Hi, welcome back. I'm Hiroya Hara from Brigham and Women's. I'm with Dr. Alex Schwerk-Thurman from Thomas Jefferson University. So we have the Fuji flash knife with the track motion, so you can see this here. Dr. Schwerk-Thurman will show how to use this device later on. Okay, and then can you show the endoscopy view? Perfect. Great, so I think Dr. Schwerk-Thurman already finished the marking and then injection. So we are going to start with the mucosal incision. Okay, so let's start. Very good, good morning. Okay, Dr. Hara, thank you for opening that. Thank you for having me here, it's a pleasure. So today we have a small incision. We're going to do an incision, a circumferential around this lesion in the stomach, leaving some border so that when we grasp with our track motion, we're planning ahead for our traction. So here's my initial incision. This is flash knife 2.5 millimeter ball tip. And we have endocut eye effect 2, duration 2, and interval 2. And swift coag effect 4 and 61. So confirming I'm into my submucosa, putting a little flush, I have some flush going in, and now we're just going to extend our incision. So you can see that Dr. Schwerk-Thurman is using the cap to stabilize the target tissue and using the needle and then perpendicularly to cut that mucosal area right now. And then he's doing some mucosal trimming to open up the submucosal space to create the mucosal flap. Alex, do you always finish the mucosal full incision before using the traction? You know, I do prefer to do a circumferential incision. I think it's about access and getting visibility. And although we have dynamic traction with track motion, I think it's a good idea to utilize one scope at a time if you can and try and get as much out of that scope so that we decrease our procedure time by using that scope that's helpful. In this case, we have an upper. We will be switching to the dual channel once we get on with our track motion. And in this case, I'm doing my circumferential with an incision all the way around. So we're going to inject. So for the audience who hasn't seen the track motion, we need a double channel scope always to use the track motion. So we typically use the regular upper scope or coronal scope for the mucosal incision. And then we will switch the scope to the double channel scope with the track motion. But technically speaking, you can still use the double channel scope for the entire procedure. But in terms of the scope maneuverability, we prefer using the regular scope for diagnosis like BLI or NBI before starting the track motion. So in this case, what I'm doing is I'm opening up gently. I want to make sure I give myself a good flap, mucosal flap to grasp as I mentioned. And I'm going to make this a little wider. And I'm going to make sure I can see my marks, which I can see. And then we're going to come into this might have to come in retro in this case. But I think we'll we'll get there. We're working our way nice and carefully. The other thing to remember to remind yourself as you're doing your ESD, as you're pushing your scope and you're getting into position, along with cap stability, remember to suction. Suction is going to be your friend. Decompressing can bring you closer if you decompress your organ rather than getting your scope all kind of twisted and turned. Do you have alcohol or like alcohol, like wipe or lens cleaner? Yeah, it's too early for alcohol for anything else. We'll start with just swipes. All right. So here, I'm going to come in, making sure I get my view. I don't always lock my wheels, but sometimes I do in a situation where I need to stabilize myself. So during ESD, we only have very small view of the part of your target tissue. So always come out and come back to see the whole entire view of the lesion to make sure you're doing well. And then sometimes we evaluate the scope position. So sometimes if the view is a little difficult, so we typically go to the retroflex to see the backside of the lesion. So Dr. Shaktharman is evaluating the lesion right now. Yep, we're getting around the back side So for those of you who are on the virtual, please feel free to use the Quick Q&A function so we'll be able to see on the real time and then we will answer each time There we go, I Think I have a pretty good lift on this back side, but I just want to make sure So I'm gonna come back out clean my screen a little bit make sure I have good visibility Opened up the front pretty well. I have my marks here. Oh look. I've made a huge Just a little issue on the inside. Oh just that. Oh boy look at this We're gonna open this up because the last thing we want is to leave him with cancer So good thing is we already have the marking so we know we are to cut so we can just like Change the direction of the incision at this point and then We can still do the unblock resection by changing the direction of the incision at this point All right, so we're gonna get here I'm gonna come in retro now that I've redirected As you can see, dr Shock Thurman is like reducing the air to be able to access the area behind the lesion So always evaluate the amount of air Sometimes you you continuously put the your finger on the insufflation. Sometimes it makes a little incision a little difficult, so It's a very important part Okay now I'm on track unfortunately, I've got a little divot there but not the end of the world So we Intentionally created this lesion on the gravity side to show how effective the traction is in this like gravity side lesions Maybe I'll inject back here a little bit more and then we'll be able to get in and show do the backside. Mm-hmm We injected the front side. We're using saline Which dissipates pretty quickly? I'm gonna suction a little bit while I have all my devices cleared. Give me a little better ability How Often do you use traction in your cases, you know, I usually use traction for many of my case I don't necessarily use it for the entire case And I'll utilize it say for the esophagus With clip line for the stomach when I'm doing I do like track motion. I have other Traction devices as well that I'll utilize needle out. Okay, so I'm gonna inject while we're there. Oh, that's beautiful Okay, so we're getting that'll give us a good lift later. Thank you and stop and we'll do the backside now And needle out so I'm gonna try come in retro And Injectors injecting injecting dictin dictin dictin stop. Yep See how we got a nice lift in the back on the side here, we're good All right a little bit here, please Check them check them dictin Okay, and stop and we'll go to the other side And once we get a good lift on this side, then we should be able to come all the way around and whether we use an IT To in the stomach or flush or a dual J or these knives They can speed up your dissection for your circumferential But the track motion will give us the ability Or any type of traction to really speed these procedures up And inject in dictin dictin Okay, inject in check in look then Okay, and that's good. Yeah, let's take a look and see if we're happy with our lift We have a good lift here, I'm happy on this side This looks lifted on this side This is in a pool and I think we're okay here as well I might add just a little bit in the back side just so that we can speed things up And then Okay, beautiful, yeah, that's great and needle back. Mm-hmm. Thank you But I do like the idea of rechecking frequently while you're in position To ensure that you're staying outside of your marks So that you don't have issues going inside And when you get a full end block resection Going in retro is definitely helpful needle out And I think that's what we'll be doing here in a moment So as you can see all this fluid is pulling right where our lesion is which is Right where our lesion is which is one of the reasons why we want to use traction Turn a patient Trendelenburg reverse Trendelenburg to try and get that pool out of where we're dissecting In this case, I think we want to Proceed with this position. So I think we can try here and try and do a circumferential and stick with the same knife Okay But sometimes if you don't have access You can use traction to help you get access and I think that's an important point That if you can't get the circumferential at some point you can come back to it and do it in stages So it looks like my dots go there and there And around here, so I'm okay here and I'm starting to as I push in get in a different angle So it's actually making me retro which is fine Come out and take a check So I think it's important to stop check stop check and I remember when I was visiting and training with some other folks Years past it would be one beep one check, which is a little more aggressive than than I am these days. I tend to Not always do one beep one check, but I do think that the theme of checking frequently is important Yeah, so yesterday we had a special ESD case and then there's a question like how to avoid perforations, so that's As I said, so we usually cut and then look back to make sure it's not going deep But to superficial so it's very important to like a look back each time probably after three or four cuts and then just to make sure So this is the biggest most important part in ESD So I'm suctioning to pull me closer as I advance my scope it pushes me out a little bit so here and I'm lifting up and doing a dissection away from the muscle if I can and As it does it flips me out which is a safer way to get away from the muscle I Have to reposition often but keeps me from getting those deep cuts and especially when I'm doing the backside I'm looking for anything deep here, which doesn't look there There's no vessels here. But this is why I would do this to open this space up a little bit to look for some vessels so cut coag cut coag So Where are we? Yeah, we're getting pretty close I'm coming in retro if you're getting dizzy because you're upside down. Let me know We'll adjust So who's awake out there it's Sunday everybody went out Saturday night Do we have any questions? Anybody want to interact and give us a story? All Right, we're getting there So I'm trying to hook this a little bit there's a little ball at the end And I think we have our circumferential yeah perfect Okay Okay, so now let's take a look I'm gonna clean up the screen suction out the liquid Take a look and see what our specimen looks like There's my issue. I started to get off cue Obviously when you're making your dots, you need to accommodate for that You don't put your your markings directly in your cancer. So this guy's cancer is right in the middle. So I'm fine Yeah, perfect. As you can see I'm making up things as I go along So here I'll suction out this fluid and then we're gonna switch out scopes and use the dual channel I'd like to show you how we mount the track motion But I'll go ahead and decompress everything so that we're set to go as soon as we get in there So for most of the ESD with the traction we typically finish complete incision because once the traction is in place Sometimes it's hard to go like get access to the area behind the lesion. So we typically oh, yeah Finish the complete mucosal incision before applying the traction And then so we have three techniques today So this is one of the attraction technique and we have two more so I will show you how to use it So there's a question from the audience. So does the proximal incision has to be made first always? Can you start with the distal incision? Yeah, so this is a very good question and Then so it depends So if you basically work on the lesion like this And then if you cannot see the area behind the lesion, we strongly recommend finishing the area behind the fold so sometimes if you So it depends on the strategy So for the traction if you are planning to complete the mucosal incision and then if you inject proximal side that makes the access to the Area behind the pole very difficult. So in that case we inject Distally to bring the lesion towards yourself and Then finish the incision distally and then Start injecting the proximally and then finish the incision if we are planning to do the pocket method always proximal side incision first and then Do amount I Expand this and slide this down. So if you hold tight here I'm gonna pull what's happened here is we've we've opened up the handle. So now when we pass our track motion through It's only gonna stay in the scope Now if we if we hadn't opened it, it would pass out of the scope, which is fine But if you're in a patient you could have some issues so just be you know cognizant that you want to You want to make sure so looking at the end of the scope? The track motion has not come out yet because we expanded but now I drop the handle and it comes out So in the package when it comes to you, it comes in this setting. So it'll come out of the Scope, so be careful Okay, so we have here I'm gonna look and look at my alignment That's there so I'm set to go with with my track motion. Closing and now I'm gonna pass my knife, thank you. You have a dual channel so the larger of the two channels it's gonna take your track motion at 3.7 millimeter your 3.2 can take your flush knife or your dual J or your hybrid T. Perfect. And so our knife is out so just yeah looking at this here's my knife coming out at 6 o'clock and my track motion it's more on a 5 o'clock so where we're gonna cut and where we're gonna be working away from track motion but it's in one one scope so we're connected but this gives us the ability to grasp you can grasp your tissue rotate it up and now my knife as I pull back with my track motion will be directly under the tissue and I can work slightly and just make small incisions small dissections and then if I need to regrasp I open I can reposition and grab a new site. Okay so let's go ahead and do a demonstration on what we're doing with our mucosal flap we started to open things up a little bit I would say start slow with your track motion you know not extended too far out of the scope initially and then you can expand and as you dissect more of your specimen you'll be able to open up and get that full right angle that we're gonna see with track motion so here's our specimen we have our dots I have a lip and I'd like to emphasize that that flap extends beyond my dots right so my lesion is well within and I'm gonna grasp here where there's gonna be tissue because what we don't want to do is damage our specimen it can it could rip and so we have to be careful so before we even do that I'm gonna go ahead and inject and just open up this flap a little bit more okay so there is a question from the audience are there any plans to adapt this device oh yeah I'm sorry go ahead so the question is if there is a plan to adapt this device for the use with a single channel system or is that not known if not able to address that okay so as you can see here so this traction device is only for the traction so they there's no like cutting capability so we basically need two arms so actually this is the idea of having like kind of like a same same concept as a surgical procedure so one arm to hold the tissue and then use the knife so we basically need two channels so that's why we want to have the double channel scope but the other thing is that this is only for the upper double channel scope I believe Fujifilm has the double channel corner scope correct I'm not deny I'm so sorry so in the future the question is it can only be used for rectal and upper ESD at this point but in the future if there's a variability for double channel lower colonoscope and then if we have longer track motion for right-sided lesions that will be very helpful for us to be able to use this device for any area in the colon in the stomach and esophagus so right now as you can see Dr. Shrakhtaman's right hand so this is the track motion it's providing very nice view of the semi-causal dissection plane and then the advantage of this device is its adjustability so unlike other traction device so those other devices has like doesn't have any adjustability of the direction and the force but he can catch any type of any area on the target tissue and then he can elevate any time if necessary so this is the biggest advantage of this device so he's adjusting the distance between the target tissue and knife at this point so we're fogging a little bit but we're gonna clean our screen we're gonna get a good view suction down take our time and then once we're nice and visible you can see this beautiful submucosal view we're still straight with our track motion and I'm just gonna open this up a little bit more without going too deep we are working a little further than we might work with our traditional ESD so you just need to get used to those views and work a little bit further but I tend to think that we can we can kind of adjust like dr. Har was mentioning so that you can so that you can get that view that you like it so here we've got a good view of this flap I'm looking for these white fibers that are hanging me up do you like to clean the lens or yeah we might have to okay let's see what's happening here so you can see his right arm is like rotating and to adjust the direction and attraction force but the thing is that we need some working space for this traction device to apply the traction so that's why we need to work on in a distant view compared to the conventional ESD all right I think I will clean the screen in a moment so I'm gonna open up grasp come out clean the screen and maybe we'll answer a question while I'm doing that you don't mind so I think the question from the audience was do you usually start with the proximal incision or distal incision so I think it depends on the strategy yeah okay I agree I think you know getting a circumferential is a is a great idea and this way you can you can focus but in your location so if I'm doing a rectal ESD I usually want to do the oral side first sometimes I'll do a pocket or a tunnel and if I'm gonna add a traction device like track motion I just want to make sure that I'm planning for that with that flap that's a much better view yeah great so if you're in the rectum or upper GI it's always helpful just it's easy to come out and clean the lens so just like a be flexible to change your mind and also in the right corner it's a little hard so you have to come out of the all the way down to the rectum and clean the scope but because we are in the stomach at this point it's very important to keep your view clear okay so that's a really nice view we're gonna get in and as I'm advancing my scope I can adjust my track motion and pull back if you look at my hands I'm pushing I'm pulling back on my track motion and pulling it within the scope and so now I've got this beautiful traction I've rotated I'm not spinning the traction knife out please thank you what I'm doing is I'm just kind of adjusting slightly but I don't want to totally roll it like a burrito or something what I want to do is just make sure that I'm getting enough torsion on it so I can see under here without winding it and I think you know this is okay but if you wind it you could damage your specimen so here we are getting a good view I want to get closer and closer and I'm gonna go ahead and just make sure the other thing to watch out for is over tension what you're gonna do with pulling too far and too hard north is you're gonna tent up muscle and so you want to make sure you're in the submucosa so what I keep doing here is looking to make sure I don't have muscle tracked in here so that's why I'm not just buzzing and cutting until I can confirm that I'm truly in the submucosa so this looks you know it's a little tough with the pig stomach it's not the same view but overall you want to confirm no matter what you're in so I'm looking here I'm looking at what submucosa and I'm rolling and I'm staying out of the muscle maybe take a little tension off and see what it looks like come back to the other side but I think we're still working in the same plane that we want to be in you still have the ability to do injection and needle back please okay and then needle out but we're getting a beautiful view so I think yes you can speed up your track your dissection time your ESD but you can also get into trouble so you have to be aware that you still need to utilize your planes and all your knowledge of your ESD from conventional ESD here you can make it faster but you want to be safe Alex you're using coagulation current right now do you typically use coagulation for not always and many times it's just cut cut cut cut cutting for cutting and then dissection there's clearly no vessels here but in this case what I wanted to do is just make sure that I'm in the right planes rather than just cut through and embarrass myself on camera thank you let's not do that right and how about you dr. how are you always doing endo cut for your dissection yeah recently I started using more endo cut because I started to use the water pressure method and then I think so yeah if you use the coagulation current in the underwater condition that creates a lot of bubbles which makes the your UV unclear so it's a very cumbersome to wash out the bubbles so with the endo cut you only have very like few bubbles during the dissections and also you can also keep the clean margin deep margin by using the endo cut so basically the coagulation current kind of like use some spark which destroyed the submucosal tissue to be able to get some more deep margin I prefer using endo cut as long as you I don't see any blood vessels so I usually go use with the endo cut until I see the blood vessel and I stop there and then either I switch to coagulation current or switch to the hemostatic forceps if it's a large artery so but it's this is again a preference some people use like swift quark post quark for all the submucosal dissection it's better in avoiding inadvertent blood bleeding but you need to make sure you're not compromising the deep margin but if you are using endo cut there is a higher risk of the bleeding if you don't care about any blood vessels so you need to see actually the dissection plane better than when you are using the coagulation current so I think that's the preference I think you can choose there's no right or wrong answer at this point so but I think the good thing is just try both ways and then choose which fits your practice so here I'm working a little longer we're starting to get our dissection underneath the lesion nicely and it's lifting and so now I'm expanding you know going left to right and trying to put out the arm to really give traction I haven't repositioned yet but we could at some point and then we just need to be careful not to rip the specimen so I'm going to continue with my dissection let it roll push it past me so I can see the planes without pulling up those muscle fibers it's a little bit of fog so I'm just taking my time and cleaning to make sure that I can see I'm going to come back and reposition Nice a good view Yeah And so I'm looking for these areas of Attachment here these white bands It's a little further than I want so I'm gonna pull in and try and work closer and take off these in the back So There are two different attraction methods, so Generally speaking there are two of them. So one is this type so basically you have the forceps and then grab the tissue through the channel, but Not a big issue But the thing is that it's like kind of like your scope is dependent to your traction So basically the movement of your scope is like captured by your traction But do you have the ability to change the location of the traction? The other one is the one we are going to show in the next hands-on Live demonstration session So we have the we can deploy the traction system in that area and then scope is completely free from the traction So again, so this is but the track once it's deployed. You don't have the ability to change direction of course So there is like a pros and cons Again, so you can choose what type of traction will fit Whatever it works for you So here I'm making up it's good that we have this little divot as we showed before Questionable repositioning is super important, especially if you need to grab other tissue and prevent from ripping so here I've Brought this in to get these edges There's a question Yeah So the question is if you are using track motion you do you tend to? Cut from left to right or right to left or is there any left to right left right on it? Okay, so is there any reason behind it? I'm trying to work with the track motion, but you know You can go back and forth the whole goal is to avoid getting you don't want to get your knife on the track motion You don't want to cut into it So I'm just trying to stay Stay off of it So I think it also depends on where the scope channel is located. In this case, your scope channel for the flashlight is at 6 o'clock. So there is no difference between left to right or right to left. But because we have the track motion on the right side of your screen, I prefer starting from left to right. And then, if necessary, just add the dissection from right to left. But if your channel is located at 7 or 8 o'clock on this screen, you don't have any ability to see the left side of the screen. So always, in that case, start the dissection from the left side to be able to see where you are cutting. I think that's probably the thing. But fortunately, this scope has a scope channel at 6 o'clock, so that's why we can do both directions for the dissection. So we're getting there. A little fog again, so I'm just cleaning. And I think it's good to keep our visibility. You want to go clean? Yeah, let's do it. Yeah, let's do it. I think it'll help us keep on track. We can come out and clean. So there's another question from the audience. It's a good question. So since we are working further away from this device, with this device, do you recommend using a distal attachment cap, or okay to leave out? Yeah, so this is a great question. So when you're using TrackMotion, because of the cap, we use it to open up for the traction, so to stabilize and also open up the submucosal plane. But because you have the traction device, you don't need to work too close to the target tissue. However, sometimes TrackMotion has some area that it doesn't work well. So in that case, sometimes we switch to the conventional ESD technique. In that case, we might have to use the cap. So for that reason, we have the cap at this point. So for example, if the lesion is located kind of like left side on the lumen or right side, or 12 o'clock, because the traction on this device comes only from 6 o'clock to like 3 o'clock, this direction. So it's not always possible to use the TrackMotion depending on the location. So sometimes we do like hybrid type of dissection, partially using TrackMotion and then followed by conventional ESD. So as you can see, at this point, Dr. Shirokutama is not using cap because we need to work from the distance. So now we're getting to the point where I can start to get the arm out a little further. I'm getting good visibility under the lesion. I'm confident that I'm in the right location. And so now I'm going to work in here and use my TrackMotion in the middle of this specimen much more. Staying off the muscle, not damaging my specimen, keeping tension off of the specimen, readjusting frequently to make sure I'm not tearing. As you take off fibers, you want to readjust to make sure that you're getting good visibility and that you're not damaging your specimen. Okay, again, don't damage. So I'm pushing out. Now I've got really good ability to get this entire specimen visualized underneath. And as you can see, the water's pooling right in our way, right? So maybe an underwater technique might be something you would do here, Dr. Ohara? Yeah. Yes, I think in this situation, if I don't have a track motion device, I would do underwater. But you're nicely demonstrating how to use a track motion. It's very difficult area in the stomach. We don't like to make it easy on a Sunday morning, give ourselves a challenge. So we can grasp the end of the specimen, or you can get within the specimen. So if you've got a really large specimen, you don't need to be at the edge of it. You could actually grasp here in the middle of it. And again, just be careful you're not damaging your specimen. You're pulling in, getting good close views, and you're not grasping muscle. Work a little further. So it looks like submucosa, but it's very white. So it's a little deceiving. So we're just making sure that we're in the right spot each time. But it still looks like submucosa even in a pig model. So that's beautiful. This view over here. So I'm going to come in. We can work a little further than we like, and I'm using my endo cut at this point. Readjusting, readjusting. So we're getting really good visibility in this, so I feel comfortable working with this arm out. And now this is really the benefit of our track motion. I've got the ability to do extended reach, extended grasp, and really pull this lesion away from us. And I think this is where your procedure really speeds up. But again, don't get excited because you could clearly have an issue. So just take your time. Make sure you're still in your right correct planes. You're not damaging your specimen. I know I've repeated that several times, but it's always the thought in my head. Where am I? Am I coming through the back of the lesion? So, usually, at the end of your ESC, the target tissue or specimen becomes very floppy, losing the support from the surrounding area, but as you can see, the track motion is providing a nice tension, and it helps stabilize the target tissue. And then, as you can see, Dr. Shirokuma is again adjusting, changing the area to capture. And then, this is the biggest advantage of this, like, forceps, grasper-type traction device. Adjusting, adjusting, cleaning, adjusting. Here we go. So, here, we had the question of, am I working left or right? Well, at this point, now, I'm going to try and get under this. I'm really going to flop this back, and it looks like I've got more on the left than I do on the right, so do I reposition, or can I adjust this so that I can do both? So, I think I'm going to try and open up and re-grasp. Come a little closer. I'm pulling in. Hopefully, we don't have to keep on cleaning, but was this pig NPO past midnight? I don't think so. I think she ate. I think she was eating, and that's why we've got a little bit of debris here. It's tough to, you know, they probably have gastroparesis. They eat so much. It's a serious business, no joking around. So let's see what we've got. We're getting towards the back side. I have two hours to do this case, right? But yeah, it's almost there. Almost there. It won't kick me out just yet? Okay. We wanted to make a reasonable-sized lesion without making it too cumbersome. So if you see that dynamic grasp that we just took, it's really key, and so now I can readjust my knife, come under here, work out, and then just do adjusted dissections for these very tough positions. And I'm tenting it away, tenting my specimen away. With a little bit of fog here, I feel like I'm in the UK. This is a London ESD. Maybe we'll just make it Seattle, how's that? Not Chicago, with the snow. Question, okay. Yeah, so the question is, like, we need baby oil from... Baby oil, yeah. No cry Johnson and Johnson, yeah. It's good stuff. We have anti-fog, which is also similar. Do you use, like, anti-fog from, like, pharmacy, or just, like... I've tried the Fuji's anti-fog, and it's pretty good. But I usually have a bottle of Johnson and Johnson baby shampoo in there. I trained in Florida, and apparently, we're big fans of anti-fog. No crying in Florida. No cry baby shampoo. I also use just the alcohol wipe. So it helps clean the lens, but I don't think it helps prevent any fogging. So I think the anti-fog would be the best one. And also, as I said yesterday, if you are worried about the fogging, or some fat tissue in the acening colon, and then sometimes you get a lot of oil on your lens, in that case, I usually go underwater technique, and then that will prevent some, like, a splash from the fatty or oily tissue from, like, sticking on the lens. You know what? I'm going to inject. Inject, okay. I think an injection is also another component that will be helpful here, because I'd like to kind of move things. So while we're getting the needle ready for injection, we'll clean one more time. And the reason I'm going to inject, although I'm getting good planes and really wonderful traction, I think you want to make sure you're in the right spot. Take the time to inject. Don't let me poke you, okay? Needle's back, yeah? Yeah, needle's back. Okay, good. That's all we need is a casualty. I saved the pig, but I poked our tech. Let's not do that. Thank you. All right. Needle out, please. Yep. Inject, inject, inject, inject. Thank you. Yep. So we'll see what we're doing here. And on this edge, so this is a very kind of, you know, it's a good model, but it's a little tough working on pigs and defining. And I think if you've got fibrosis or other issues, thank you. Stop injection. Let's see. Get this outside edge. It's not going to hurt. That fluid's going to dissipate pretty quickly. And inject. Okay, and stop. Let's take a look and see if it's done anything for us before we take out. It's pretty good. You can see it's fibrotic and white, and you know, this is part of the scarred stomach, but doable. Yeah. This is, you'll challenge or find these challenges in your ESD as well, whether it's going to be fibrosis or question mark, fat, that fat you have to ask yourself, are you, you know, in the right spot? Why is it not coagulating? Knife out, thank you. But take the time to get good visibility. It's going to help you in your ESD, your confidence, your care for your patient. I'm coming in close. I see my plane is this. The other thing I like to comment on here is go from the known to the unknown. So if you don't, if you can't see your exact spot that you need to be, your plane, find a spot that you know that you have it. And that'll give you confidence that you're in the right spot. And you can usually get your known from the edge. This area is very fibrotic, but as you can see, the traction is giving a very nice view. Even though this is very fibrotic, Dr. Serektaman can tell where to cut by having this strong traction force. Nice. It's almost at the edge. Nice. Nice. So let's not damage our specimen. Stop check. Stop check. So here now I'm working away, so I don't think there's one way to work. I think we've gotten through our fibrosis. We're going to readjust and we're going to take off the back end of this, and then we're going to have more coffee. I don't know if anyone else wants a coffee. Here I'm buying, okay? So nice. This is ideal. So you can see it's almost like the laparoscopic or trans-anal surgery where your assistant or your right hand is holding the tissue while your left hand is cutting some mucosa. This is ideal, like triangulation and also like traction. So nice. So I've readjusted, and now we're fully right angle on our track motion, and now we can come and readjust. Good visibility. I will say that the end of the procedure is when you need to spend a lot of care. You're tired. It's been a long case maybe. You need to make sure that everything's perfect. Don't rush. Just take your time. Even if you've extended your stay with the ASGE Video Center. Great. Nice. So you saw that, Dr. Shaktaman, push it that way. Yeah. Perfect. Very nice demonstration. Thank you very much. Thank you. Beautiful. Thank you very much. And now we're going to move on to remove our specimen as well. Thank you very much. You see the smoke? Okay. So you can see the specimen has been retrieved. You can see the old marking dots in the specimen, which means it's unbroken, R0 rejection. Great. Thank you very much, Dr. Shaktaman. Thank you. Thank you very much. Thank you for having me. So next we have Dr. Huang from Stanford. He will be showing short track attraction method. Thank you very much. We'll be back in five to 10 minutes. Thank you. Thank you, everyone.

endoscopic submucosal dissection

Fuji flash knife

dynamic traction

gastric lesion

track motion

circumferential incision

submucosal flap

double-channel scopes

Dr. Hiroya Hara