Next session, I would like to demonstrate the hybrid knife and the track motion. Track motion is a new traction method that requires a double channel. And it goes to the larger channel, 3.7 cm on the right. On the screen, you can see... It disappeared, but the working channel is 3.2 on the left side and 3.7 on the right side. 3.7 on the right. So, this device goes to the right side. Oh, that's actually the tape, I can see. Interesting. So, this is the bendable forceps. You can do open-close, open-close. If you keep closing... Could you show them the hand? This is a neutral. That means it's still open, but you can still keep closing. And endoscope image as well. And it bends. Thank you. And then, what you can do is just talk left, right, with this outside. And it's an automatic brake, so you don't have to keep holding. If you want to have this tension, just let it go and just keep working on your dissection. You can see it opens, straightened up, opens. And you can target this area. There's a tape. I'm going to grab. It's not purposeful, but it was left over here. And you can pull to the right, push out. This is the maximum. You can even pull back and talk more, talk left. So, there's a very huge amount of freedom. Push-pull, rotate right and left, bend less. Can I open? Bend more, bend less. It's a really nice interaction device. And I guess this is very good with scissors forceps. That's right. So, the only problem, not the problem, the issue is that if you have this traction, your scope doesn't move freely. You're kind of fixed on the wall. So, it usually works better with the scissors or IT style. You don't have to move the scope itself. So, that's track motion. The other one I'm going to demonstrate is a hybrid knife. Hybrid knife has the electrode in the center that extends all the way to the five millimeter. That's the huge difference, this way, between the other knife. Because the other knife has a very fixed length so that you know how much you're incising into the tissue. This one, the length is variable. Variable means you have a flexibility, but it can sometimes move up and down. So, that sometimes causes yourself danger. Especially in the retroflex position, sometimes knife length suddenly changes. Therefore, please be careful in case of using this device in a retroflex position. Exactly. In the retroflex, it sometimes pushes the needle out, so it gets longer. When you're passing into the channel, the knife has to be closed all the way. And then, pass it all the way. There is a cap at the edge, but I can't see it. So, open the knife all the way. There are people who want to see the tip and just keep dissecting this way. To me, I'm so used to the dual knife or other knife that has the insulated part of it. So, pull back. I typically just a little bit out. This is about two to two and a half millimeters. That's the utmost I'm going to use. Probably, I'm using about two millimeters out. Once I fix, then I'm going to extend. The other feature is here, the water jet. Water jet is a micron-level high-pressure stream. It can penetrate the mucosa and just swallow into submucosal layer. It does not penetrate the muscle. So, that means that it bounces back to the muscle layer that causes effective submucosal injection. So, it's called sometimes a needleless injection. I marked this area for demonstration of truck motion. That's the bottom of the gravity. It can be a little challenging, but we'll see. All we do is just make a little bit indentation and try injection. If you see it coming back, what you do is just a brief end cut. End cut. End cut. Usually, we can inject even through the healthy mucosa because it has really high pressure. We call this STEP. STEP means Selective Tissue Injection by Pressure. So, it's usually very effective. So, in the esophagus colon, it works just inject fine. The stomach, especially the pig, you need a little bit of break. So, apply the end cut just briefly and then inject so that the mucosa is effectively broken. But you don't want to push too hard because you can penetrate through too deep. Once you inject, the STEP is a little different. We're going to do cut, cut, cut, inject, cut, cut, inject. You hear the beep. Beep actually signifies 1cc. I usually cut to inject 1, sort of the rhythm. I wish I have a little bit longer cap, but let's go with it. So, we're going to go a little left. Oh, that's so slow. And because of the relatively thick electrode, this hybrid knife requires a little bit higher setting comparing with dual knife J or flash knife. Thank you. And then once I cut to inject, you can see the injection lifting a little more away from you and it keeps cutting to the left. Inject again. And you see a little more coagulation effect because the electrode is a little bigger than... Oh, it's not connected. There you go. Thicker than other knife. So, I'm going to go to the right. I'm going to use a little more bend. It's not so sure. Inject one more time. And cut, inject, cut. It looks very smooth and seems very safe. And what kind of solution do you usually use for hybrid knife? So, hybrid knife is approved with the use of saline. Okay. So, saline with indigo carmine or methylene blue. And a similar way we can do the trimming. There's a little fiber, so I just cut it. But you can always also use... Oh, it's a precise set. Precise set needs a little more directional order. So, you have to go a little more to the direction you want to cut. And again, I usually use a little longer cap to just hold it down. With the double channel, it was actually fitted with a different type of cap. Norio, there is one question from the audience. Yes. I see that you are not using the distal attachment cap with track motion. Does it put the operator at certain disadvantage because cap is such an important component of ESD? Exactly. The track motion sometimes interferes with the cap. So, this is fitted with a much shorter cap that you cannot see. But actually... But still you have a cap. Yes. We can see the rim of the cap at the 11 o'clock side. So, this is probably 2 mm or 3 mm lens cap. Right. It's not that ideal for regular method of the ESD. So, for track motion, that's a traction method. We can go around a full circle before we move on to the semi-causal dissection. But it's always important to make the Mikozo flap so that you have an area that you can open up with the traction. So, it means that before applying track motion, you should dissect a little bit more to have enough space to grab it. Yes. So, here I injected saline and then I'm not seeing good effect. So, let's try to change to swift quag. Oh. Thank you. Of course. Yep. Sounds great. So, we're using a little bit higher wattage. But that's too much. I think the thickness of the knife is so robust. You saw the huge spark. Let's inject one more time. It's pretty much same as what you saw in other flush knife and dual knife. You want to touch the tissue so that the water doesn't bounce back and it directs into the semi-causal space. And injection itself can open up the semi-causal layer. And it's important for me to just keep looking at the tip of the knife so that I'm not cutting something I don't want to cut. So, trace again, similar way to open up. I wish I have a longer cap. But I think this is big enough flap. Yeah, I think it's good enough. Right? If you try to do dissection too much into the semi-causal space without seeing it, you tend to see more bleeding. Yeah, yeah. I'm going to go to the distal part from you. This tape is kind of in my way, so I'm going to push it away. Here, doing the similar way. Let's clean it up. And first, make an indentation. I know that it's not going to penetrate easy, so I'm going to do a quick end cut, inject. A little bit more. One more end cut and inject. 2cc injected. And usually we can see the marking much better with the cap. I'm going a little bit down, which is not the best move because you're going onto the muscle. Once I see the direction, I move on to the direction I want in the forward movement. Yeah, yeah. Pulling back mana is usually effective, but at the same time it tends to go deep. So we should be careful not to make a perforation during a mucosal incision by pulling back mana. Absolutely. So once you cut a little bit, I didn't go around to inject, so there's not much injection here. You always want to make sure that you inject interchangeably. So inject, one, two. I wish I can see that. It's really powerful. We can easily lift up the target region by a hybrid knife. This is a great merit of this device. That's right. So one, two, cut. You're getting close to the non-injected area. Inject one more time. And one, two. You don't need to rush. And this is saline, so even the over-injection can go away. And if you're not so sure how deep you're going, you always look back. The semicircle is visible, and the needle length is not changed, so that's good. I'm going to do a little trimming here. And then inject again. There is another question from the audience. Visibility seems to be hindered by not having the cap a little more ahead of the scope, especially for submucosal dissection. Absolutely. Yes, it is true. But because of the truck motion, it is a little bit difficult to keep the much longer cap. Yes, so I'm a little struggling in that sense. But you see, the use of the knife is similar to the dual knife or plush knife. The tip of the insulated knife, the portion of the sheath, is visible. That means that I'm using only the length of the knife, which I determined to be 2-2.5 at maximum. And it's a little more slanted angle, so I'm not going to be going onto the muscle. And then keep moving forward. There's a marking on the right. If you're not so sure, inject one more. Lift it up. And the face towards you. Now, Norio is controlling both the up-down and the right-left channel together with his left hand. It's a very important technical tip. Thank you. By the way, many of the physicians in the United States go from inside out. And that makes the endoscope a little more unstable. So we recommend having the umbilicus inside your arm so that you can rest. You don't have to grab that tight. And I've seen all the experts do the same way. I injected and everything is just lifted up nicely. So I'm going to go to the direction I want. Gradually trace the marking, next by next. It's a completely safe situation. Because just before the mucosal incision, he injected lots of solution and took the tissue and lifted it up and cut. It's quite safe and very, very effective. Yep, thank you. If we press down the knife, it goes too deep. And sometimes it causes an injury of the blood vessel within the deep submucosal layer. So to avoid the bleeding situation, we should hook the muscular submucosa with the tip of the knife. Then cut it to the luminal side. That's a safe way. So I'm going to do a little more trimming using swift quag. There's not much difference in the method here. The goal is to make sure that you get the exposure of submucosal layer. With some hemostasis you can achieve so that you can have a clean surgical field. Here I can inject towards the center of the lesion. It's like a mushroom cap. And then a little more trimming. I think everybody is now curious about... Trach motion. Okay, now it's coming. Let's see. This is open-close. You change the direction of the endoscope tip and grab the edge and close. Now this is a holding motion. I can push from here, but that's not going to be effective. So pull back, talk right and left. I want to bend a little bit, so I'm going to push out, bend a little more. And that will give me much more robust talking. Oh, that's great. The problem is the knife direction. I have to probably struggle. Yeah, and also by grabbing the target lesion, control of the endoscope becomes a little bit difficult. So understanding the length... The submucosa gets so much wider. If you go this direction, it's going to be going to the mucosal direction. If you're going to go this way, it's going to be muscle direction. You have to choose where you want to cut. I've realized that once you fixate it, this area gets a little more stable. So I use the endoscope maneuver, rotate gently to the right. And you see that the traction gives a really nice separation. So I use the coagulation current to bust it out. It's much safer and quicker. Now Norio is controlling up angle and the torque has reached to the left side. Then the knife itself goes to the left side. That's right. So if I torque right, actually the traction goes to the right as well. I mean, torque right, knife left, traction right. So it's just kind of a separate... Like this movement. Exactly. So that's exactly what you want to have. I push and I'm wondering, is this a muscle that's being pulled up? Right? So that's one other thing that if you have a robust traction, you have to make sure that you're not seeing the pulled up muscle. Because even fibrosis, without fibrosis, this muscle layer can be pulled up in your way. By the way, there is another question from the audience. How many milliliters is being injected with each step of the foot pedal? Each step of the foot pedal. One cc, if I inject one pip, that pip is one cc. So I found that one cc is usually adequate just to add into the semicosal space. And coming down on the sides, rather than going up for the mucosal incision, can you comment? Sides of what? Coming down on the sides? Side. Both sides. Coming down on the side rather than going up for the mucosal incision? Oh, coming down. Oh, sorry. So if you come... Cutting by pulling back means coming onto the wall. That means going deeper, deeper onto the muscle. So that means you can cut the mucosa effectively, but potentially you're going deeper and deeper and injuring the muscle. So going forward, actually push the knife away from the muscle towards the lumen. That's the way that is always much more safer. Yeah, that's right. Agreed? Yeah. And with the traction, we talked about it during the electrosurgical generator and the setting, the coagulation current actually works much better. Cut current is cut what you get. So it's just not too effective, but coagulation current just bursts the surrounding area. So I'm using a coagulation mode and gently sweep to the torque right, goes to the left, as Naohisa explained before. And it's interesting, if I push, traction moves away, so it gives me another traction. That's a great situation. By the way, in case of using traction, some kind of traction, we should carefully check the lifted area because sometimes muscle layer also lifted up. As you can see on the left side, we already see the whitish muscle layer. So be careful not to touch this area. Absolutely. So this one inside out is another safety. And if you don't have much vessel vasculature, you can extend all the way to the five millimeter, go up all the way open. And then that would accelerate the process, but I'm not recommending it. Coagulation would do it this way. But if you scoop the target tissue from inside and going to outside, it is relatively safe, even with the long length of the braid. That's right. And I'm still seeing the needle tip. Do you find a lot of modifications to traction in the braille, or here you would be less important? Yeah, I think you can, of course, change the grasping area, grasp areas and push, pull back. But then it's going to be a little more difficult to find the good traction. So whenever things are working, I tend not to change much. Then you have to figure out what's the best way you can push away. And maybe this works well. But the working area is a little bit far. That's going to be a little drawback. Let's see. It is a dependent portion. It's usually very difficult to dissect. But with the traction, it just kind of keeps separating because of the surgeon's left hand is available. By the way, is this traction device only available for the upper GI because of the length of this device? Correct. This is only available with this use of double channel aposcope. I think I like this. I can bend a little more like this way. Oh, that's very good. And push in so that this is more of a regular ESD position. Inject, expand. I love it. And then keep going at it. It's a little bit too wet. If you're not seeing the effect you want, you can always increase the power or get much less tissue. This is getting a little more less traction. So I'm going to move to the right, push it away, and push the scope. It's getting a little more difficult to approach, so I use the knife. Moving up is safe. Inject here. The other one. This is 1cc, and oh, it's already nicely lifted up. So I'm trying to feel what's the best way to approach and give attention. Any feedback, any suggestions? Probably you should grab the central part of the back side. I was just thinking about it. It's a little more difficult to do, hopefully I can. It gives too much tension? No, I think this is fine, as far as you're not ripping. You can always add more injection. I'm not seeing a good cut area, so I'm going to do the endo cut, or, yeah, it's endo cut. It's robust cutting, but you can cut whatever you touch. It's precise, but it's not fast, but when it's difficult, it is a good method. There is a question from the audience. Is TracMotion device FDA approved in the U.S.? It is FDA approved. Already started selling from last year? Yep. I'm using Spark to just make it easier and the coagulation effect is more robust. Is it easy to adjust the needle length when the scope is retroflexed? For the hybrid knife? Yeah, retroflexed, it can be a little challenging, so you have to wait a little bit, wiggle, to just finalize. Until it becomes stable? Yeah, exactly. Okay. Using a snare with multiple grip as described by Dr. Inoue, would that be better traction than this device? That's a little bit difficult question. Both technique has merit and demerit. Yep. I wouldn't call which is better. There's a situation one works better and one may not work better, so ... This device can change, but not change all at one time. You can. Yeah. Using this traction device prevents closer work with the knife? Closer work? Yeah, yeah. You can try to pull back and push the scope in, but the traction effect gets a little less. In that case, you can torque and ... That's good. Yeah, then ... Yeah. That's it. Oh, very good. Thank you. Thank you. Retrieval is easy. Yeah, yeah. Retrieval is very ... Retrieval is even better because you grabbed it already. Yeah, yeah. That's right. It came off. So I guess this traction device is very good for the big region located at the greater curvature side in the stomach. It's potential. This double channel scope actually is very flexible, so it can do most of the procedure that you want to do with the regular scope, but it has some demerit. Again, the freedom of the movement is a little bit limited because it's just a little thicker scope. It's amazing how much of the retroflex you can achieve. That's great. But you have to understand the length is a little longer. And with ... Is this in the rectum as well? Rectum, definitely. This is an amazing part. You can see the device is out, but it retroflex so well. This way? Yeah. Yeah, yeah. Now, bending function is quite good, although the rigid part is a little bit long. So sometimes it works like magic. Sometimes you struggle. So you have to be just creative in the situation, and you don't want to stick with the one thing. If it doesn't work, probably you should just change the method. So let's move on to the suture, and there's an adapter that comes onto it, and it ... Okay, let's do ... Yeah. Can I have the cap for more ... I'm using a double-channel overstitch, and first this handle is attached to the biopsy channel area. Is it okay with this cap? It's way bad. Yeah. Do you want me to take the cap off? Oh, yeah. You have to take the cap off. This was the cap attached, actually. You barely saw it. And Fuji worked with this device to make sure that it works well, and actually it works in the regular diagonal direction, and it works really well. Here's a suture tip holder, and the suture is loaded, and then I'm going to pass it on. When you're passing down, we're going to open this arm, suture driver, what we call, to make sure that they won't come out with this. And once you push it out, pull back into the channel, and load it up, release, and open. So now you have the needle tip with the suture. Once you're ready, loaded, you're going to go into the site of the suture closure. And next, I have to give credit to Sergei Kansavoie. Can I have a hot biopsy forceps? I started using the hot biopsy forceps because this is without the central spike, so you can grasp the tissue. It has little teeth, so it has traction. I don't usually use for coagulation, but it just gives me a really nice holding of the tissue. Now, what we're doing is a closure of the mucosa. So this is different from perforation closure. You don't have to go into the muscle. So what we want is to grab the mucosa open, close, we're getting a little open, close. So grab the edge of the tissue and open the needle driver. And if you pull the tissue back, you get this mucosa part. And mucosa to sammyukosa, you bite onto it. Oh, hold on, I didn't grasp it yet. Okay, open, release the tissue, open. Now you have one suture here. Next is we have to loosen this suture so that we can move the device much more freely. You have to withdraw into the channel, close it, reload, release onto the needle driver, then pull back a little bit. So we're feeding the suture a little bit into the lumen, shake it off if you need to, and then move on to the next site. You see, if I open this up, it may crisscross the suture. So you have to correct that. I'm going to take this back, move to the right, and let it come out to the right. So then if you take the right side, you don't capture the suture within the suture area. Open, next, close. I'm going to grab the tip, open, close. Then you probably have to push in a little bit, pull back the tissue. I'm going left to right. My plan is left to right, left to right, left to right, to vertically close it. Here amikoza, samikoza, capture back, open, open both, so now second suture is in. So now you have to go to the left side, you're going to close to the left, feed it in, diverts, it's loaded on the right place, and next thing, we're going to go here. If you can grab the mikoza only, you can always use the endoscope, and just do it without the forceps, but you see, the grabbed tissue is very thin, it's not going to hold it. So I have to probably bite it again. Firingorio is working for suturing, I would like to answer the question from the audience. There is a question, don't you think that traction device can cause damage to the target region that can affect pathologist work? If you grab the mikoza surface, it sometimes cause tissue damage, but by grasping the edge of the target region or backside of the region, probably there will be no problem, but please try to grab just the edge of the healthy mikoza, that is the best way. If you grab the surface of the cancerous region, it sometimes causes tissue damage, and it causes the unreliable pathological evaluation. And there's another question, are you using an Olympus, Pentax, or Fuji double channel scope? This is Fuji double channel endoscope, and fortunately, this two channel endoscope is approved for the use of colonic procedure, but because of the length of this endoscope, it is available to approach up to sigmoid column, but it is already get approval from FDA, so you don't have to worry. Absolutely correct. So while you're answering question, I just kind of twist it around to just make the suture upside down, so that I won't crisscross with the suture I have already, pull back, that's better. Okay, now I feel better. See this original suture is still going above, so I have to go to the right, I'm going to the right, this direction is correct, and go to the right side, open, close, and pull back, push in, pull back, get the ideal tissue amount, okay. Let's go to the left again, oh, yeah, I'm on the right side, very good, and this forceps really works well. So you don't have to use a herics? Correct, herics can be used, but I found this hot biopsy method really works well, thanks to Sergei. To pull back a little bit, give attention, I don't like the amount, this is good, you see the amount of tissue, it won't tear up, open, close, now we're getting close, when I talk to the surgeon, they won't need to do this much of the close suture, that's what they say, I tend to do a little more closer, like here, but the surgeon probably would do here, close now, and pull back the tissue, get what you want, a little bit more, sometimes you have to hold with a pinky, oh, then you have to release it, unfortunately, because then you cannot keep suturing, that's a good question, sometimes this side gets bent, so you cannot load it onto the needle driver, then that's the end of the suture, so here I want to make sure that I'm not crisscrossing, see the top part is the original suture, it's kept above, so that it won't be captured, open, into the sutured area, open, close, so this forceps is just holding onto the tissue so that I can grab the tissue I want, a little more, that's good, yeah, sure, open, and how much training do you need when you initially perform this procedure, so the suturing is not that difficult, you can do the X-Plan lab, probably like 5-10 sutures, and you have to be comfortable, and in human, probably you have to do 5-10 cases to be really open, comfortable with it, simple, right, very effective, unfortunately we cannot get this device in Japan, I know, I want to make you feel envious, we have a lot of things we don't have, so for now, I'm trying to go inside out, going back, there you go, this might be too much tissue, so I'm going to be adjusting it, now this is a little tricky, because my, the needle holder has backside, so I have to come out first, then open it, so pull back inside again, needle holder, or driver comes out, my suture direction is correct, and let's do the final bite, probably this bite would be adequate, open, open, close, open it, pull back, pull back, pinky will work, it's almost like a mattress suture, open, so then what we do, we can probably do one more here, but should we, or should we let it go? Oh, it looks already fine. Okay, I agree, so what you do is just push it outside the channel, release the needle tip, that's going to be a T fastener, and then we pull from the original insertion of the suture, so if you pull towards the distal end, proximal end will be pulled in, so I'm going to go to the original location, close to, and gently pull, so that we can start initiating closure, so the tissue is getting approximated. Another question, which suturing device do you prefer, the one for two or the one for single channel? So, you know, we all get accustomed to the double channel initially, and then it works well, it's a little bulky and you have to have a double channel scope, single channel suture works well, but the configuration can be a little difficult, it won't be always in one direction, it can be modified, or but it just unintentionally moved to the vertical sometimes, or horizontal, and the tip is a little more protruded, so eventually we decided to just stick with the double channel, in addition, for some reason, single channel suture system became more expensive, I don't know, it's the company's decision, so this is a cinch, I push it out, you see the the spiral area that you say, and gently tighten up, start bending, so that probably is adequate, okay, now cinch, we're just going to close and cut, and here's a cinch placed, oh okay, very nice, now I could have just done one more suture here, and that's how you keep suturing to close the defect, but as far as there's no perforation, it seems okay, right, and do you have any experience using X-TAC, which is also suturing device? Right, I have to say that the X-TAC is approximation device, it's not suturing device, because it can approximate four points, but it won't give a good seal, so I use that to approximate edges, when you have like four or five centimeter defect, and then follow with the clips, yeah, yeah, to complete the closure, okay, yep, okay, thank you very much, a wonderful demonstration, we really enjoyed and find that, oh there's another question, when do you close the ESD defect, or you just leave them open? That's a great question, so I want to ask, get your opinion as well, but multiple randomized prospective studies have shown the benefit of closure in the colon, in the right side of the colon, if the size is more than two centimeter, there's no hardcore evidence that the closure is more beneficial in other situation, but frequently if the patient is on anticoagulation, we tend to close to reduce the risk of bleeding after the ESD, now interesting thing is the right side of the colon definition is a little different in the study to study, one study defined from the proximal to splenic flexure, the most recent study defined as proximal to the hepatic flexure, so it's most of the transverse and ascending will be more beneficial to close to reduce the risk of bleeding, I think I tend to do closure if I see the muscle injury to prevent delayed perforation, what is your practice? In case of having perforation, of course we close everything, but if there is no muscle damage, we usually don't close, because at least in Japan, we keep treated patient at least three days after the treatment, that's why we can keep the safety of the patient, and of course in case of doing large urinary resection, we should close it completely because of the higher risk of having delayed complication, such as delayed perforation, it's really dangerous situation, probably due to the presence of pancreatic juice and bile acid, the risk getting really high, that's why we always try to close everything in the duodenum. Great. In my practice, I just close the detector in the duodenum, and in the colon, I don't close so far, and even with minor perforation, just closing the side of the perforation with a hemoclip, that's good enough, but maybe in the future, right side of the colon and high risk, like comorbidity and anti-coagulation, maybe closing the detector is beneficial. Great. I'm much more conservative after the procedure, if I damage a little bit muscle layer or high risk of the delayed breathing because of the anti-coagulant patient, so we are closing double layer suturing. First, I close the muscle layer, then to reduce much tension to the muscle, we are closing mucosa to mucosa. It means almost full thickness closure. Interesting. What happens to the clip onto the muscle? Does it come off eventually? Yeah, between the clip, it does come off. Oh. Do you think this suturing device can be used in the duodenum? It can. I have used the closure of perforation in duodenum. It works well. Whenever it's accessible and you can pull the tissue and bite, then you can place the suture, but if it's on the anterior wall, it's going to be very difficult to access. And I'm a bit afraid about the organ outside the duodenum. If you capture the bile duct or something like the pancreas, it tends to be more on the medial side, that area that we tend not to do any intervention because of the complicated structures. But absolutely, it might include some of the peri-intestinal structures. So that's why I'm focusing on the mucosal closure here. If there's no perforation, you don't have to bite in the muscle or the serosa. That's the important part. Absolutely. And of course, the closure, I wanted to mention that the most recent studies talk about quality of the closure. That means that there's no exposure of samicosa. That's a high-quality closure. That is more effective than just placing clips. Do you think all ESD defects must be closed? No, we already did. Great. Thank you very much. It was a fantastic session. Thanks for the experts and masters.

video

demonstration

hybrid knife

track motion technique

incisions

retroflex position

traction

suturing

Q&A session