hood

Saline injection

Mucosal incision

Submucosal pocket

Branch vessel identification