Thank you very much for this nice introduction and I would like to thank both Dr. Fukami and Dr. Yahagi for inviting me and especially for giving me this very difficult but also very very important topic for today's lecture. This is a list of my disclosures. Unfortunately, no matter how good your technical skills, if you started to do ESD, from time to time you will run into complications and we are not really trained to deal with those complications as a gastroenterologist. Surgeons by training are used to deal with the bleeding, used to deal with damage to the organs, but even if you are a surgeon, doing ESD is very different from doing procedure laparoscopically or open surgery. Especially if you are in a narrow space like esophagus or if you are in the colon and you started to get bleeding, that is very different than stopping the bleeding inside the peritoneal cavity. During surgery you have your assistant and you have ability to triangulate if you are using, for example, laparoscopic instruments. During endoscopy you don't have it, especially during flexible endoscopy when everything is moving and you have to fight against peristaltes, against bleeding, against the heartbeat. So dealing with complication during ESD is very different no matter what is your background. And ESD complication can be divided into immediate complication, those are bleeding and perforation, and delayed complication. So bleeding is the most common event during procedure. And bleeding especially common, there are certain factors which you need to take into consideration whether you will encounter bleeding more often or less often. For example, if the polyp has big size or the polyp has advanced histology, there will be more blood vessels and so the chance of bleeding is higher. The farther you moved in your ESD career, the more experience in flexible endoscopy you have, the less complication you obviously will have. And it's very important to use electric current controlled by the processors and it was shown already in the previous talks that it will help you to prevent complication such as bleeding. Bleeding can be arterial, can be venous, and we heard several excellent talks regarding cautery for control of the bleeding. But don't forget, sometimes you may not be able to identify the blood vessel right away and to slow down the bleeding, it's very helpful to just inject solution there in a large volume which will compress blood vessel, slow down the bleeding, and then you will be able to stop the bleeding with electrical cautery. And the clips and then the loops are not that helpful to stop the bleeding in the middle of the procedure. If you apply the clip in the middle of the procedure and then trying to complete ESD, it will always be on your way. So try not to do it if you did not finish the ESD yet. And do not forget about some additional techniques which are very helpful. For example, most of my patients, and this is the problem with United States. In Japan, the referring physician will not touch the lesion and you usually do an ESD in somebody who did not have procedure before. In United States, most of the patients who will come for your ESD already had some intervention, excessive biopsy, a lot of scar tissue, and so the chance of bleeding is higher. So the first thing which you need to do, you need to keep the area of the bleeding clean. And for that, you use water irrigation, or if necessary, you change position of the patient so that the bleeding vessel will get exposed. Unfortunately, it's not always possible. And sometimes you will get like a situation like this. This is the live demonstration which I did outside of United States. I look at the lesion. I said that this is invasive cancer. That's not something for ESD. But they told me the patient is old, not a surgical candidate, and that's the best we can do for her. So why don't you do it? So foolishly, I agreed to do it. And I knew that it's just a question of time when it will become a full sickness resection. And when it became a full sickness resection, then first it was progressing okay. But then I got into the major mesenteric arterial bleeding. And this is not a bleeding from submucosal vessel. This is a real artery from the mesenteric vessel. And by the time I got coagrasper, the whole area was already completely closed with blood. And at that point, there is no way that you can find the origin of the blood vessel. So what to do in this situation? The only thing which saved me in that situation was hemispray. Hemispray at that point was not indicated for colonic use. Hemispray was only available and cleared at that point for use in the upper GI tract. But look at this blood clot and look at this collection of blood. There was no other way. So I sprayed hemispray there. And to everybody's surprise, it completely stopped the bleeding. So since that time, hemispray is always available in our endoscopy unit. We rarely need to use it, but you need to remember about this option. If you get into really major bleeding, then hemispray may be the answer. Hemispray is a temporary control of the bleeding. And after you completely stop the bleeding, then you can go back and see exposed blood vessel and cauterize it and complete the procedure. But most dreaded complication is not bleeding. It's perforation. And Dr. Abbe said at the end of his talk a very good phrase, and I'm going to use it extensively in the future. He said that colonic ESD is a battle with perforation. And that's so true. The wall of the colon is thin, and the rate of the perforation during colonic ESD is much higher than rate of the perforation during EMR. But the size of the perforation during ESD is much smaller than the size of the perforation during EMR. When you apply the snare, and if you are unfortunate enough to grab the muscle when you are doing EMR, then after you cut, there will be a big defect. If you're doing ESD correctly, and you are not doing big zip-type incision, if you're moving one millimeter at a time, then if you created perforation, it's usually very small during the ESD, and that is much more easy to close than the large size of perforation. You have several options for control of immediate perforation. If you are in the esophagus, you can apply covered stand. You can do some closure with the endoscopic clips, and some people still advocating to do it. But I look in the past, and this is one of the example. Again, this is the lesion which was already operated on by somebody, and that created a lot of scar tissue. So after I cut out that lesion, then unfortunately it created a big hole in the colon. So to close the perforation of this size with endoscopic clips is not possible. It's full-thickness perforation, and you can see half of the peritoneal cavity through that hole. So what I do, I use endoscopic suturing device, and endoscopic suturing device mounted on a double-channel endoscope. So you have your second channel, which you can use very similar to a surgery. So you put a grasping forceps through it. I prefer to use hot biopsy forceps because if I get into blood vessel when I puncture the wall with the needle, then I can immediately stop the bleeding and keep my view fold clean. And you cannot use coag grasper because it's not really holding that well. But you can see that I'm suturing that perforation full-thickness, and at the same time I'm not going into the peritoneal cavity. So I'm closing it from inside the colonic lumen, and the perforation is getting smaller and smaller. You cannot achieve such airtight closure of the perforation of this size with just closure with clips. Clips are providing only mucosal closure. So I would not feel comfortable closing the perforation inside the colon with endoscopic clips. And so this is the end of the procedure. So everything is closed completely. And of course, the first thing which I do if perforation is encountered, then I ask anesthesia to give antibiotics. Usually I do Cipro and Flagyl. And that's the end of the procedure. The lumen is not narrowed. Perforation is closed completely, and the patient will complete seven days of oral antibiotics, and that's the end of it. So I wanted to look into that issue. Each time when I was closing perforation with clips in the colon, then there was a problem and the patient would not be able to tolerate that. And in the upper GI tract, yes, you can close with clips. For example, if you have gastric perforation, you close it with clips, you put patient for NPO, you put NG tube down, and you aspirate, and you can get away with it. With colon, you cannot get away with management like this. So you can see this is our initial experience many years ago. So you can see that each time when I was trying to close colonic perforation with clips, it did not hold. And then I had a case where the patient had a lesion in the cecum. I cut it out, and it was a small perforation, closed it with clips. The patient woke up, post-procedure, a lot of pain, obviously free air on the x-ray. I took her back to endoscopy unit, remove the clips, close it with sutures. She wake up second time, and there was no complaints at all. That was many years ago. So since that time, every perforation which happened in our endoscopy unit is closed endoscopically with the suturing. And you can see some of those are mine from ESD, and the other ones are not mine. I don't do screening colonoscopy, and I practically don't do EMR anymore. So even if perforation happened in endoscopy unit, and somebody calls surgery, they say that, did you ask Sergei to try? And so even surgeons who did not believe us that it's possible, reliable closure of colonic perforation with suturing device, now fully on board. The perforation which happened during procedure and bleeding which happened during procedure can be controlled with a very high level of success. But unfortunately, some of the complication can be delayed, and there we don't have that much control. It's practically impossible to predict who will have delayed bleeding and who will have delayed perforation. And delayed bleeding and delayed perforation happen, as you know from the literature. And there were several studies which look into the rate of delayed bleeding. It was not about ESD, it was about EMR, but I don't think that it's important how you remove the lesion, piecemeal fashion or remove it in one piece. What is important is the size of the defect post-removal and how much of the muscle is exposed. So the first study was prospective randomized study, which was published almost 20 years ago. And they look into the lesion which was less than 10 millimeter in size. And they're randomizing to two arms. So some of the defects were closed with clips, others were not closed with clips. So there was no difference. When the lesion is smaller than 10 millimeter in size, you don't really have to close it. Those are really causing delayed bleeding. And even if it happened, you are not really preventing anything by applying the clip. And then there was an interesting study, randomized prospective trial, where they used hemoclips to prevent delayed bleeding post-EMR. So this study said that there was no difference in the rate of delayed bleeding, whether you apply clips for closure or if you don't apply clips for closure. There was a big problem with that study. First of all, they enrolled a lot of patients. One third of the patients had pedunculated lesion, not sessile lesion. And second of all, the size of the polyps was small. So they enrolled a mean size of the polyp was less than 15 millimeter in size. So my take on this two study is that if the lesion is less than 15 millimeter in size, you don't really need to waste your time and you don't need to waste endoscopic clips trying to prevent delayed bleeding. But then there were several studies which were in favor of closure of the mucosal defect post-removal of the large sessile lesions in the colon. So it started with Dr. Rex, who looked retrospectively into the patient who had 20 millimeter and bigger sessile polyp in the colon. It was not randomized study, but it demonstrated if you leave the defect 20 millimeter or larger without closure, and yes, they were removed in piecemeal fashion, but I don't think that it makes any difference. So if you leave it without closure, then about 10% risk of delayed bleeding. If you close it with endoscopic clips, then the risk dropped down to 2%. So this study was heavily in favor of the closure of the defects post-ESD. Then Dr. Paul did a randomized controlled trial, which confirmed that if you're dealing with colonic lesions, which are sessile, non-pedunculated, and bigger than 20 millimeter in size, then average benefit is that the rate of delayed bleeding decreased from 7% to 3%. But surprisingly, when they look into subcategory, the risk benefit ratio was even high on the right side of the colon. So if the lesion located on the right side of the colon, then the rate decreased from 9% to 2%, which is quite similar to the study by Dr. Rex. However, on the left side of the colon, those patients who had closure with endoscopic clips, they had more delayed bleeding than those who were left without closure. They were puzzled with that finding, but to me, it is very obvious. I don't think that there is any contradiction there. On the right side of the colon, the stool is liquid, and the clips are barely holding the mucosa, and liquid is not really opening up that lesion. The mucosal closure with clips may be adequate. But on the left side of the colon, the stool is solid. So first of all, the clips closure is too weak to keep that defect closed. And second of all, stool, which is solid, probably tears the clips apart, and that cause even more bleeding on the left side of the colon. So my take on from this study, if you don't use suturing device to close defect post-endoscopic submucosal dissection, on the right side, you can close it with clips. On the left side, you better just leave it open. And finally, there was another study from Spain, which looked into the higher risk group for bleeding. And it demonstrated that in that group, also large non-pedunculated lesion, more than two centimeter in size, the risk of bleeding before closure was 12%, after closure decreased to 5%. It was randomized control trial, and to me, those results are very convincing that you should not leave defect post-ESD without closure, otherwise there is a big chance that you will encounter some post-procedural delay bleeding. We looked into our initial experience with closure with endoscopic suturing device, and that's how it looks like. So you can see a big lesion located somewhere in the rectum, and obviously, yeah, by the way, the biopsy was already available, it was a cancer, so it needed to be removed in one piece, obviously doing ESD here. And after ESD and removal of the lesion, it leaves a big defect in the colon. And again, it's the left side of the colon, so in this situation, closure with clips will not be helpful, first of all. And second of all, the defect is too big to use endoscopic clips to close. So I'm using endoscopic suturing device, and this is the size of the defect. And endoscopic suturing device, I prefer the one which is mounted on the double-channel endoscope, and that's what you see here. I rarely use separate stitches. I prefer to use a continuous suturing line. And the quality of the closure which you can achieve with endoscopic suturing device is not any worse than the surgical closure. And this is the end of it. We are dropping the needle, and you can see how well the defect closed. It takes probably five, maybe seven minutes to close the defect of this size. And that's the end of the story. And the patient can be sent home right out of the endoscopy unit. So traditionally, after endoscopic submucosal dissection, the patient is admitted to the hospital for several days because of the risk of delayed bleeding and delayed perforation. In United States, it is prohibitively expensive. I know that that's the current practice in Japan and in Europe. But in United States, the money accounted and admission costs too much. And we started to do that. And in 2014, I was less busy, and I look in my results. It's not updated. I did not have time to go back to that. But here is what I did at that point. For a year and a half, for 16 months, I removed lesion in 460 patients. And you can see that smaller lesions were removed with EMR. And the size of those lesions which were removed with EMR was less than 2 centimeter in size. Bigger lesions were removed with ESD. They were, in average, 3 centimeter and more. And the lesions which were 15 millimeter and less were left without closure. The one which were less than 25 millimeter were closed with endoscopic clips. And finally, the biggest lesions were closed with endoscopic suturing device. So even those who were left without closure, really small lesions, I had delayed bleeding, and I had delayed perforation in some of those patients. Those lesions of the medium size, which were closed with endoscopic clips, the rate of delayed bleeding was 2.4%, similar to the study by Dr. Rex and similar to the study by Dr. Paul. And in the group of the patients who had the largest lesion in the colon and were closed with endoscopic suturing device, there was no delayed bleeding, no delayed perforation, although the size of those lesions was statistically significantly bigger than the one in the clip closure group. Finally, the last delayed complication is stricture formation. Delayed bleeding and delayed perforation usually happen within first two weeks post-procedure. Stricture formation usually requires several months before it develops. And predisposed to development of the stricture, if you remove the lesion which is already located in the narrow part of GI tract, for example, esophagus or prepyloric area, and also if you are dealing with a large lesion, for example, if you're removing esophageal lesion more than 75% of circumference, there is a higher chance of stricture. Rectum is more forgiving because the stool is solid, so it's kind of self-dilated. So rectum, you rarely have a lesion unless you remove, you rarely have a stricture unless you remove the lesion which is bigger than 90% of the rectal circumference. And although most of those strictures can be treated with endoscopic dilation, you still, it requires a lot of effort, and some of those dilation can lead to the perforation. So it's much better to prevent those rather than to treat those. And this is my first experience in rectal reconstruction, 36-year-old woman, mother of six, and I did not see her before procedures. She came to me and the referring physician said three centimeter polyp in the rectum. She came to me and I started to get consent and she said for the last two years, each time I go to the bathroom, piece of meat falls out of my rectum. At that point I realized that it's not three centimeter polyp and you can see that the lesion is circumferential and it is occupying the entire rectum in size. So you see we started ten minutes to four and it took me about four hours to remove that thing and obviously there is a higher concern about possible high grade dysplasia or even cancer and lesion is starting right at the dentate line. It's definitely circumferential for most of the rectum. So this is the end of it. We are removing the whole lesion in one piece, but after removal it created a huge defect. Practically the entire rectum is denuded from mucosa. It is not only more than 90%, it's 100% of circumference and here it will be a very nasty stricture and I'm not sure that I will be able to dilate that stricture properly. So this was my first time I did rectal reconstruction and with endoscopic suturing device now I'm doing it slightly differently, but nevertheless the whole idea is to transplant the sigmoid mucosa to the skin and to completely close that defect after you remove the lesion. So I will just move it a little forward and it doesn't take long, but this is the result. So this is the entrance to the rectum and you can not see any more muscle tissue here and this is the lesion so it's about 14 centimeter in length. I had to cut it out to position there and it's about 11 centimeter in distance. So this is the same patient. You can see there's her medical record number and she comes, the procedure was done in December. Now the same patient come nine months later. She disappeared for nine months and when she came, look at this, this is a normal looking rectal mucosa and there is no stricture and she never required any dilation or anything like that. This is another example, the patient was sent to our surgeons and they said that four centimeter polyp in transverse colon. So the surgeon said, can you remove four centimeter polyp? I said, sure. It was not four centimeter polyp and it was practically circumferential lesion in the transverse colon. And again, there is a chance that it was a high grade dysplasia, maybe even cancer inside. So I needed to do a dissection to remove the entire lesion. And after removal of that lesion, again, there is a big defect which is exposing muscle tissue there. So I'm doing reconstruction of the transverse colon and after the full reconstruction, like this, you can no longer see any muscle. And the patient goes home and it is 2014, April 2014. Patient goes home and disappears and she doesn't come for any follow up but, and this is the last digits of her name. And then it's 2014 and then five years later she came for follow up. She decided to come for some reason. And you can see how this area looks like. No stricture, wide open area and very small amount of the scar tissue here. So the reconstruction of the tight place, I am doing it in the esophagus, I am doing it in the ileocecal valve, I am doing it in the pre-pulmonary area and I am obviously doing it in the rectum all the time after every ESD procedure. So in conclusion, endoscopic submucosal dissection is a highly specialized procedure which require advanced endoscopic skills, a lot of patience, endurance, and meticulous, unwavering attention to details. Post-complication during and after ESD can be corrected endoscopically. And endoscopic suture enclosure of the large mucosal defect post-ESD is the best prevention of delayed bleeding, delayed perforation, and formation of strictures post-ESD. Thank you very much. Thank you very much. Very, very impressive talk. I always very much enjoy your talk. I think there are lots of questions to Sergei. Yes, please. So if the patient is restarting an anticoagulant or antiplatelet, does that affect whether you're closing the defect or not? And then second question, it's interesting, your reconstructions, can you use it for esophageal ulcers which are not healing? I'm sorry, esophageal what? Ulcers which are not healing, non-healing esophageal ulcers for the reconstruction. Thank you. For the first question, if the patient require anticoagulation, more reasons to do something to prevent bleeding. So it's more incentive for me to do coverage with the suturing device so that they can resume anticoagulation faster than they were supposed to. So I would do it even if the patient is not on anticoagulation, and I would definitely do it if the patient require anticoagulation post-procedure. And yes, you can cover, now people are doing it to cover non-healing ulcers, to cover fistulas, and for example, frequently people are trying to do it to close non-healing ulcers post-gastric bypass. The rate of success is much less in those situations because you are dealing with chronic inflamed tissue and the margins are very rigid, so it's practically like a cartilage there. So it's not the same as to do reconstruction right after ASD and trying to close chronic ulcers. Yes, possible, but the effect is difficult to predict. Yes, please. So I liked your comment about the hot biopsy forceps. So the issue with the current coagulation grasper through the colonoscope is that they have very small jaws. Now the hot biopsy forceps say that they only open to 2.8 millimeters, but it seems a lot larger than the coag grasper. So in your experience, can you just comment on that, if the hot biopsy forceps are sufficient for soft coagulation through a colonoscope? Thank you for the question. I actually was not using coag grasper for a long time. You know, today, during one of the earlier talk, I find out, I think that Hero said that the devices for ASD were available in United States and were approved by FDA in 2008. For some reason, I was not getting this till 2011 or till 2010, and including coag grasper was not available for me. So I was always using the hot biopsy forceps, and I'm still using it from time to time. The problem is that if you see the blood vessel, and if you grab it with hot biopsy forceps, you can bite off the blood vessel, and so you create the bleeding. So I still recommend to use coag grasper when available, but definitely hot biopsy forceps, if you are in situation where coag grasper is not available, they will do the same thing, except you need to be much more careful when you are using that. I'm not recommending hot biopsy forceps over coag grasper. Yes, preferred instrument for prophylaxis especially is the coag grasper. Another issue with hot biopsy forceps is that the teeth are very sharp. So if you grab something, then the dead tissue, coagulated tissue will stay on it, so it's quickly become unusable, so you need to remove and clean it. And coag grasper doesn't have sharp teeth, so you can grab several times, you can cauterize several times, it's still working. But if you're using hot biopsy forceps, that tissue become an isolator, so you cannot really use it without cleaning it. So to summarize such a long and probably not a straightforward answer, I would prefer to use a coag grasper. And coag grasper for the colon should not be used in the stomach because the active branches are much smaller and not sufficient for big submucosal vessel in the stomach. And similarly, coag grasper for the stomach should not be used for the colon because the shaft of it is too short and it will simply not go through the colonoscope. It's very important that if you got into the bleeding and you're asking for coag grasper, insist that the nurse will look into the package because if it is a device for upper GI tract, there will be picture of the stomach. If it is device for the colon, then it will be picture of the colon and you should get the appropriate one. So coag grasper for the colon is effective in the colon, not effective in the stomach. And if you don't have it, then you can use a hot biopsy forceps, but it's not the ideal version. So a couple of questions from live and virtual audience. First one, a large colonic perforation in the cecum usually isn't forgiving in the sense of allowing the endoscopist to pull out the scope, mount the suturing device and go back to the cecum. Passing the suturing device in an intact colon is challenging, let alone when there's a perforation of significant colonic disaffiliation. How do you recommend approaching such a perforation in the cecum? It's a great question and it's not really question to me, it's question to Apollo because for many years I bugged them and JR is sitting there and laughing, but it's not a laughable matter. I keep saying that they needed to create device which is mounted on the colonic length endoscope, not on the upper length endoscope. Yes, that's definitely not easy to get a short gastric double channel scope into the right colon. But before Lumen device was available, that's what exactly I was doing. I was going all the way to the right colon with the double channel upper scope. Since the Lumen device is available, things changed dramatically for me. I start all colonic ESD, especially on the right colon, especially in the cecum, I start with the Lumen and the Lumen create for me a conduit from rectum to cecum. And then I can remove colonoscope many times if I need to clean it or if I need to switch to the upper scope. There was a question from Professor Yamamoto regarding use of the short colonoscope for ESD and that's the opportunity which we now have. In United States, you shorten the colon with the Lumen and then you can take even upper scope and go to the right side of the colon to do ESD. And then, if God forbid, there is a perforation, it's not that difficult to put a double channel scope through the shortened Lumen into the right side of the colon. But the author of the question is correct. Perforation in the colon, especially in the cecum, is not forgiven. The stool is liquid there. And if you did not create a watertight, airtight closure, there will be leakage, there will be spillage into the peritoneal cavity and there will be a disaster there. Great. Thanks. Another question, can X-TAC do the same job as a new device to approximate edges? I do not think that X-TAC is providing adequate closure. X-TAC was designed for mucosal closure. So it's not really much different than closure with endoscopic clips. And my problem is that clips or X-TACs just approximating mucosa. And if you are dealing with full sickness perforation, you have to approximate muscle to muscle. And so you have to do a full sickness closure, whether it was intentional full sickness resection or unintentional perforation, you have to do a full sickness surgical quality closure. So X-TACs is not the answer. The only answer is endoscopic suturing device. Thank you. Okay. Any other question? So there's another question to, I think, Seichiro. How to recognize invasive cancer during ESD and differentiate cancer causing decimoplastic reaction from submucosal fibrosis from other reason? Okay. Thank you for the question. Honestly speaking, it is very much a challenge to differentiate fibrosis only because of the peptic ulceration fibrosis and tumor invasion. Tumor invasion looks a little bit yellowish, but it is absolutely almost impossible to differentiate between the two situation. So anyway, you need to complete submucosal dissection if possible, if possible, as much as you can according to your skill level. Can I also add to this? Unfortunately, in United States, CUDA classification is not used as much as it should be. And I frequently get a patient who was referred to me and they said that big polyp and the biopsy is just tubular villous adenoma or just adenoma. But when you look at it, and there will be area of CUDA5 pattern. So that's the place where they should have taken biopsy from. To take biopsy from normal adenomatous tissue doesn't really benefit us. So if the patient has CUDA5 pattern, there is no reason to send somebody like that for ESD. This patient has to go straight for surgery. That's right. I completely agree with you. Therefore, it is mandatory to check the lesion carefully beforehand. And we should remove the mucus from the target lesion, otherwise we cannot find a deeply invasive area. We should carefully check the entire lesion before attempting endoscopic resection. And I also have to add that there are some people in the United States who claim that granular type of the tumors have very low chance of cancer and so EMR should be the way to go with that. I disagree with that. And frequently granular type can also have CUDA5 pattern on it and have invasive cancer already inside. So no matter you are dealing with sessile serrated lesion, non-granular or granular, you look at it extensively, you wash it out of the mucus, you use NBI. And if there is any suspicion, the patient is, don't gamble. The patient is better off going for surgery rather than for endoscopic procedure. There may be one exception from that rule. If you have a lesion which is located in the distal rectum and sending patient like that for surgery will mean colostomy for the rest of their life. In that situation, it may be that it would be a good idea to do if there is a question. If there is no question, CUDA5 pattern, invasive cancer, no question, surgery. But if there is a question, then I would rather do ESD as a staging procedure. And if it doesn't show invasive cancer there, then that's it. Patient will leave with the rectum in place. But it would be a travesty to send patient with benign lesion in the distal rectum for colostomy, for anterior rectal resection and colostomy for the rest of their life. And then the biopsy come back negative for cancer. That is probably basis for the lawsuit too. Okay, yeah, one more. Yes, please. I have a quick question about the suturing device. When you apply suturing device for perforation, the luminal air goes into the peritoneal cavity. How can you keep the endoscopic view and prevent pneumoperitoneum risk? This is excellent question. So there are certain steps in our endoscopy unit which we go through. First thing, if I think that there is a perforation, it may not be perforation, I may just think about it, immediately ask for antibiotic. The second thing which I ask for, I ask the nurses to go and check the stomach to see how distended, how soft or firm stomach is. And then while I'm doing closure, I want them from time to time check the stomach again to see if it's getting firmer or not. If it is not getting firmer, if the vital signs continue to stay stable, then there is no problem. And the thing is that if you are dealing with a big perforation, then air goes easily in and out of the colon into peritoneal cavity and then back into the colon. It's really created tension pneumoperitoneum. Unfortunately, the biggest problem when you are dealing with a small perforation. When you have a small perforation, then it work like a valve. So you distend the colon and the air gets pushed into the peritoneal cavity and it cannot go back. So very quickly, the patient can develop very tense pneumoperitoneum. And then you will have the next thing which will happen, you will see that the patient becomes tachycardic, blood pressure fall down, and then the colon gets collapsed because it's pressed from outside. I don't want to wait for this to happen. So the nurses will check the stomach. And if the stomach getting firmer, we have a virus needle, this laparoscopic needle to create pneumoperitoneum. It's a single use, it's sterile. So you quickly wash the stomach with the betadine and you put that needle and you connect it to the syringe filled with water. And then the air will start coming out of that. So you basically convert closed tense pneumoperitoneum into open pneumoperitoneum. After you put it, then there is no problem. You can distend colon as much as you want to and the air will come out through that needle. So the air will not get trapped inside the peritoneal cavity. So the stomach will not get distended. And then at the end of the procedure, after I finish suturing, I want to stay there with the colonoscope, insufflate the colon, and make sure that there is no air coming through that virus needle. That will be my leak test to prove that it is airtight closure of the perforation. And it's really needed, but you need to kind of learn the steps. If it happen, you will know what to do. Is tracheal intubation and mechanical ventilation necessary or can it be done with just sedation with tracheal intubation? You can do it. But the problem is that, and this is one of the differences which we have with ESD in Japan and ESD in United States. In Japan, you have compliant patient. And for example, if you need the patient's position, you can do ESD under sedation. If you need to change patient's position, you just tell anesthesia, let the patient wake up and ask the patient to turn from the side to the back and so forth. In United States, it's impossible. No matter how good you did with ESD, if your patient wake up during the procedure, you will never hear the end of it. They will be complaining that they did not get adequate sedation, they were awake during the procedure. So in United States, if you are doing ESD anything longer than one hour, I put patient for general anesthesia. If they wake up in the middle of the procedure, they will write, they will complain about me. In reality, it should be complain about anesthesia, but nevertheless, you will get the blame. But that is the other problem is that, and Norio mentioned that already, that patients are big and you put them into position, usually I start on the left side, right? And then they are under general anesthesia and if you need to change position and rotate the patient, the patient is lying there completely out and paralyzed. You have to do that. Your nurses have to do that. You will quickly get a lot of enemies in endoscopy unit if you are trying to rotate the patient. So I never choose better position. I don't even look for gravity. If I'm asking to rotate the patient, it means that I'm so desperate that there is no other way around. But I don't do that. I don't rotate the patient at all. It's completely different situation in our country. Sometimes our patient looking at the monitor during the long lasting procedure and sometimes we talk to each other, can you change your position? Sorry, sorry. No, it's okay. Can you see the monitor? It's a really strange situation. Sometimes I'm a little bit nervous, but it's reality in Japan. It's possible. But I really agree with you in the American situation. Impossible. Yeah, yeah. Okay. Okay. Any other question? Everybody happy? I really enjoyed this great morning session, but we have much more exciting hands-on session this afternoon. Before going to the left, please enjoy lunch. Thank you very much.

endoscopic submucosal dissection

complications

bleeding

perforation

stricture formation

electric current

hemispray

endoscopic suturing devices