Welcome back. So I'm with Dr. Juha Wang from Stanford. We'll be using this gold knife, 2mm from the Microtech, and also we have the short track. So as I said, this is a through the scope traction device, so Dr. Juha Wang will be demonstrating the live case to show the gastric ESD with the short track. Alright so we have the short track device. We have the gold knife first, so go ahead and put out the knife. This is a gold plated tip, go ahead and do a little injection. So it injects through the center, okay that's good. It has a relatively narrow channel, so it gives a nice high pressure injection. And so what we're first going to do is, since we're doing a traction with the short track, I'm going to go again in the gravity dependent portion so that it's a legitimate scenario where you're going to want traction, we don't have gravity, we're working against gravity. So the first thing we're going to do is marking, so needle back. So when I do marking, I typically do it with the needle retracted. This is ex vivo porcine tissue, so we're going to use a fairly aggressive coagulation setting. I'm using actually a spray coag setting to do the marking because it makes some nice marks. Let's test that. Yep, so this is what the mark is going to look like. So we'll do a decent sized lesion here. All right, we'll go on this side, let's see, and then we'll move in. So you can see Dr. Wan is using his body to stabilize the scope while holding the knife. Or sometimes you need to support the scope, so it depends on the stability of your scope whether you need to hold on to the scope or you can have the device. I almost always support the scope on my body, even if I'm rotating. So I use my right hand more for advancing the scope and maybe subtle torquing maneuvers, but most of the torquing, especially for upper ESD, is done with my left hand and my body. So I'll rotate. So if I stabilize the scope on my belly here, I'm in a very comfortable position for one. I'm not having to hold the scope in this configuration. So I just support the scope a little bit and then I can, if just some small shoulder rocking, I got quite a bit of motion that's very, very steady and controlled. And then I use my right hand to adjust the distance, right? And so I can just kind of maneuver. And then I also want to use suction too. So I can do, you know, two things with marking. And I think, you know, there's one school of thought. You never take your hand off the right, you know, or your right hand off the scope. I'm not of that school of thought. I mean, most of the procedure I do with my right hand and control it. But there are some times when I, especially when I'm doing some device manipulation, I want to stabilize the scope to my body and then I just, I can move it out. And marking is one of those, because sometimes I want to see where the lesion is to make sure I got the right distance. If I'm moving the scope, I often can't see the lesion. And so if I want to see where I'm going and kind of have a broader field of view, I will just stabilize the scope to my body and then move, move my body to do the markings. Right. Okay. So this is a very important part to do some like a very subtle movement while doing your ESD. If you're holding like, your right hand is holding your small wheel, you're not going to be able to do some subtle movement during ESD. So by having the control on the scope by your body, you'll be able to adjust the length of your device very precisely. Okay. So we've done our perimeter marking. So now we're ready for injection. Very good. Thank you. I always want to control the, your inflation. You don't, you want to make sure you don't ever over distend, especially with injection, because if you're distending the lumen, it'll make it harder to do your submucosal injection. And you might not get a good lift. So always make sure that the lumen is adequately decompressed before attempting a submucosal injection. So depending on where my lesion is, I'll decide where I want to do this lesion. This one's a pretty straight lesion. If I'm in the colon, I often will start my injection distal and move proximal or, you know, in the colon, it would be, I'd start oral and come back anal. But in this particular configuration in the stomach, the direction of my injection is going to go away from me. So it's actually going to be more efficient for me to inject from, from proximal to distal. Okay. So we'll just go ahead and inject. Okay. We've got a nice injection there, stop. And then I'll build on this injection. So right at the base inject. Beautiful. Okay, stop. Then we'll build here. And again, I'm stabilizing inject. I'm stabilizing the scope with my body. This makes it much easier to do the injection. Okay. Inject. Stop. Then we'll keep on building on this. Inject. I'm moving at the same time, stop. So this is the principle of a dynamic injection. And also in my needle is going in inject, basically where I'm anticipating my cut line to be back, stop, inject, stop. And then here, it's kind of the distal margin. So I'll come back here. And then I'll start my injection over here. Inject, stop. Do you penetrate a little deep and pull back the needle? Yeah, I make a sharp, because the one place, you don't want to be superficial. And inject into the mucosa, just above the muscular mucosa, because then you often get a hematoma. And so that's even worse. So I inject and then pull back, inject, stop. So occasionally, you can make intramucosal injection, which usually cause a hematoma, which makes the mucosal incision very difficult. Stop. Good. So this is a decent size lesion inject that I've created here. Stop. Yeah, and even with the needle injections, you want to be precise. I mean, ESD is all about precision. Inject and precision comes from stable scope. Stop. Inject. If you're in your stomach, do you prefer using dental floss or short rack, which is more? So yeah, the stomach is the one area that it can be a little bit hard to do. Sure track my inject. I prefer stop. I prefer let's go and get the knife. I think I've got an adequate circumferential injection there. I prefer sure track in the colon in the stomach. I will often use a clip in line, okay, but yeah, technique. So in the US, we usually don't use dental floss, but we'll use a suture, long sutures. Is it like overstitch suture or just a surgical suture? You can just use a surgical suture. Is that nylon or like a silk? Yeah, nylon. Yeah. You just have to make sure it's long enough. It doesn't matter which one it is. Silk is fine too. You just have to make sure you get one that's about 200 centimeters, right? So all right. So now with the incision, we always talk about being stable. And this is another point where I use my device. I pin the scope again, be stable. And the key is to make sure you get mucosal injury before you start moving laterally. So I'll tap. I'm not in yet. I'll advance it again. I'll do it one more time. So now I'm in. So now this white disc is flush with the mucosal surface and all I'm going to want to do now as I'm doing my mucosal incision is to keep that white disc kind of floating on the mucosal surface. All right. So kind of keeping the view of our mucosal markings. I'm using suction to keep it as perpendicular as possible. I don't want to be tangential. And then I'm very deliberate. I'm not trying to do this real fast. I'm not staying on the pedal. If you hear, I'm just tapping, right? I just tap. You know, in a real live situation, there's oftentimes a lot of blood vessels. And so if that's the case, then sometimes I'll cycle through to get some coag or I'll switch over to dry cut. But it's almost always a cut current. So let me just see where my markings are. So my markings are here. So I can come back over to the right now. So you are cutting from six o'clock to 12 o'clock. Do you sometimes do opposite direction? So the key is you want to make sure you're cutting away from muscle, right? So I don't like cutting backwards, because you can dig the knife into the muscle. So I like to keep the muscle in front of me and making sure that my my knife movement is not going into the muscle. That's the most important thing. Yeah, it's very important. But when you're using needle type BS knife, always start from proximal to the scope and then go away from the muscle. Yeah, because if I were to cut back this way, I'm cutting into the muscle, right? And so I think you're at higher risk of perforation if you do that. So then now we're going to go the other way. And again, I just I don't I don't rush. I just want to make sure that I'm in good position and very precise and accurate with each one of my cuts. You can see each time he's not rushing at all. So he'll just adjusting the tension and also direction after each cut. So this is very important, but don't rush and then check the direction and then just adjust the direction and the tension. And if you notice how I'm holding the scope, I'm still pinning the scope to my body. I'm working, I'm controlling the scope with my right hand. But what this does is it takes a lot of the tension. If I hold it like this, then I'm like way, way, way too dependent on my right hand and it I'm not as stable. So if I stabilize the scope with my body, then I just have to, I use, I just use my fingertips. Right. I'm just holding the scope with my, my fingertips and I have very good control over the scope tip. Right. And that's just kind of very subtle movements. Okay. Very nice. We got that. Let me just get this last fiber. Okay. So we just, now what I'm going to do is I'm just going to go around and trim a little bit, but we can do a little bit injection first. So needle out. Yep. And then let's go ahead and inject and inject. Yeah. Hold on. Injecting. And one thing about this knife is it can get clogged periodically. So you want to. Yeah. I think it's clogged. Yeah. So one of the things you want to do when it gets clogged is to hit cut on some tissue while you're gently applying pressure. And that can often release the clot. So go ahead and hit inject, steadily inject. Yeah. It's going. It's released now. Right. That's a great point. So that's kind of a good trick with this, but what we should have done periodically is I should have had you inject every now and then that preventing clogging is easier than unclogging it. Okay. So what happens there, the mechanism of that is the cut current creates a spark and that spark releases the coagulant that's in the, at the tip of the knife. And as you apply pressure and the spark releases the coagulant, you're shooting off the coagulant. So it's a nice trick. Yeah. Go ahead and inject. Injecting. So let's inject about three cc's. Yep. Okay. It's three cc's. So I'm going to just take this and. So trimming. So you'll look ideal. This screen is not at the ideal position. I shouldn't be looking back like that. Ideally the screen should be right in front of me. And so we're doing a little bit of maneuvering. When you're trimming, you want to trim underneath the mucosal lip. Okay. So you want to make sure that you're not trimming into muscle here. So just right on the mucosa, you want to trim right on the mucosal lip. When we do this submucosal dissection, you're going to, you know, you're going to cut basically in the middle, SM2. But again, for this trimming portion, the safest place to do it is just right under the mucosal lip. Okay. So there, I think we got pretty much full release on that side. And so let's go on the other side now. Go ahead and give me a little bit more injection here. Oh, hold on. Excuse me. Sorry. Inject. Injecting. Injecting. Is it injecting? Go ahead and inject a little bit more. Yeah. Okay. Let's see what's going on. Go ahead and inject here, and you can inject while you're cutting. That's why I don't like using a foot pedal for my injection. I like to have my assistant inject. Yeah, well, you know, one trick if you're kind of even close to muscle, if you inject if you have your assistant inject as you're cutting, that that fluid cushion will push away any muscle. Okay, so you're unlikely to have any, you know, muscle injury if you're injecting and cutting simultaneously. So it's a great point. And again, give me periodic injections just to keep that needle clear. Okay, so now we've done and when you're doing traction, it is critical to make sure you get a good circumferential incision, you want to make sure you release all the sides, you see kind of submucosa everywhere. Because if you don't do that, then at the end, you kind of pay for it, it gets a little bit hard to clean up the little parts. So I have just a little bit of tethering here, I think. So I'm going to try again, we're in the gravity dependent portion. So we're struggling a little bit with the fluid here, but that's okay. Cut current works great underwater and under sailing. So you just want to be very precise. One more fiber here, and then I think we'll be ready to Okay, okay, so now I just want to do a little bit more trimming underneath here before we apply the shirt track. So go ahead and inject a little bit here. Okay, that's probably good. Okay, so now we're just going to trim this a little bit. Okay. Nice. So let's go ahead and go with the SureTrack. Thank you. Thank you very much. Yeah. All right. All right. So when you're placing these retraction devices, one thing I like to do is, do we have a little bit of a lube? A lube, okay. If not, we can just do it. Oh, thank you. We can just do a little bit. You want to lubricate this a little bit just so that it goes down the channel okay. So a little saline is fine. A little dab of lube is good. Again, stabilizing the scope on your belly here really helps to keep the scope stable and you can easily advance it. So you see the rubber band, it's like a figure of eight, right? It has two holes so you can use it. It rotates. So when you deploy this, you want the rubber bands at 12 o'clock. So that's good. And then I'm going to come back and then I want to have a good view of the mucosa. Okay. And I want to just indent it a little bit. Go ahead and close. I want to make sure I don't have muscle or anything like that. So that looks good. Go ahead and deploy. Deploy. Okay. So next we're going to get a second rubber band. Thank you. I mean a second clip. And so I'm going to deploy this just directly above. So Dennis talked yesterday about placement of clip of traction and the direction of traction. And if I were to, I think intuitively people think, okay, we want to move the traction kind of back here because it'll help to open up the flap. But what happens then is as you dissect the lesion, you lose traction. And then it becomes a little bit harder to identify the plane. So what I like to do is I like to place the traction either directly above me or even a little bit behind. And that creates this kind of tenting. And then you can then use your cap a little bit as well to help with the traction. And then in the stomach, the key is going to be judicious use of air basically to reveal the plane. So I'm bringing the, I'm decompressing the stomach all the way to bring the tissue down. Okay, so we're going to open. I'm going to go for the top one because it has two. If I ever want to redirect it, I can kind of use, hold on, go and close, open, sorry. That's all right. That's good. I'm just going to try closing there and there. Okay, good. So now I'm going to go straight up. I'm going to suction down, make sure I got it all the way. Okay, go ahead and open. Okay. And then when I asked my techs to close, I asked them to close slowly. You'll grab more tissue. And the same thing with biopsies. If you close slowly, you'll grab more tissue. So close slowly. Close slowly. Closing, closing. Close. Okay, good. We got good tissue. I can pull back and confirm that. You want to fire? Yep. Deploy. All right. Because, you know, one thing that happens often is that people want to fire too fast. And then that causes like slippage. It'll cause both slippage and there's some recoil that happens with these types of catheters. And so you won't, you'll get suboptimal tissue. So now I'm going to use, you can see I'm going to use air to really show me my plane. Okay. So now we've got great traction coming. We'll do the knife. So the other question is probably where to place the traction. So is this only where you start cutting, like a dissection? Or where do you prefer? It depends on how big the lesion is. And, you know, some big lesions I'll actually use multiple traction devices. But I think always kind of the direction that you're going, where you want to lift the flap. But sometimes if it's big, if it's really big, you know, I'll actually put a clip in the middle on the subucosal side, right? To lift it up. So it really, you just have to think mechanically and you have to think in terms of in 3d on what you want you what you want your traction to do. Okay. Needle out, please. Yep. So now. So one thing that you have to be cautious of when you use traction is it can bring up muscle, right? So you have to make sure that you just don't cut blindly across, because muscle can be pulled up. All right. So you just want to make sure you have a good plane. All right. So you see blue and you see the tenting. And again, at this point, I go for mid, mid sub, like the SM2 layer, right? Because you don't want to get too close to the mucosal layer, because you don't want to have a positive margin. And then you don't want to get too close to the muscle layer because you want a layer of submucosa to protect the muscle, you know, to prevent any delayed perforation. But here we just have a nice plane. And so I don't actually need any more injection because the plane is so clear. But we do have a knife that if we wanted any more injection, we could go we could get it. When I do this, I like to go all the way from end to end. So I don't want to stop here. So I try and continue all the way, all the way to the end, release the ends. So in this situation, the scope channel is in almost at the six o'clock. So it doesn't matter where to, so left or right or right to left. Exactly. If your scope channel is at like seven or eight o'clock, then you want to go mainly from left to right. If your scope channel is at four, four o'clock or five o'clock, then maybe you want to go a little bit more from right to left. Can you show us the whole entire view of the tool? Okay. Yeah. So here. Beautiful. Okay. If I have too much traction, then I can, you know, I can suction some air out. But this is kind of just ideal. Actually, let's come out real quick and let's just clean our lens. Clean the lens. Okay. We have a better view of everything. And also your assistant, you need to clean the knife too. So what do you use to prevent the lens fogging? I actually, I learned from Peter Dragunov. So I use a little bit baby shampoo, just a touch of baby shampoo, and it really helps. You can use some Fred. There's some anti-fog. But I, I found that the baby shampoo is by far the best. Okay. So let's, let's do just a little bit of an injection here. Just to, you know, just to show the plane a little bit, go ahead and inject, stop. Let's inject over here. And you don't want to use too much injectate because actually injections make each cut less efficient. Right. So you just want to inject just a little bit there. Okay. So now we can see the plane really well, and then we can easily finish our dissection here. This is, this is one time if like, you know, it's, it would be appropriate also to use an IT knife, right? So if we had an IT knife, this type of situation is almost ideal for an IT knife. And if you use an IT knife, it's a little bit different. It's like an outside in, you would kind of hook the outside and go in. With these needle type knives, you usually start inside and you go out. Right. And so I'm going to... It's a nice structure, like a demonstration. So, oh, I think it's just... So we lost the tension, but this is a great example. I intentionally did that. All right. So now what we're going to do is, we're just going to grab another clip because this has, this has two, this has two... But you're going to use the new rubber band, right? So you want to use a new one? I just need a clip. Oh, clip only. Oh, okay. Got it. Right? Because, because it just fell off the... So I still have one more hole, or I can even grab that, that initial hole. So if that happens, this is, this is why it's nice having this particular rubber band, because it has two holes. So if, like, if, if you wanted to redirect it as well, you can just kind of use loop cutters and cut the top one, and then you have a second one, and then you can put it, place it in a different location. So, but here, we're just going to grab, all right, go ahead and open, so go ahead and close slowly. Sorry. That's all right. Let's see if we got it. Okay, I think we got it. Then I want to suction down. So here, this, the scope that we're using is not a scope that I typically like using scopes that have at least a 3.2 millimeter channel, again, because I like to be able to irrigate and suction. So I, unless I'm in the esophagus, I almost always use a scope with a therapeutic, at least some type of therapeutic channel, at least like a 2.3.2 millimeter channel, if not a 3.7 millimeter channel. I'm kind of not totally, go ahead and, oh, well, let's, let's try it. So we'll go again, straight up, go ahead and open, and slowly, okay, so let's get some tissue here. I'm going to suck, suction, try and get it to get in here, get some good tissue, go and close slowly for me. Closing slowly. Okay, that looks good. Go ahead and fire. Fire. Deploy. Okay. So. Yeah, very nice. Okay. And then hopefully with that, we'll be able to just finish. Thank you. Let's get the knife back. Yep. So that one probably happened because I put in a little too much air. So I'm going to be a lot more careful. You want to be conscious. So this, the air pump is on high, so I just want to be very judicious with my air use. So stomach has a very large caliber, so it tends to be. Needle out. Yeah. So, you know, in the stomach, again, that's why this can be a little bit challenging in the stomach because even though you don't fully distend it, it'll, you know, the distance is pretty far. So in the stomach, I actually do like to use like a clip line pulley technique if I, depending on the direction that I want to cut. So you can see the difference between track motion and this device. The good thing with this device is that the scope, your scope is completely free from the traction device itself. So you can, you're not like no longer restricted by the traction itself, so it's not dependent to the attraction. Correct. Yeah. I think good traction, you know, good traction is whatever works, right? But ideally you want the direction of the traction to be opposite of your direction of cut. And so that's one of the issues with traction devices that are attached to the scope. I like this SureTrack because it's also so simple and it's probably one of the cheapest modes of traction, you know, it's basically just the cost of two clips. One thing that's nice of what Microtech has done is they don't charge extra for the rubber band. So basically it's just the same cost of two clips. That's nice. Yeah. I think that's smart. I know some people use rubber bands, you know, dental rubber bands, you know, this is designed so that the challenge of dental rubber bands is they can fall off pretty easily. And so this is designed not to fall off. So now you can see Juha is tilting the scope so he can only use the large wheel. So instead of relying on the torque, this is more stable. So this is why he's tilting the scope. One key to ESD, I think what makes ESD different than like EMR and colon procedures, you have to you have to be able to manipulate the small wheel. And you not only have to be able to manipulate the small wheel, you have to be able to manipulate the small wheel with just your left hand. You can't be doing this. So you'll you will never survive doing ESD if you can't manipulate the small wheel with your left hand. You still want to minimize the amount that you have to do that. But there's a lot you know, the tip control is critical when doing ESD and that that includes the whole. Yeah, that includes the control of the small wheel. Okay, so here we're almost done. So beautiful. Look at that. Yeah. Very nice. Looks like some type of statue. Okay, so we'll go ahead and finish this. But you know, if I would have taken an IT type knife with this, we could have been done in like five minutes, you know, so, but also very, very easy to do nice. Now it's like a hanging drape or something like that. Beautiful. All right. Thank you very much.

Endoscopic Submucosal Dissection

SureTrack traction device

gastric ESD

gold-plated knife

body stabilization

submucosal injection

Dr. Juha Wang