So, hello everyone and good evening. So in Japan, just the early morning. So, anyway, so I hope the introduction of, I really appreciate the introduction of Dr. Fukami and Dr. Hagi. And I would like to talk about the traction method during ESD procedure. So, traction is very simple, like a surgeon's left hand. So, keep tissue traction. So, this is my COI. This is a very nice shot. So, three years ago, before COVID, I really enjoyed joining this course. So, unfortunately, this year, I'm not in person, but I remember very well. So, okay. So, talking about the traction technique, now we have several techniques. So, with the external traction, we're using some forceps side by side to the endoscopy shaft. And another one is internal traction in the GI tract. So, we pull using a sub-device to keep tension to the tissue. And the other, a little bit advanced technique is using magnetic traction method and the double scope. So, historically, maybe I think as far as I know, Dr. Imaeda is the first person to report the usefulness of counter-traction during ESD. This is his report. So, in his first report, he used grasping forceps to pull up the specimen. So, currently, at least in the upper GI tract, clip with line technique is the most popular technique, I think. So, like this. So, just fix the thread to the one side of the clip arm, and then we place the clip at the proximal end of the mobilized tissue. Then we can create a good submucosal tension. So, submucosal space, using a tension, submucosal space widely open, and then subsequent dissection of the tissue becomes easier and faster. So, one of the commercially available devices in the tract. Okay. So, another doctor reported that the combination of the clip and the sneer, this is one of the modified technique of clip and line technique. Next, I'd like to talk about the internal traction technique. So, most of the doctors, first, endoscopists try to use the rubber band to keep tension. This one is the most popular, multi-loop traction device. This is the most popular internal traction device, simple and popular. This is the report, the application of this device for colon ASD. Another commercially available device is the SO clip. This is a spring and loop traction technique. And maybe I think Dr. Yahagi introduced you already. So, this is an end-rifter. So, an end-rifter is also a nice device attaching the, so this is in between the external traction and the internal traction, a very nice device. So, please ask Dr. Yahagi detail the application of this device. So, this is the RCT. So, you are evaluating the usefulness of our spring and loop clip traction. And you can see a statistically procedure time getting shorter. And this is another RCT, so clip and line method. Procedure time, yes, getting shorter and also perforation rate, it's also reduced. So, it becomes a safer procedure. So, because of the good visual field. So, Dr. Abe, Seiichiro Abe, he reported the review article that's covering very wide aspect of traction technique. So, in his summary, he said that the clip and line traction reduced the procedure time and the semicircular tunneling. Semicircular tunneling technique, it's one of the application of the POEM procedure. So, both of them, anyway, keeping some traction, some tension to the specimen, anyway, getting the procedure faster. And clip and line traction reduce the risk of muscle injury as well. This is in the stomach. So, clip and line traction is useful in at least greater curve regions. So, greater curve regions is, of course, you know, lesser curve. Originally, naturally, the tissue, anatomically, tissue has the adequate tension, but in a greater curve, more and more floppy. So, this traction procedure makes procedure faster and safer. Okay. So, particularly, not always we need traction, but once we encounter some difficulties to dissect, in such a situation, try to apply traction technique. In the colon, some internal traction device works well. So, particularly in the right side colon, external traction, it's a little bit difficult to apply. So, internal traction method works well. Okay. So, finally, I would like to introduce our favorite procedure. So, we have reported as a multi-point traction technique. This is an external traction. So, for example, this is application of this technique in the upper GI. So, like, once we make a proximal flap, we fix the regular sneer to the tissue using the clip device. So, we fix this snare wire in a multi-point. And then, when we close the snare, so, mobilized proximal tissue is rolled up. So, this also makes the lateral incision easier. So, this is a sample. This is a squamous cell carcinoma, not so many in the US, but anyway. So, first we place the marginal cutting. So, like this way. In this case, the lesion spread near circumferential. So, we first place a circumferential mucosal incision. And then after that, so, this is a preparation. Now we try to catch the snare wire. This snare wire is a, we can accept any snare wire and catch it, the re-openable clip, and then bring it to the site. Now you can see a proximal edge of the lesion. So, anytime endoscopic view, we put the first clip to the proximal edge of the mucosal. And then, so, now we are placing the first clip at the top of the proximal edge. So, first anchoring has been done. And after that, so, we are trying to place the second clip, a lateral placing the second clip. So, in this case, we are approaching to the right side. Okay. Catch the snare and tissue together and catch the lateral incision site. Okay. So, second clip has been placed. So, we can accept any type of commercially available clips. So, third one is a left-hand side. So, we can place the third clip. Okay. Okay. Okay. Then, so, we close the snare wire. So, mobilized tissue or anchored tissue is loaded up and then make the submucosal dissection much, much easier. With attention, submucosal space is widely open. So, we can easily access to the submucosal tissue. And then, so, this is a lateral side. We can do the same thing. So, at this moment, of course, a distal attachment, a transparent cap, that works well to keep a good visual field. Anyway, so, we continue. Then, another point, the technical point is always keep, try to keep a close-up view. So, that makes the procedure safer and accurate dissection. Okay. So, this kind of attraction technique is particularly useful when we approach the distal end of the specimen. So, because distal end is, at the end of the procedure, a specimen becomes very floppy. So, our distraction method makes the procedure easier. So, this is the end of the submucosal dissection. Nearly circumferential mucosal dissection completed. So, next, I'd like to briefly talk about the FATs beyond the ESD. So, now we have a technique to complete the ESD, endoscopic submucosal dissection. And the EMD, the endoscopic mass layer dissection, endoscopic ESSD, endoscopic subcilosa dissection, and finally, endoscopic full-thickness resection is the future. So, this is the level of a deeper layer dissection, if necessary. So, when we approach the GIST or the submucosal tumor derived from the muscle layer. So, this is our case. Okay, so this is a report from the ESSD, endoscopic subcilosa dissection. We also dissect the muscle layer. So, at the time, the first report was done by a Chinese doctor. This is our case. So, you can see, now we are dissecting, this is a GIST tumor, the small GIST, but the FNA identified, FNV identified the GIST tissue. Now we are dissecting the muscle layer. Yes, now in the middle video, we scoop up the mobilized muscle fibers and then try to cut it. The light side, you can see, just the cilosa, the remain. So, behind, so light top, middle. So, you can see the surface of the pancreas. So, because this tumor is located at the lesser curve and the posterior wall. So, sometimes we apply the double scope traction method. So, because, in this case, the tumor is extended to out externally. So, after dissection of dissection of tumor itself, we try to keep tension to the tumor using the second scope and the snare wire. This is a most powerful traction technique. So, this is the endoscopic view. So, our second scope, light side, you can see, we place the snare wire, try to catch the tumor itself. And the, this is a combination of the mother scope and the baby scope. I'm sorry. I'm sorry. So, we catch, tumor has been catched by snare and then try to pull it back to the proximal. And then, so we can see some cilosa fibers. Well, then, so a mother scope, in a retroflex view, we are approached behind, behind this tumor. Now, this is a dissection of a subcilosa tissue, some, some muscle fibers, step by step. So, we, we routinely using the triangle tip knife, but in this case, we use a IT knife. Okay. So, finally, the tumor and the covering mucosa has been mobilized like this, and then a good tension. Okay. So this is a demonstration of another traction technique. This is also powerful traction. So we apply the technique to our dissection of epiphrenic diverticulum in the case of EGJ, outflow of extraction. So this was the case. So esophageal gastric junction is a little bit tight, and we can recognize well the epiphrenic diverticulum. So endoscopic view, right side you can see a G-junction, and the left side, the orifice of a diverticulum, okay? So in this case, we create a submucosal tunnel like a POND procedure, and then try to dissect the diverticulum. In the submucosal space, you can see diverticulum, shoot diverticulum mucosa passing through the defect of the muscle layer. Now we are dissecting the, in between the diverticulum and the muscle layer. Okay. So at this moment, so we need to put the traction, bring the diverticulum itself, invert it into the natural lumen. So using the second scope, we place traction like this. So this is a second scope view. So yes, we sack, we sack the target mucosa in the cap and place the snare. Snare wire is coming outside the scope, and then we can make a traction, external traction. So this one is using the snare, so we can keep a strong traction. Then once again, in a submucosal space, we are approaching to the medial stenum. This is the, some connecting tissue or in a pleural and the diverticulum. Okay. So after that, so hold the diverticulum has been inverted into the soft lumen. So after that, we close a muscle defect using the suturing needle through the endoscope. So now we are, yes, this is an inverted mucosa then, so we dissect it and then close it using some clips. So this is a resected specimen. So this process is totally almost same to our surgical procedure. So dissection of the diverticulum and also closure of the muscle defect. So several months after the procedure, so volume pass very well endoscopic view. Yeah. So no more diverticulum. So this is a volume swallow, shows a nice passage. So everybody, thank you so much for your kind attention. The take-home message is attraction. We can accept any type of attraction. So attraction makes procedure faster and safer. Thank you so much for your attention. Thank you, Haru. You always make me remember that you're a surgeon. One question, when you're doing the traction and the triangle, mini triangle knife, which current were you using? Is it spray or swift or? Yeah, so when we use the, generally speaking, so it depends on the situation, but generally speaking, now we prefer to use the spray coagulation more. That makes the procedure faster. So spray coagulation, the 50 watt effect too. Great. Thank you. And any question from the audience? Great opportunity to ask him a question. I have a question, Noria. During these subserosal dissections or removing gists that are very close to full thickness resections, how are you not losing insufflation in the stomach? It looked like you had very good views during your dissection. So it's a very, very important question. So it's, we have several technique to control the, to control the, we keep maintain and the good insufflation in the stomach. So of course, once it becomes the, once we, as long as we keep the serosa, so we can keep a good distension of the stomach. But once we put the injury to the serosa layer, so intra-stomach gas is a leak, leak to the abdominal cavity and we lose the endoscopy site. So that's a problem. So we have several technique, but if I talk, it takes one more time. So I cut it. So one of the simple technique is to insert the blocking balloon. It's one of the technique. And another simple one is keeping the traction. So keeping the traction. So actually we have some leakage from the stomach to our peritoneal cavity, even though if we keep good traction, we can place a closing clips. So it's one of the simple technique. And another simple one is to tap the abdominal wall using the, so some various needle or something. So evacuating the intra-peritoneal gas out, then we can keep the intra-gas leak insufflation. That is a small tricks, but so it's another important category. So today's course is ESD, not endoscopic full sickness resection. So I don't talk not much, but if we have another chance, so I hope we can discuss much about the, how to control the, how to manage if it becomes endoscopic full sickness resection. Maybe next year's advanced course is gonna be the topic. The final question, well, I guess two. One is I tried the multi-point traction before and the snare I use was stiff one. It did not work well. So I saw that you use the crescent knife, crescent snare. Is that for CAPEMRs? Is it really soft one? Yes, thank you so much. So that is, it's an important point. And particularly in the esophagus, we use the very thin snare. We can accept any type, but as Fukami sensei mentioned, sometimes your snare wire is too stiff compared to the fixation power of the clips. So in order to avoid the drop off of the clip, we use a very thin snare that is commercially available for the CAPEMR. Great, and the last question is- In the stomach, we can use a regular clip, a regular snare. Snare, thank you. The traction is always kind of make us wonder. In retrospect, we should have used much earlier. And once you get used to it, we tend to just finish without traction. So in your opinion, is on-demand traction is better or routine traction is better? It depends. So I think I recommend so young doctor, so routine basis, but yeah, I think on-demand, on-demand use of the traction is a best answer. So if you can do the ESD without traction, easily completed. So of course not necessarily, but if you feel some difficulties during procedure to dissect or keep a good endoscopic vision. So in such a situation, I think it's better to use a technique of attraction. So we can accept any type of attraction. Great, thank you. Any question? Final moment, once, twice. Oh, Hiro, Hiro has a question. Dr. Inoue, thank you for the great lecture. I have a quick question. So if the lesion is located at the greater curvature side or lesser curvature side, do you feel like there might be some large fissile that could prevent to complete the fluid thickness reduction or ESSD because of arteries? So your question is attraction at the greater curve side and then- Yeah, ESSD or EFDR at the greater curvature side. There are a lot of like mental arteries. So do you feel it's a little risky to do that procedure in that area or? So, yeah, thank you very much. It's a anatomically very important question. So of course, you know, if we dissect the sub-therosal layer so we don't have not so much risk to direct injury to the adjacent vessel injury, but anyway, so it's the same to a regular ESSD procedure. So as long as we keep a good endoscopic vision so we can identify the exposed vessel. So before cutting, we can coagulate these exposed vessel easily. So the point is keeping a good endoscopic vision. Once we lose the good endoscopy vision and so when we cut the tissue without confirming the no large blood vessel, so sometimes cause a severe bleeding. So particularly when we perform the full sickness resection, we have to be very careful. But the, so outside stomach, the anatomically lesser curve and the greater curve is a position, the feeding artery coming. So a branch of a left gastric artery or a branch of a epiploid artery is going around the stomach, of course, you know. So when we approach to such a field that we have to be a little bit careful. But in the anterior wall, posterior wall, of course, you know, there is no large vessel, large artery, so it must be a little bit safer. Thank you very much. We have a online question from Mohammed Qadir, who's asking, can we use multipoint snare traction in the colon? Aha, so it's a good question. So multipoint traction in the colon, so we never applied it. So because in the colon, so the first reason is very simple. I'm not a colonoscopist. I'm focusing on the apogee, the esophagus and the stomach, so I have no experience to apply the multipoint traction technique to a colon. So Dr. Mayo, Tanabe Mayo-sensei is there? Oh, she's doing the hands-on session right now. Ah, okay. So in the colon, she has a responsibility for colon ESD. So in the colon ESD, I think use some other traction device. So particularly in the right side colon. So because external traction technique, so whatever, it's a little bit difficult to place the traction through the long way to the target area. Great, thank you. Ken? I'd just like to thank Haru for making the effort for this early morning discussion from Japan. I also wanna know, when you do your resections that go through like this, do you ever use ultrasound to map out large vessels to avoid them, or do you just do it during the dissection? Aha, so myself, thank you very much. It's another important question. So I myself do not use the ultrasonography to identify the large vessel outside the wall or inside the wall. I don't use it, but once I heard the lecture of the, that was Dr. Stavropoulos, so he mentioned that when he dissect the diaphragm in the case of a difficult caratia patient and the old, in his case, so he used the ultrasonography to confirm no large vessel. So I think, so your suggestion is correct. If you, if all of you feel the during procedure suspect, and yes, you have, we have to know, or the external anatomy, so we may use the ultrasonography. That's the best, one of the, particularly if you perform the USFNA or some other, so if you are familiar with using the ultrasonography, so it's a best objective sort of identification of the large vessel. Thank you. Great, that's a good question. Sometimes the GIST tumor has the feeding artery from outside and not from the internal musculus propria. So it's important to know where the feeding artery is coming in. Agree, Dr. Inoue? Yeah, yeah, yeah. You are right. You are right. That's sort of like of Kami-sensei and Ken and everybody's familiar with using ultrasonography. So yeah, for you, it's walking in the park. You can identify the vessel. That's a safer technique, I think, method, I think. Great. Thank you so much, Haru. It was a great lecture and we'll miss you here. Thank you again. Me too, me too. I miss Chicago.

traction method

ESD procedures

tissue traction

external traction

clip and line technique

upper GI tract

submucosal tension