Okay, welcome back. I'm with Dr. Amit Bhat from Cleveland Clinic. So this time, it's going to be the last session for today. We are using the Medtronic multifunctional knife with Prodigy wire for the traction. All right, hi everyone. So we've taken a simple lesion here in the stomach. We've already made markings around it, and we're going to do our circumferential incision. So with this knife, I just want to show you, it has a needle knife component, so it can act like a normal needle knife. Then we can put the needle knife in, and it can extend and actually become an insulated tip knife. So it's a way to get both knives in one device. So to begin with, we're going to go to the needle tip knife, and we're going to start off making an initial incision, and one of the key things that we want when we do traction is we generally start off with a circumferential incision. Because after you do traction, it can become challenging to get to all the mucosal areas. That's a great point. So we always finish, complete the mucosal incision before applying the traction. So that's the key. Nice. So we're going to go from the other side now. This corner's sometimes become a little more challenging here, just want to make sure we stay at good length. Then here we're going to start some trimming to make sure that we get rid of any muscularis mucosa that can hold a lesion down. Normally I would do this with coagulation, but in the pig model we're using endocot. In the gastric ESD, do you typically do incision with the needle portion and then do dissection with the insulated tip? Exactly. So I love insulated tip. So I think to make the initial incisions to get the access to the submucosa and the trimming, the needle type knife is nice, but the insulated tip knife is a really good way to be able to dissect quickly. So here we've made our mucosal flap, if I can find my lesion again. You can see that there's good separation between the mucosa and the lesion, which means we've got through that muscularis mucosa and the lesion should be amenable to good traction. Now the device that we're using is called the traction wire. It's a two-set device, you do not need to remove the scope, the scope stays in place. And the device simply fits through the accessory channel of the endoscope. I'm sorry. No, I struggle with that as well. They say it's supposed to be one twist, but I can never get it. Sometimes when I'm scoping, I sometimes just wait for the assistant to get ready. So here, we'll sort of show you the principle. So this is an endoclip that's got a wire pre-attached to it. We want the wire to be at six o'clock, so Hiro's moved it right there, opened the clip. And mostly when we open the clip, the wire changes configuration, that looks good there. So here, we want the clip to grab the mucosa well. We don't want it to grab the muscle there. So you can see here, I'm visualizing what we're putting the tissue on. So close. And now I feel I've got a good secure grasp of that mucosa, deploy. And now we've got the wire that's dangling down. So then I'm suctioning to bring the other side of the stomach as close as possible. You can see there's the resection defect that was done before for a prior ESD. And here at this point, I sort of want to plan out my strategy. My strategy is I want to grab only one side of the wire with the clip. And as you can see, the hardest part is really unwinding the equipment. Now I understand how techs are feeling when endoscopists are watching me. We'll just blame Ross. Rotate the clip to be at 9 and 3, if you can. Yep, that's good. So here, we're generating, making sure the pig stomach tends to be a lot thicker. Close. Mucosa. So we just want to make sure we've got a good grab. Deploy. Release. Beautiful. Now, we're going to inflate. And once we inflate, then the traction wire starts to give its traction. And because of its length, it has flexibility. It's less likely to be pulled off. It can adjust as you dissect along. And the more you inflate, the more traction you get. You can also, because of its flexibility, put it right on after your mucosal incision. So I'm going to show you the first part with the needle tip, and then we'll try to change to the IT afterward. So let's put the needle tip knife on. That's good. Now you can see, with traction, we don't have to be as close to the submucosal layer. We can actually dissect from a distance, because you can see that space where the muscle layer is as well. And once you have an open area to dissect through, it's much easier to precisely know where you're going through. I think we should have chosen a bigger lesion here. No, but this shows the basic principle of traction in a knife, how to use the knife. So yeah, great demonstration. So we're going to change over to the IT knife. Open. And you can see, we haven't even re-injected, right? So the other part about traction is there's an advantage, because you don't need to inject as much, because the space is kept open. I'm just making an edge now, so to allow the IT knife to be able to hook around. Now you can see the IT knife, you actually need to cut under tension to be able to cut through. So we're hooking that tissue, and it allows for really fast submucosal dissection. You have to be careful, because you can cut vessels and other things, because you're grabbing so much. But the electrical density is less on the IT knife, so it tends to have more coagulation effect. As you can see, we're already at the end of the lesion here, and we're able to, boom, dissect through. Wow. So fast. Very nice. Thanks. Beautiful demonstration. Then this clip is designed to be atraumatic. So we can show you that there's two ways. You basically retrieve the lesion and the wire at the same time. The grasping force, yeah? Yeah. Okay, perfect. So there's no teeth on the anchoring clip, so when you pull it off the mucosa, it causes less trauma. You can use a snare, you can use whatever device is available, and you can be able to do it. But I'm just going to show you the easiest way, is to just grab open the clip itself. Close? Yep. And as long as it holds on that, okay. Now you can see we're pulling both the clip and the lesion and the traction wire all out in one simple go. All right, there you go. Open. Close. So now, do you routinely use the traction for your cases, or sometimes on demand? So more and more, I think the traction is, I think, the next evolution of the ESD, right? And we try to use it as much as possible, and I think it really speeds up and reduces the time for ESD. But not all lesions need traction. Sometimes traction can actually harm you as well. So for esophageal ESD, we like to use tunneling technique. If it is a very large lesion, we use clip line. For colorectal or gastric ESD, we love to use traction. I think gastric ESD is absolutely just beautiful with traction, especially rectal or colon. Yeah, very nice. So you're able to see how the traction works in the stomach. Because this traction wire has a very long wire part, instead of like a very small rubber band, it has a capability to apply the traction for the gastric lesions. That's a great demonstration. Yes, that's a good point. So the stomach is very capacious. So unlike the colon, there's places where you need a longer wire to be able to get to the other side. So the traction wire comes in both at 20 millimeter and 35 millimeter, based on how far that opposite end is. Thank you very much. That was a great demonstration. This will conclude our live demonstration session.

gastric endoscopic submucosal dissection

Medtronic multifunctional knife

Prodigy wire

traction technique

Dr. Amit Bhat