Hi guys, so we are going to start the live demonstration of the ESD knives. This is Dr. Fei Inoki from Showa University. He will be demonstrating the IT knife for the gastric ESD. So now I have this dual J knife here. So this is 2.0 dual J knife. So he is going to start with the marking of the laser. Whenever you are using the IT knife, you need to have two knives. So one for the marking plus initial small incision for the IT knife. And then followed by IT knife. And then he is going to start the marking. Are you ready? So for the generator setting, we have end cut I, effect 3, duration 2 and interval 3. Is this your normal setting? Yes, I think so. And then post quark effect 2 and 25 watts. Hero, an important point to remember for those of you guys out there that are practicing on ex-planted models that the settings that you use in live animal or in humans are different than the one that you use in ex-plant. Usually in ex-plant you need higher settings. And the reason is that the water content of the ex-plant is lower and you need the higher voltage basically to accomplish the same tissue effect. So whatever we are using here today right now may not necessarily directly translate into the settings in humans. I have a question. Yes. Is the knife open or closed right now? The dual knife. When you are making the marking. With closing. Close, yeah. It's enough with dual knife. And then first we have to inject. Yes. Okay. So that point is important when marking the knife needs to be closed actually. Yes. And a common question that we get is where to start injecting. Can you lead us to that decision making? Yes, yes. Okay. And then when using the IT knife we usually inject the distal side of the lesion. And because we move the IT knife with a pull back, therefore we make the injection at the distal side of the lesion. Yeah. Okay. Another way to think of it is at 12 o'clock. Basically, yes. Depends because whether you are retroflex or forward view it's always at 12 o'clock. Thank you. Another thing I noticed you are injecting outside of your dots, not into the dots. Can you tell us why that is? Sorry, dot? Marks. Mark, dot. You're injecting. Yes, yes, yes. Because the injection flow, sorry, is towards the tip of the knife. Okay. Then please imagine the flow of the injection fluid. So you can inject and then the distal part of the mucosa will elevate. Thank you. Okay. Sorry. And then first we will make the mucosal incision for the entry part for IT knife. So you don't inject all the way around? Only one area? Actually, yes. If you are really good at ESD, you first inject the whole region. But if you are not familiar with ESD, so first you can inject on the one part. So you can see the elevation of the mucosa. Like this? And then you can... I believe that even for those that are advanced ESD, it's a good idea to inject just at one side, because this is a crucial step right here, getting that initial access to the submucosa. Okay. There is no rush. And the first important thing is to make the entry to the submucosa, And then probably you can see the submucosa. And if you feel it's too shallow, you can add the cut like this. It depends on the situation. Probably it's enough. Okay. Let's move on to the injection. This issue came earlier in discussion in the question and answer session, but the first move with the dual knife is in, and then lateral. Yes. Sometimes novices tend to immediately move lateral, and then you end up with too superficial of a cut. Injection. Injecting. Thank you. Injection. This is a beautiful demonstration of another important point. You see the injection is in the previous foothill of the injection. Yes, yes. Not in a fresh spot that has not been injected. Okay. I think it's enough. Yes. Okay. And then, actually, I want to tell you an important thing for ESD. Actually, I brought it from Japan. It's the importance of deflation, the importance of the control of the volume of the air. It will make the situation different. So please remember, you naturally inflate. You naturally inflate. Therefore, deflation and the control of the volume of the air is very important. If you deflate, the membrane and the semicircles will be thicker and softer, and you can grasp more lesion. And then, please remember. Thank you. So there's a question from the audience. What's the setting for marking, post-coagulation? We typically use soft coagulation for the marking. And the reason is… Sorry. That's okay. But I cannot cut with itiner. Because this entry part is too shallow. Too shallow. Too shallow. And then add. Back to the marking. Soft coagulation is the typical setting for two reasons. One is you don't want to actually puncture the mucosa, because then when you start injecting, fluid will start coming through the marks. And the second reason is that when using soft coagulation, you tend to get less char on the knife, and you don't have to clean it. So if you're using post-coagulation spray, the knife tends to char. So as you know, the post-coag has a very strong spark, so sometimes it's too much energy to the thin mucosa. So if you are using it for horny PSD, just to make sure it's not going too deep, you can make some mucosal hole, which makes the elevation very difficult. But this is the extremal tissue, so that's why we are using the post-coag. I have a question. Yes. So you now have the choice to cut to the left or the choice to cut to the right? You're choosing to cut to the left. Why? Because the knife comes from the left side, so it's easier to cut this side. Because it depends on the actual situation, so it depends on the gravity. Yeah, yeah. But now I can't. So in general, you cut the downside to gravity side first, which is in this case the left side. Yes. Perfect. And then move the scope or move the device. Move the scope or move the device. Because we have the insulation tip at the tip of the knife, so we can cut like this. And then IT knife is weak for the lateral cut, like this. And then we have to move on to the other side. Okay, and then... Hiro, do you... Yeah, go ahead. Sorry, as I said, we naturally inflate like this. Then please deflate. So periodically you have to evaluate the amount of air just to make it softer. Right. Hiro, you wanted to ask something. Yeah, so I think I wanted to emphasize that because Dr. Inoki did some mucosal trimming, now the tip of the knife is deep in the submucosa and then he can do the effective mucosal incision. That's some submucosal dissection. Hiro, do you usually hold the scope and leave the knife there or do you hold onto the knife? In general, I like to hold the scope. Scope, okay. And keep the knife in the same place. Correct. And one important difference also, Hiro, thanks for bringing this up, as you probably noticed, the knife is extended from the scope quite a bit. As opposed to the dual knife where we work very close to the lesion, with the IT knife we work from some distance. Yeah. So that's an important difference. Okay. Beautiful. And then we can add the… So the depth is enough, but now you make the trimming like this. And then you can check the depth of the lesion, like this. Okay. And then sometimes you can use attraction, but now I will continue with… Do you want to inject at this point a little bit more? Yes, we can inject. Okay. From novices, I think this will be a good point to inject at this point, to get a little bit better of it. Excuse me. And then deflate, deflate. So one of the downsides of the IT knife is that it does not inject. Yes, yes, yes. On the other hand, it's a very efficient instrument, so once you inject you can very quickly finish the lesion. Yes. The other thing is I feel like the IT knife creates a lot of smoke like this, so periodically you have to suck the air to clean the ESD fuel. Yeah. Exactly, right. And then I think this scope is not the therapeutic one. Correct. Because the channels… Do you want me to take this off? Is it okay? Yes. Oh, okay. So the channel diameter is not large, only 2.8. Excuse me. Do you typically use therapeutic scope for your gastric ESD? Yes, yes, I think so. Because you get better suction, I assume. Yes, yes. And then… So there is a small tip for the injection, so needle in. And then you can elevate the lesion with the sheath of the needle, and then you can needle out and then inject. Beautiful. Okay. Small technique. Okay, enough. And then let's move on to the device. Okay, probably the mucosal flap is made, and we can go under the lesion. Or, and then if you… Similarly, if you go into the lesion, please deflate. Yes. Deflate, deflate, deflate. And you can see the difference. Or the trimming is not enough. And then the needle out. Okay, let's go. Okay, let's try. So this is the initial flap creation here that we just did. And now we have nice access to the sub-mucosal. And then catch the edge and then cut. And then from the other side. So guys, this is a beautiful demonstration of the typical IT knife technique, edge to edge. You want to catch the edge on one side and carry it to the edge to the other side. And mostly use the blade of the knife rather than the back electrode. Nicely done here. And then if you deflate, you can easily go under the lesion. So deflation is very important. And then let's attack the edge. And then edge. And then you can continuously see the edge. And then now go back to the center of the lesion. Okay. You can cut like this. Beautiful. Very nice. Thank you very much. Thank you. Very well. Very well. Okay. If this was a life case, do you typically coagulate vessels? Yes, actually, yes. The problem of the gastric is actually the bleeding. And sometimes severe bleeding. So we have to coagulate with a coagulant spa. Sometimes. Do you usually cause the defect of the gastric VSD? Actually, it depends or no. No closure. No closure. Because the frequency of the delayed perforation and the delayed bleeding is actually low. Yes, considering the cost and the time of the closure. Okay. So how long does the patient typically get admitted? How many days? After the ESD, two or three days. Two or three days. Okay. The patient will be on the PPI. Yes. Okay. So this is an important difference in between Japanese practice and U.S. practice. In the U.S., most patients get discharged the same day. And that's why in the U.S. we tend to favor closure. The other reason is that closure with clips is difficult in the stomach because the mucosa is thick. In the U.S., though, we have the overstitch device, which makes closure fairly easy. So there is no one-size-fits-all, so you have to take multiple considerations. If the patient has to go promptly on some anticoagulation, maybe closure is a good idea. If you're planning to discharge the patient, maybe closure is a good idea. On the other hand, if the patient is otherwise healthy, no anticoagulation, and you're going to keep them in the hospital anyway, then you can leave it without pneumonia. So it is something that you should consider on a case-by-case basis. How about applying any prophylactic gel or powder? Gel or… Puristat or… Actually… Yeah, I know that's available in Japan. Yeah, yeah, yeah. So we usually use the Puristat for the oozing. Okay. Yeah, yeah. Oozing. Okay. Not at the end as a preventive measure. Very good. How about in the esophagus? Do you use Puristat for stricture prevention? No, so we don't use that. Okay. Yeah, yeah, yeah. Okay. Well, since we're on the topic, what do you do for stricture prevention in the esophagus in your practice? In the esophagus, we actually use the steroid injection. Yeah, yeah, steroid injection. So if the mucosal defect is large, yes, more than three-fourth, and then we will inject. Okay. Got it. And then oral prednisone too, or… So actually, the oral prednisone is not a standard treatment. Okay, only topical. Only topical, yeah. Okay, thank you. Yes. And when do you bring the patient back for the first dilation after esophageal ESE? What time after the ESD? Actually, within one month. Okay. Yeah, yeah, yeah. So this is a very important point. You don't want to wait until the stricture forms and mature collagen gem forms. You need to start early dilation. Yeah, yeah, yeah. Typically, within three to four weeks. Yeah, yeah, yeah. Rather than wait and then dealing with mature stricture. Let's see whether there is any questions online. We don't have anything. I noticed that you are using cutting current for the submucosal dissection. Yeah. Is that what you usually do in your practice? Yes, yes. Actually, I use the… I prefer to use the cut. Because if I see, actually, so the obvious vessels, so we use the coagulation mode. Is it like strong post-coag or just low setting of post-coag? It's a post-coag, post-coag. Regular post-coag. Regular post-coag, yes. Because the coagulation mode will make the submucosal shrink. So you don't like the dissection plate to be shrunk. Yeah, yeah, yeah. Okay. So you use cut as long as you don't see any blood vessels. Yeah, yeah, yeah. Okay. That's a good point. It's an excellent point. Another downside of using coagulation for the submucosal dissection is that you char your deep margin and you may end up with a positive deep margin when actually you have taken the entire lesion out. So multiple considerations here. Well, this was very nicely done. Thank you very much. Thank you. Thank you very much. Thank you very much. Yes. Thank you. So we'll be back in 10 minutes for the next session. Dr. Nishimura will be doing EST with the pro knife. Pro knife, yes.

Gastric Endoscopic Submucosal Dissection

IT knife

Dr. Fei Inoki

Showa University

ESD techniques

post-ESD management