Okay, very good. So we have some mucosal defects in the previous ESP, so Dr. Fukami will be using the X-TAC device to close these defects. Great, thank you. Thank you so much for staying. So whenever you complete a resection in a large area, so there's a big, large defect, when you close it, it reduces the risk of the delayed perforation and bleeding. And we think it's really beneficial. But the large defect, you cannot really simply close with a clip. And there's some different type of clips available, but X-TAC is an intermediate method to close the gap. So this is a more approximation device. The four tacks of the screw goes into the mucosa, into submucosa, and all four are connected with a suture. And then at the end, we gather them and do the cinch to close them up. First thing you need to do is just place this one, sorry, upside down. This is an X-TAC holder, and you slide it up, and you go around the biopsy forceps and situate over here. There's an arrow, so the arrow goes towards the biopsy channel. There's a sheath that just protects the scope channel from the injury from this X-TAC. This is mandatory to put all together and gently insert. You can choose to put a little lubricant here. And here, I don't know if you can see, this is a protector holding just to make sure that it won't come off on its own. So you push this sheath all the way here, and wait until you situate this. There is a tack, and you just pull this out and separate them. This is extra tacks, and pull the suture straight, thank you, hero, and pull back a little slack, and slide one side, and slide the other side. You see, two, three, four is showing, so this is the right direction. Now when you're ready, you pull this out, and people just snap or just take it off gently, either way. And this is all gone. And push all the way inside. Let's show the endoscopic view. Here's the tack. So, hero, could you close this engagement that we call engagement? If you close it, it's just going to spiral clockwise, and that keeps this screw into the tissue. And if you don't like it, you can unscrew it open, go to the counterclockwise. It sometimes just catches the samikoza because there's a little notch to keep the tissue in the spiral screw, but you may be able to disengage it if it's wriggled. At the end, close all the way. Sometimes slippage happens. If you want to get more acquiring tissue, then you can ask them to do extra rotation. Next, we have a tack ready, so the next thing is strategize how you're going to close it. This is a gastric defect, and the wall goes on this line, so it makes sense to close this right and left. And most of the x-tacks, it's best to do away from you to proximate to you. I tend to do right and left, right and left. Some people do right, right, left, left, kind of box shape. I think it's more of a preference. For the closure, I don't like to get too much of the mucosa because it's kind of imposed, so I get the carton a little bit inside, right here, and I'm going to go in the middle so that we can add more clip later on. Okay, Hiro, engage. You're going to give a little bit more pressure, okay, stop, disengage. It's slipped off, so I'm going to just get close to it, I'm going to give it a little more width, engage, slowly, engage, engage, engage, that's perfect. You can start to see the twisting of the mucosa, go engage fully, and if I do wiggle, it just goes final squeeze. So now it just screwed into the mucosa, you can just enforce, you can just do extra, just to demonstrate, and you can try to engage, okay, okay, that's good, all right, so I'm going to ask you to deploy, let it go. Okay, I press the button, and then push it down. Yep, push forward, so now attack is situated in the mucosa, I pull back this one gently so that it won't pull, thank you, you're an excellent assistant, open, and so open means it's ready to engage the X-Stack again. Clip into the second X-Stack, feed in, most important thing is to make sure that you hold the suture so that it won't get tangled, and I'm holding with the left hand here, and gently feed it in, make sure that the suture is not tangled, that's perfect. The second one, I want to go to the parallel to the left side, again, I don't want to get too much, but not too little, let's do engage, put the forward pressure so that the X-Stack engages in, perfect, perfect, so it starts to spiral, so that's good enough, I can make sure that it's in, okay, deploy, the second is in. So we'll repeat the same process, so he actually reload position, and number three, gently, sometimes this comes off, if you have a left hand in the suture, then this X-Stack, if it accidentally comes off, you can still engage manually, so don't, no rush, exchange, and then feed it in, this is the most important step, that the suture won't get tangled with the X-Stack, if you feel any resistance, stop and come out, and make sure the suture is having a good tension, as I said, I like to go right on left, and I'm going to go this side, okay, engage, okay, I'm closing, closing, closing, good, this, this is really towards the edge, but this is helpful for closing the gap to make the semi-coda disappear, deploy, this is just a high-quality closure, so that last one is a little bit going to be free, so let's engage again, if you take this off, the suture becomes free, so you have to make sure the suture is grabbed again, thank you, assistant would give attention, X-Stack is in the channel, hold with the left hand, and then I tend to monitor how the suture is going, if the suture is not moving forward, you're in a good shape, if I let it go, and see the suture move forward, that means that you lost the suture tension, so you just get back on the tension, for larger defects, so do you use multiple X-Stacks, or do you only do partially and use other devices, that's a good question, so typically what I do is, once I have an approximation with the X-Stack, I add with the clips, but as you mentioned, if the defect is really big, you may need an additional set, so we sometimes use two X-Stack sets, or maybe three, do you do the same way? Yeah, I sometimes use it only for approximation, and follow the bike, yep, okay, engage, I still believe that getting not too much of the mucosa towards the defect is important, for closure, okay, deploy, okay, all right, beautiful, so now last thing is, approximate all four, you can see there's approximation already, and this is not a suture, so what you do is just pull back together, if all four gets together, that's as tight as you want to get, so I think we're in a good shape, one last thing, you have to take this sheet off, otherwise you screw, we frequently just forget this thing, once the X-Stack is in, there's no need to protect, and this cinch device doesn't go through the sheet, okay, here's one difference from this overstitch, is that this has a little notch, so that X-Stack won't fall out, so when we try to push it through the channel, you feel a little tag, a little resistance, but you have to get really gentle pull, just pass it through, so at the suture, end of suture, there's a knot, that's by design, we made it so easy, but usually there's a little bit tag, and they get really anxious, yeah, okay, so make sure that there's attention to this suture, and there's no need to pull too much, and once I put the cinch device in the channel, again, I hold the suture by left three fingers, like a guitar, right, and pull back a little more, making sure that it's not loose, okay, then introduce the cinch device, the last tip is to make sure that the tip of the cinch won't go in between these tags, won't go in between these tags, I typically try to go from the top, and the last one is here, so you can go from here as well, you don't want to put the cinch tip of the white tip within the X-Stack system, so I gently put them together, this is as tight as you can get, okay, let's do cinch, yeah, ready, yep, drop this stopper, I keep the tension, go, yeah, and once the suture is cut, you pull back gently, let it go, beautiful, that's just X-Stack, you see the almost nice closures at the distal end, you add several clips, and maybe a reinforcement clip here, because again, this is an approximation device, so I usually sandwich the clip, and that would reinforce the closure, thank you, thank you, that was a beautiful, excellent demonstration, thank you very much, thank you.

X-TAC device

mucosal defects

endoscopic submucosal dissection

sutures and screws

wound closure technique