Thank you. Good morning. Congratulations to the course directors, Peter and Hiro. You collected fantastic t-shirts, worldwide experts. So I'm going to start my lecture talking about tools for ESD, and it's more of a basic stuff, but I want to let you know what we're thinking, how we're going to use those tools. I'm a consultant to CREO and Boston Scientific. Those are the steps of ESD. I'm not going to go through the whole thing, but you have to really plan well how you're going to execute the ESD, and you have to choose a scope, and then start with the marking, with the selected device, and inject the fluid, cut the tissue, use a traction maybe, and do the hemostasis as needed, preemptive coagulation or reactive coagulation, and close. I prefer to close at the end, and then retrieve the tissue and process the specimen at the end. Things first, the endoscope. We choose the endoscope for some reasons. The length is an important aspect. We don't use an intermediate colonoscope here in the United States often, but the intermediate length actually makes it much easier to handle. You can make it shorter to make it stiffer, so it becomes more one-to-one movement, so I have one adult colonoscope in the intermediate length. The channel size is important as well. Most of the time, you hear that the larger channel is better because you have the tools inside, but you have a frequent need for suctioning fluid, blood, and if you irrigate, the water may be coming the way. Channel size matters, and the visual quality, the chip, and if there's a zoom capacity or not, that's another aspect. Frequently, if you use a PCF, pediatric colonoscope, there's no zoom function except for some companies. If you want to really do a good examination, you may want to choose first adult colonoscope or upper scope with zoom function, and then either continue on or you exchange the PCF for better handling. Many of the company's spec sheet has a lot of information, and nowadays, we see the water jet direction and the device tool channel exit. Those are very important things. I wanted to mention several key new endoscope. One is a therapeutic PCF coming from Olympus, which has a much shorter bending portion, which make it really agile within the colon. You can use it in a duodenum if you need. It has variable stiffness, and moreover, the channel direction is much more centered at the bottom, and the water irrigation goes to the center, so you really focus on the field of the interest. Another one is the Fujifilm came up with this slim therapeutic gastroscope. The amazing part is it's much smaller in the format, 7.8mm with a 3.2mm channel, so it has the capacity to suction past pretty much all the tools, but the diameter is very small, so this is a great upper endoscope for the intervention. It was just passed the FDA approval, so we probably will see more and more, and I think there are several scopes in animal lab. The other thing is a double channel endoscope released by Fujifilm. It has a much better bending capacity, even with the tools inside, and it matches really well with overstitch, so this scope is really something to think about. The other thing is scope guide. If the colon is very difficult, you may want to use a scope guide. All the adult colonoscopes are compatible. You can pass a scope guide into the channel and see the configuration. I'll show you the channel location, what it really means. This is adult colonoscope coming from right, going to the left. This is a new therapeutic pediatric colonoscope, so the tools go centered, a straight shot towards the center. The water irrigation comes in this area, too. This really became the workforce in the colon ESD. The upper scope, the channel comes from the left, so naturally you tend to go left to right because you can see what's coming into the way, so it kind of modifies how we approach the lesion when you're doing the dissection. Next is a cap. We really have to have a cap attached at the end. That would act like a counter traction when you push against the tissue and keep the visibility better. At the same time, this cap can be used to tamponade if there's any bleeding. You tamponade it, be ready for exchange of the tool, and then once you have hemocytic grasper, then you can just apply the cautery. For colonic ESD or difficult areas, this cone-shaped ESD hood is frequently better. There are two types. One is a short ESD, and one is with the channel guide. The appearance is a little different. Length is only one millimeter difference, but it makes you feel so much different, so you have to get used to one of the tools, but this makes it much easier to go into the semicosal space, as well as keeping the pocket or tunnel creation easier. We're living in an obese society, unfortunately. 40% of people in the United States are obese, and the Overtube setup is frequently ideal because you can get a lot of exchange of the tools. You can come out and wipe off the scope and go back in with different scopes. There are two types available. One is the rigidizable Overtube. One is the double balloon system. Both have good features. You have to get used to it. You cannot just do on-demand if you're not used to using it. So if you plan to use the Overtube system, you have to use it frequently to get used to the feature and make the best use of it. Injection needle has several diameters. The 23 gauge is much easier to push. Your assistant would love you if you use a 23, but a 25 can be used as well. If you use a thick solution, 23 is recommended. The length is variable, usually 4mm as a standard, but you can go from 3 to 6. You can choose which one you acquire and you get used to it. Maybe a short one is better for semicolon injection, but in a gastrochemical it's sometimes just too thick, so you have to have a longer one. Nowadays we're moving towards more of an additional injection through the knife because that negates the need for exchange. At the same time, on-demand expansion of semicolons is much better than just exchange and give the long-lasting solution. So most of the time, we change the saline or Hespan injection through the cutting needle. In addition, once you have access to semicolons, you can choose to use a pump or you can use a handheld syringe. For increasing efficiency, some institutions use a 3-way coke stop, so that you attach the syringe and the IV bag to the other side, so you change the direction and aspirate the fluid and just refill quickly. For the flip pump, I suggest to use the lower power initially. If you use the high power, it gets bubbles and too much water, you have to end up in suctioning more fluid. Now injecting the variety of color, there's a preference, I tend to like more and more lighter color because I can see the structure better. But at the beginning, maybe it's better to have a much more blue color so that you know exactly where you're cutting in. The only thing is if it's too blue, then all the field can be blue and you can obscure the vasculatures. The saline plus epinephrine, the epinephrine was really debated. Several run-by control studies show that in gastric ESD, it is beneficial. The shortened time, it can be helpful. But in other locations, we still don't know. So typically, I don't use epinephrine nowadays, except for gastric ESD. If you use it, it's more than 100,000 or more diluted. Common fluid is a heta starch, methyl acetyls, a hyaluronic acid at a good dilution. You can use indigo carmine or methane blue. I prefer indigo carmine because the color is much more bluish. The methane blue is a little more light color. And a lot of commercially available injection fluids are now available. I would suggest to read the GIE editorial written by our friend Emmanuel Coronel at MD Anderson. It lists all the available commercial fluid. Now come to the knife. We are seeing a lot of additional knives. So we have to really see what the benefit of those knives. The length is a variable. The Fuji flush knife has a much more variety in the length. And other feature on other knives is original IT and IT2 increase the cutability. IT nano is used for more of a delicate area like esophagus and colon. Hook knife, TT, and duo knife all came into the JET function. So it's a little more costly, but probably you should use the JET function with the knife incorporated. 1 to 1.5 millimeter is recommended for colon duodenum. 2 to 4 is esophagus to stomach. Most of the time the standard is 1.5 and 2. You choose to use the longer length. Now more knives are available. The hybrid knife has been there for a long time, and I totally apologize. I was going to plan to put the hybrid flex, which is a new knife, which is a fixed length 2 to 3 millimeter, I'm sorry, 1.5 to 2 millimeter length. And it doesn't have this variable length. And it's a little bit smaller in the needle tip and much more flexible. So that's what's going to help through the animal lab. That's a really great addition with a really fine high-pressure water jet. Prodigy came up with this convertible needle tip and IT knife. It doesn't have an injection capacity. We see these two classic knives are kind of a go-to knife, duo knife, flush knife. The other knife, like a pro knife, with a really good injection through the center of the knife, it's a 1.5 to 3 millimeter and a similarly gold knife with a gold plated. It has less adherence of tissue and three varieties is available. Speedboat, you don't get to use this this time, but this is a bipolar knife, only available in this format if you use a bipolar knife, and the tissue reaction is really phenomenal. SB knife and the clutch cutters are available as scissors type. Now scissors is a little more cumbersome to use as you have to rotate in the right plane, but it has a capacity to grab safely, coagulate, cut. So it tend to take a little more time, but it's much safer. Some physician prefer this knife over needle tip because you can perforate really easy. However, you have to get really used to it. I know that the SB Junior 2 is available, haven't confirmed it's available in United States yet. So it has a little better function. You can see all these knives merging together. These are kind of serrated opening. What's absent in the SB is coming in to incorporate it. So multiple knife has a similar function, and you have to know what's the cut ability, what's the power of coagulation, because thicker knife give more coagulation. You have to really adjust the power on the electrosurgical unit. So try out and see how it fits, and adjust the power in the electrosurgical unit. I think towards the end, the traction-assisted ESD is getting more popular, and I think it's really help you at the beginning. It reduces complication. The speed increases. The procedure time cuts in about 30%, and it can be used for liquid location and lesions. When you have those lesions, first thing to consider is the strategic approach. The pocket creation method was actually reported in attempt to conquer difficulty with the fibrosis. If you have a pocket, the fluid doesn't go away, so you maintain the lifting of the submucosa, and this needs a ST hood so that you can just go inside really quickly and in agile fashion. But then you don't have the loss of traction. So pocket creation is one, and the tunnel method is becoming more popular. Shyma, you're calling it the bridge method, right? And this is a very similar technique that is kind of evolving in different ways. The external traction is the first introduced to aid the submucosa dissection because you have to expose submucosa. And once you have the tension, application of electrosurgical energy would disrupt the tissue really quickly. So the procedure gets so much faster. Clip and line method is the first thing we have been adapting this technique. You put the suture around the arm of the clip, introduce into the target area, grab the tissue so that you have a tension by pulling this suture from outside. There are multiple ways to modify it. There's a bendable forceps or double scope method. It tend to have interaction between the scope and this traction device, but it may work. Those things are very useful because it tend to give you more dynamic traction because you can change how you give the traction. The external traction is typically one direction because you just kind of keep pulling. So we modified that. Hiro and Philip G has published this pulling method with a suture. You can attach the suture by putting over stitch, bind it, and bind the opposite location, and that creates a totally different direction on traction. You can do the similar thing by applying a clip when you're using a clip and string. So that's a pulley method, and this is a suture pulley method. The other way is a clip and snare. You can attach the snare onto the clip. So that will give you pull and push method. And to make it stable, Haru and Dr. Shimamura published a multi-point traction method. Essentially, you clip the snare onto the target tissue by two to three so that it becomes stable, it won't come off, and you can do the pull and push method. Other thing is internal traction. These are not available in United States, so I skipped that. We have a wire traction device that Dr. Bhatt is really familiar with, and elastic traction device with a rubber band. Those are pre-arranged clip with this traction device. And then once you apply onto the target tissue, you grab the opposite side of the loop and either attach to the proximal part or opposite side to give a traction. This curvature with this wire give a natural traction, keep going up and up. Or you can put in the opposite side and give a really kind of a bouncy, the variable traction, rather than similar way. And it comes with additional clip so that you can attach to the opposite side. Now, in an area that they don't have capacity to buy those devices, people tend to use a dental rubber band. That goes through the channel. You grab with a clip and bring it down and do the similar thing. And I've been to India, they created this multiple rubber band traction system. They're getting more creative, making it in a cheaper way. You're gonna see the track motion. This is a double channel scope system. It's situated inside the channel, so you don't have to use it. And it can be on demand, but you have to use a double channel endoscope. When you push it out, this portion comes out and with this handle using with the right hand, I open and close. And open close goes from continuous transition from grasping to bending. So you can adjust the bend, how much. At the same time, you can rotate. And the feature is it locks position automatically. So once you have the good position, you can just let it go and you can continue on dissection. So you can try out, I think this afternoon. The only thing is that this is within the same endoscope. So both move at the same time. You feel like you have great traction. Once you try to start cutting, it just doesn't work that way. So you have to figure out how to make it work. When it works, just beautiful. If it doesn't work to figure out, it frustrates you sometimes. So there's the traction method. Hemostasis, we have only one variety of the devices, coagulation grasper, coagrasper. The small one is a conic size. It has a reason. It's a long length, but because of the smaller head, it has a little less aggressiveness to avoid the thermal injury. The standard is the center one. And there's a big one, a gastric coagrasper that grasps the larger vessels, typically present in the stomach. So if you have trouble, then you can pass this one and give a much more coagulation. Typically, we use a soft coag and then using a needle knife, you can do the low energy delivery to just pre-coag the vessel before you cut. If you have trouble, you can apply this viscous hydrogel to temporize the bleeding and you can just see where the bleeding point is, then apply the cautery for permanent seal. Now, new image modality, probably you have heard RDI is available as a new system. It changes the light source similar to MBI. It's a wavelength is different. So reflection make the blood, make the yellow. And some of the blood make it transparent. So you can see the bleeding point much better. And it gives you some calmness. I've done several times. The only thing is image quality degrades. You can see the difference, right? So when I was using it, I feel a little uncomfortable because I cannot see better because of the image difference. But definitely you can see the bleeding point better. So that's something that you can use. I feel comfortable looking through the red. So I don't really need that frequently. But at the beginning, it's really probably nice modality. Now, the lastly is a closure. We have multiple clips over the scope. I mean, I'm sorry, over the scope clip is not used in ESD arena unless you have a big perforation, but still it's very difficult to close with over the scope clip because the wall is thinner. So we resort to the clip or suturing and or this in-between extract system. There's a four tags, create the approximation and through the channel. I want to just introduce the newer clips. There are a variety of clips available. One thing you can see the tail length is really different. So once you deploy, sometimes the tail just get into your way. So you have to choose the right clip. Most recently, the standard length became longer. So the bigger clips are available. 11 was standard. Now the multiple companies has a much larger format. And two clips are worth mentioning. One is a dual action tissue closure device. You can close the right and left separately and deploy all at once. It comes off right away. So this is a really great tool to approximate the large defect. At the same time, there's a different company has this aggressive teeth called Mantis Clip. I can capture the one side of the wall, the mucosa. When you bring it to the other side, it just doesn't let go because the angle is 90 degree. So those are two clips that you can use for a closure of larger defect. Lastly, Dan, this is for you. He did a fellowship for the Interventional Luminal Fellowship and he was working really hard to pin the specimen. The pinning of specimen is actually to recreate the shape so that you can orient, you get to know exactly how you removed and what the margin look like. Sometimes the shrinkage makes it very difficult to recreate the shape. So just pay attention that don't make it as a different shape. We occasionally put the marking to the oral side, but I really like to discuss with the pathology tech. This is my tool. You can go to the Hobby Lobby. It's really cheap. You don't wanna see the big, the red and yellow plastic hothead. This is really nice, number 17, 1 to 16. Please mark it down. And the clip, cork board should be thin and it floats to the, on the formerly. Now there's a kit for the pinning, but these two sets really works well. So that's a tool. I'm sorry I went over time. Thank you very much for your attention. Thank you.

Endoscopic Submucosal Dissection

therapeutic devices

hemostatic tools

traction methods

image modalities

specimen handling