I'm with Dr. Sergei Kantsevoy. He has this overstitch device, and he's now looking at the ESD defect, so one of the ESD defects that we just created. So can you switch to the endoscopy view? Perfect. So Sergei, so you're at the defect side, so what type of suturing closure are you going for? So I always do the closure with a continuous suture, and for defect of this size, or maybe even three times bigger than this size, one suture will be good enough. And you can close from right to left, or from left to right, it doesn't really matter that much. So what we are gonna do, we will go from here. This is the first puncture. That's where my cinch will be positioned when we finish closure. So I took one bite. So you always take the mucosa in? Yes. Part of the mucosa. And then I went into the submucosa, I open it up, and I don't want any dog ears to happen. So I want to spend some time trying to close the corner of this. That's the second bite. Perfect. And then I'm gradually going to make the third bite here. Okay. Do you do outside in and inside out? It doesn't matter? It doesn't really matter. Got it. It's an approximation. Yes, the approximation, it doesn't really matter. At the end, so we finish that corner. Now I need to prevent the crisscross. So you see it's on top of my suturing arm, I dropped it, right? So you saw that the suture was around the, like the body of the suture. Around the suturing arm, and so I went above it. Now I'm starting to close the defect, and you will see how it's getting smaller and smaller. I'm taking good bites, not the small ones. So the suture on the needle, so this is a leading suture. The other one is called a trailing suture. And then always we don't want to cross it. So you can see that Dr. Kansavo is getting the needle on the left side. You see, and if I create crisscross, it would not close it when I try to cinch it. So that's why I do it like this. And I constantly paying attention, where is my leading suture, and where is my trailing suture. Perfect. So you always close the defect? Yeah. Okay. Every defect post is there close, especially if it is located in the narrow areas, areas which I don't want to get small in diameter when I finish, because then the scar tissue unpredictably can narrow down the diameter of the lumen. And whenever I put my first bite will be my lock, cinch position, wherever I drop my needle, that's where the last bite. How far do you like millimeter or centimeter apart do you get the bites? Like every- Probably five millimeters at least. Okay. Otherwise, when you will start pulling it, then it tears through. So practically, I already closed the defect. So I don't want dog ear on that side as well. So my last bite will go into the healthy tissue here, something like that. So Dr. Katsubo is getting another suture, like a bite outside the mucosal defect. Outside of the normal, in the normal mucosa. The defect is closed. Now I will need to drop a needle and you don't want to drop it inside the endoscope. You have to push it out, release it, and here it is. Perfect. So now we're taking this out. And so this is a cinching device. So cinching device with the overstitch always goes to the initial bite area. The first bite. First bite, yes. That's where the cinch will be positioned. And there I will feed this suture. Perfect. And if you give me a little tension, because without tension, this cinch may turn around and then it will be a problem. Okay. Okay. Okay, you can let it go. So so I'm keeping it under tension. How much tension do you usually not much too much. All you need to do just make the mucosa touch each other. If you apply any tension after that you put in a schema on the suture line, just strong enough to approximate just approximation. And now we can cinch it please. Yep. Okay. squeezing. Okay, perfect. That's the end of the story. And this is just the defect, which was completely closed. So here you see, that's the defect. And that was just a piece, which was cut off. It was still in the stomach, but that's the end of the defect here you see. You do, you make everything look much easier. So there's a question from the audience. Is this remaining suture before cinching the leading suture? No. So basically the training suture, which is the comes through the channel, is that correct? The training suture is staying there at the place where we put the first cinch, right? And that's the cinch will go on top of that training suture. Yes. And put in there. And the leading suture will be the one which is coming to the suturing arm and then to the needle to the suturing arm and to the needle. So the training suture will stay behind. And here you can see how we close the defect entirely close. Beautiful. Right. And that's where my needle is. You see the needle here. This is the needle. So we just get approximation. And there is no dog ears, there is no open defect. And that's how it should look after the closure. And no matter how large is the defect, that's how it should look like. Beautiful. And it took very little time. So probably if I was using clips, it would take much longer than that. Yeah. And the quality of the closure would not be comparable to this, because it's not just mucosal closure. It's closure, which involves both mucosa and submucosa. So even if I try to open it up now, it cannot open. If we close it with clips, and I push it like this, clips would fall out and the lesion will open up. That's a great point. So when you close the defect for the gastric ESD defect, do you still give the PPI or do you like a limit the duration of the PPI? I don't do PPI. Oh, so you don't, you never do? No, I never do. That's good. No. If the colon is very dirty, and I close it, then I put antibiotics. I don't want any infection. But other than that, I don't. Yes, please. There was a question. So next question is trailing suture should be under leading suture as far as possible. Under the leading suture. Trailing suture should not crisscross with the leading suture, but that's all. And it doesn't matter if you go from right to left. If I go from right from here to left, right, then the trailing suture, the one over which the cinch will go, will stay to the right. And the leading suture, the one which will go in and out of the suturing arm will be to my left. If I decided to go from here, from right, from left to right, then the trailing suture will stay here on the left, and the leading suture will go to the right of the trailing suture. So basically, the leading suture shouldn't go above. Should not crisscross. Crisscross. Okay. Yeah, I think this answer this question. But here you can see that the defect is closed completely. So what you want to repair, there is a FIG? Yes, there is. No. Oh, yeah. So can you show stomach from outside? I want to see how it looks. Thanks. Yeah, sure. Because this is not the full thickness suture, I don't think. You will not be able to see that because it's not a full thickness defect. So there is no suture coming over. I intentionally did not take the muscle into the suture. And that is why because I was not taking the muscle into it, you don't see my suture. But you can see like some kind of a fold convergence because of the suture. We never see the suture from outside. There is no suture. It was my intent not to do full thickness. I don't want to touch with the needle any tissue which is outside of the stomach. But that's how it looks. Yeah, beautiful. And it's very fast. Thank you very much. Thank you. So guys, if you have any questions, you can submit the question and then we will try to answer during the next tomorrow's session. Thank you very much for the great demonstration. Thank you. So okay, so this concludes today's live demonstration. So thank you for your attendance and we will see you tomorrow. Thank you very much.

overstitch device

ESD defects

continuous suturing

mucosal and submucosal closure

defect closure process