Good morning, everyone. My name is Sawonee. I'm with Dr Aihara and Dr Dragunov here, demonstrating the ESD using dual knife. Now we already marked the target area. This is in the proximal part of the stomach. This is a marking dot. So I checked the gravity is opposite. And I can retroflex as well, although it's slightly limited movement. But my plan to remove, to do dissection here is to start from the lower part and do the standard flap creation technique. So we'll start injection maybe just 50%, 60%. And then microsaw incision, dissection about 50% to 60% before I complete the microsaw circumferential incision from the top. Slightly yellow. Okay, that's okay. I can see. This is the Needle Master from Olympus, 25 gauge. Okay, 2,506 gauge, sorry. But inside, you can inject a very thick solution. Inside is almost like you inject 23 gauge needle. So we want to see that injecting and we see the lift. If you inject, you know that we inject, but you don't see anything lift, you probably inject to the polytonium. So you have to adjust your knife position. Okay, inject, please. Injecting. Okay, stop. Now, because it's not lifting anymore, I don't keep injecting. Move. Jab a little faster and pull back. Inject. Injecting. Injecting. I want to emphasize this point that we made earlier, but it's worth repeating again. Someone is injecting outside of the marks, not inside. So when we're doing EMR, we typically inject the lesion itself. Here, we're injecting outside of the lesion. Injecting. Injecting. Injecting. It's a little hard to see blue because the mucous is thick. I adjust. Okay, inject more, please. Injecting. Injecting. Sorry, what type of solution do you use for the lifting? The one we use here is... Oh, no, the, like, for your cases. Usually, I use Endocrot for mucosal injection. Endocrot. Yes. Are you injecting? Yeah, I'm injecting. Okay, stop. Needle back. So Endocrot is a high viscosity solution from Olimpus. Yeah. Needle out. Because it gives you a really high lift and lasts a long time. But inside the mucosal dissection, I just use Tetrastar's methylene blue. Inject. Inject. Injecting. Injecting. I do exactly the same. I use Endocrot for the mucosal. Okay, stop. Needle back. It's not lifting anymore. So that means that I'm just going to start cutting from what we have. Needle back. And we can add injection through the knife. So the knife we're using now is the dual knife and 2.0. 2.0. Yes. Dual J. Thank you. Okay, needle. So the injection of this needle comes through the cutter. Cut the sheath. Not through the electrode. Something you need to keep in mind. Needle back, please. Okay. And when we do injection, use hand injection or you can connect the fluid injection from the needle to the pump. Either way is okay. Okay. So, open knife. Yes, it's open. We have the Endocrot mode on and I'm just going to use Endocrot. I wanted to ask you a question. Yes. You have the choice to work in forward view or in retroflex. You chose retroflex. Why? Because in a forward view, this lesion becomes unforced. So it's not easy to see this cutting line. Therefore, I do retroflex in this area. But in the proximal part of the colon, I might be able to do in a forward view as well. So I want to check. So I penetrate already. I see blue. Now, once you see that your knife is through the mucosa, then you can move laterally and avoid putting too much tension like this. This is not good. It may jump or the electrical current is actually lower because increased tissue contact. So just appropriate amount of tension. You have a better cut. And I also just put air gently. I don't keep air all the time because if I keep putting air all the time, this target in retroflex is going to go away from me. I trace now underneath. So you're just retracing right now. Yeah, yeah. Just trace the mucosa. Yes. Very important step. So I suction to make now the submucosa to be slightly thicker. Now I use the sheath of the dual knife and lift up slightly so that the tip of the knife go a little bit away from the muscle. So that's fine. Now I'm going to cut more. I like to do mucosa incision slightly, maybe two, three centimeters, and then trim. Rather than do the very long cutting line because the fluid tend to still stay in that area before. I want to now see the steel lift. If I keep cutting and I come back, this fluid cushion may disappear. So I'm just going to trace it now rather than keep cutting the mucosa. So now the knife is completely parallel to the muscle. I think Dr. Nam is resting the knife on the muscle. So that way she can keep the knife completely parallel to the muscle, avoiding the perforation. So basically like what we discussed this morning, I can go underneath the flap now. But I want to cut more this side. So that was the point of our discussion earlier this morning. You want to create that flap early. So now the flap is created, you can continue with the circumferential mucosal incision. Now I cannot go up with the bending, so I'm going to un-retroflex a little bit to see. I'm not sure that the fluid is still there. Maybe I can inject more this side. But now that I have the flap open, I'm just going to do some work there. Open. Okay. So hook the corner. So what we were discussing this morning, people refer to this as doing one sector at a time. I'm injecting. That's my preference. So that part, I have a small amount of fluid, so now I inject. Close the knife. It's closed. Okay. So this knife, we show you how to... Stop one second, please. Now it lifts. But I try to change direction of the scope to see if I can cut up. Okay. So if I do like this, I just need to be careful not to place the cap to the wall, because you're going to make submucosal cushion thinner. She's showing she's not putting the cap too much against the mucosa, so we still have the good cushion. And then instead of cutting it down, she's lifting it up, so the knife will not approach to the muscle. I would love if we can show the stomach up close. So you're hearing this message over and over again. Look, the stomach is almost completely deflated. This is an important point about TSD. Okay, inject. The more you inflate, the thinner the wall and more easy to perforate. So keep it deflated. I'm going to put this rag back just to keep it moist. Adjust the bending. I try to adjust the bending a little bit. Okay. She's tapping. So each time you can see that she's applying the tension to the tissue and then while changing the direction. So by doing this, she has more control on the scope and the knife, too. So here you see the muscle plane, but if you want to inject, make sure that the sheath of this knife has contact. Okay, inject, please. You see? Inject. Stop one second. Or this part, if you want to inject, you can make it while your knife is open. Can you open the knife? Yeah. I made a small little hole so that I can push the knife in and inject. Inject. I can still also inject when the knife is open, but it depends on whether you have contact or not. Yeah, thanks for clarifying that because that's a common question that we get. Do you inject with the knife closed or open? And you can do either. Yeah. Then when will you complete the incision? Right now, if I keep continuing, I will have a hard time finishing the top because it's going to flip up. It's going to flip over at some point. Yeah, flip over. So I should complete the mucosal incision at this side. Can I have the injection? Yeah, of course. The good news here, Sawanee, is that you have good access in both forward and retroflex view. Yeah. But if you don't, that will be problematic. You need to finish the side that is away from you. Otherwise, you'll have a problem at the end. Yeah. And I usually prefer doing the more difficult side of the lesion first. Yeah. Same here. I don't see any question. Setting marking for us. Okay. Yeah. So in the patient, I use soft coagulation to mark. But in the pig stomach, I use forced coagulation because it's more difficult to create the dot. Okay, needle out, please. Needle out. Jab in, pull back, inject. Injecting. Inject. Injecting. Jab in, pull back, injecting, injecting. Injecting. So now we inject, but I don't see much happening. That means it's not lifting anymore. I don't keep injecting, stop. Okay. So when you inject endocrine, do you start with endocrine or like saline? I usually start with heterostage or saline. Heterostage, okay. That way, I don't accidentally inject endocrine in the muscle. I see. Inject. Hold on. By the way, if we inject a thick fluid into the muscle, sometimes muscles splitting up into the cutting line. Yeah. Okay, are you injecting? Yeah, I'm injecting. Okay, stop. Sorry, I didn't hear. Inject. Inject. I'm going to take this opportunity to emphasize that the endoscopies and the system need to constantly communicate. What we call in the military is called false loop communication. When someone says inject, he or she says, I'm injecting. That way, he's confirming that he heard her and he's doing what she advised him to do. That's very important. In my unit, I ask my assistant to keep saying that, repeating, I'm injecting, I'm injecting. Yes. Until they really stop injecting. Some people like to ask their assistant to say one ml, two ml, three ml, and so forth, which also helps. I try again. I try. When I cut toward the right side, it might become close to the muscle. I have to slightly pull back. Instead of keep going, I come and check. Okay, so it's penetrated. Now, go back in. But don't do this because the plane saw this kind of shallow. Don't use the cap to place on the cutting line. This is a beautiful demonstration. The white ring, the white plate at the end of the knife should be gliding over the mucosa. If you lose sight of the white plate, that means you're too deep. And that's dangerous. So the fluid doesn't really stay a lot. I can still cut, but I will not cut very deep. Now you can see the knife is perpendicular to the mucosa. This is to penetrate the mucosa and expose the submucosa. And once she's in the submucosa, she will change the angle to make it parallel to the muscle. Right now I just check the depth. I'm not trying to go underneath it right now. So this is, again, trimming the incision. You want that space wide open as you see it right now. There was a few fibers there nicely, nicely done there. Be careful here because sometimes you can perforate when it's perpendicular like this. Okay, so I can see the muscle behind. Close the knife. Okay, inject. Okay, stop. So now I think it's wide enough. Okay, I'm just going to cut maybe a couple more times. Okay, close. Inject. Okay, stop. Okay, open please. Okay, open please. Yep. Okay, cut and check. Okay. Okay, open. So at this trimming, do you typically use endocut? Yeah, usually I use endocut for this. For the clinical cases? Yeah, yeah, yeah. How about you, Dr. Ara? Or you will switch to post or swift when you see the blood vessel? Yeah. Okay. So now I can go underneath now, but we're just still trimming. So muscle is here. Okay. This is what I learned from you, Dr. Ara. Initially I used close, please. Coagulation the whole time when I do dissection, inject. But a lot of smoke and char, so I change to the way you do, which is inject, inject, inject, stop. Which is cut, use a cut during submucosal dissection unless you see blood vessel. So I go up instead because I can see better. Instead of going down, I go up because I can see better cutting up. And then just connect. Just connect the line together. And this is the end of the line. Open. Okay, let's see. Okay, it's cut not very deep. I'm just going to close, inject. Injecting, injecting. Okay, stop. Just trace a little bit, open. Open. You can see Dr. Naomi is using just a tip. The knife is not too deep because she just wanted to just cut the surface. If it's too deep, you will make injury to the muscle. So it's a little, you need a very fine control on your knife. Initially we planned small incision, it become bigger and bigger. Okay, so now I'm going to go retroflex again. Back to the flap that you already created. Yeah, back to the original side. Beautiful. So now from here it gets to be fairly straight forward. Some difficulty to approach that side. So I have to start a little bit further. No, I can't get there. So turn the scope the other way. See if I can get any deeper. Okay, now I can get deeper but I have to push the scope. I pull the scope back. Dr. Nam, do you typically use one knife per case? Because here you can easily pull the IT knife. Yeah, usually... And that will speed the things up but it's a lot of expense. Yeah, usually one, unless I feel that changing will significantly change the time. If it's a little bit, I try not to open another knife. Here you will be done in five minutes with this knife. With the IT, it will be done in two minutes. Not a big difference. And the other thing is safety. If you have a lot of respiratory movement and so forth, the IT knife is somewhat easier to control than the middle type of knife. Okay, so hook the corner. So you can see... I actually want to look up more but I cannot look up anymore. I'm just going to cut close and pull the scope instead, right now, so that I don't accidentally... If you look at Dr. Nam's hand, she's always using the torque on the scope, not the small wheel. Right now I use the cap to find the remaining cutting line, which is here. Stretch the fiber, tension helps cutting. Beautiful. Okay, that's the last cutting line. Okay, I actually want a higher area. Okay. All right. Great job. Beautiful. Thank you. So this is the standard Microsoft lab creation technique. And after you're done, make sure you check muscle injury or blood vessels. Okay, thank you. Beautiful. Any questions? Thank you very much. Thank you. Thank you. No more questions, okay. No more questions. Okay, thank you.

Endoscopic Submucosal Dissection

dual knife

submucosal lift

retroflexed view

Endocrot

safety considerations