Good morning, everyone. OK. This is going to be a fun conversation. We get to talk about ESD flap in front of the world's experts. Nobody's nervous. Don't worry. Some disclosures to mention here. Boston, Fujifilm, Lumandy, Libori, Olympus. Thanks. So what I wanted to do is just jump right in and give you this slide to just kind of meditate and take a look on it as you're enjoying your coffee this morning as we discuss creation of a mucosal flap. On the left here, we see a large lesion. There's some dye on there. Somebody's doing a little bit of chromoendoscopy, looking at the edges. And on the right, you can see there's already been an incision. And the big features here to kind of point out. Let's see if this mouse works. Great. So over on the right-hand side, they're working for both. So basically, we have our distal cap attachment here. As you can see, the lesion is here. And this area here is what we're describing as the flap. And you might say, OK, big deal. We've already made the incision. Let's get going. Go ahead and do your incision. And then get into your ESD. Our whole point is to get this entire cap underneath this area without ripping the specimen. Our goal is to do this procedure end block without damaging our specimen so that we can get a good pathological evaluation and full removal. So with this image, this is really the key that we're looking for in the beginning. And then what are we doing when we're looking at this? We want to talk about evaluation initially. So before you've made that incision or injection, we have to think about a couple of things, right? Where is gravity going to be as we're dissecting? There may be better angles that we could approach. So our initial incision site needs to be evaluated before we've cut anything. Our angle of entry, are we going to have good access from where we're coming? Depending on whether you're working in the rectum, throughout the colon, the esophagus, or the stomach, we'll talk about the duodenum at the very end. We want to take all these things into consideration. And then our margin. So as we heard with Dr. Fukami, he was mentioning traction. In the beginning, maybe this isn't exactly what you want to use as other devices. You want to work on gravity and just getting access to this specimen. So your margin is going to be important. And then how much of the margin do you need in normal mucosa? So as we do our injection and our peripheral lift, we want to see where is this specimen going to flop? And how are we going to access this? And I say this over and over because the evaluation is key. We all want to do the ESD. We want to get through it. It's going to be a longer procedure. We want to get there. So your setup, like anything in life, is going to be clutch. When you prepare properly and you take your time to do the evaluation and your incision, you're going to make life easier. So as you watch these and you think about that, think about as you're injecting, where is our specimen going to go after I've injected and made my incision to get in? And then we're ready to do our incision. Mucosal depth, really important. So we're going to do our incision. Essentially, off of the lesion, well away, so that we can give room for the cap to get under. And then we have to think of, are we going in and through just the mucosa into the submucosa, avoiding that deep cut, that muscle in this situation? So going back again to the length of your knife, how much knife do you have out? What are you cutting? Those are all really important parts to consider. And you'll see this in the lab today. So this is an image just to remind us for hemostasis. As you're making your initial cut, most of your vessels, a lot of your vessels, are going to be in that mucosa. Yes, you're going to have plenty in the submucosa. As you can see here, we've got it highlighted. But the issue here is that you want hemostasis. So with your cap making that incision, you want to be able to see. Luck of the draw, yes, you could go ahead and tap a vessel as soon as you get into the submucosa. Now you've got to put your cap for tamponade, hemostasis, and then widen that as you're opening up to get your cap under. But remember, those vessels are going to be very superficial. You're not going to work in bleeding models today. But your idea is to make sure that as you're making your first incision, superficially is better, making sure that you're cutting and coagulating any vessels you see. And then take your time to visualize as you get into the submucosa. So what are we doing when we get in, right? So our goal, as I mentioned, is to the insertion of the distal cap attachment. Or in our case, we're just going to call it the cap. And it's critical here to allow for dissection of the submucosa. You've got to get your cap under there. And there are different types of caps, which we talked about as well, whether it be tapered or straight. The length of your cap is going to make a huge component as to how much you're getting in. Our goal with the flap, you want to visualize for improving safety with your cap. And you want to get under there safely so that you can do your dissection. Obviously, we want to avoid perforation immediately or at any point. Deep muscle injury, so we're cutting and we're making sure we're getting in with injection. And then treating bleeding as we're going. And a big one here to mention, specimen damage. So many times we're doing our dissection and we've gotten in and we're coagulating. Clearly, we want to avoid getting deep injury to the muscle. But you also have to keep in mind that we don't want to damage, if there's fibrosis, if there's issues, damaging your specimen and making a hole at that point. So as I go through this, I want to kind of take a break here and spread it throughout the room. And maybe I'm just going to start at the back of the room and get some insight from some of our faculty. Why don't we go way in the back? Dr. Yang looks attentive and ready to give me some comments. I would love to hear, are there any pointers that you would have as you're doing your ESD flap, Dr. Yang? One of the key things about when you start doing the mucosal incision is not doing it too superficially. So a lot of people, when they start with the knife, they don't penetrate into the submucosa and they basically skim that mucosa. And the problem about doing that when you don't find the submucosa is you're going to hit these superficial mucosal vessels. And then the oozing is going to start, yet you have not splayed open your dissection plane. And then that's when people start getting anxious, they start hitting the quack pedal. And you don't have visualization of the bleeding, your knife is getting charred, and that's where perforation happens. So you want to get a good lift, and when you make that initial mucosal incision, you want to have the knife perpendicular to the mucosa and puncture through into the submucosa. Once you know that your knife is in the submucosa, start cutting to the side. So that's a key thing to getting that mucosal incision started. Thank you, yes. I'll start off where Dennis left. So after you've gotten into the submucosa, it's really important, in my opinion, to maintain the right rate of cutting so that you're not flipping out from submucosa out and making these jagged cuts. You're riding this crest from submucosa to mucosa, and you're creating this microtension with the cap. And so you're going at the same rate. You don't want to lose that plane and create these cuts that are going like this, and so your whole specimen looks jagged. Ideally, you'll do a very long run because you've paced yourself in the way you're cutting, and you're not bunching up tissue, and you're cutting just the right amount of tissue, and it becomes a very Zen thing where you're breathing and moving and breathing and cutting. So I like that. And I think that's an important point as we go through this and we start talking, avoiding too much coagulation and avoiding flipping out, right? So you never want to flip out. Who wants to flip out, right? Keep it cool. You don't want to flip out of the lesion. You don't want to flip out during your procedure. You want to make sure that you're staying there because that's where you can get kind of specimen damage or just kind of jutting off, and your knife will bounce and maybe hit the muscle. So if you are going to angle yourself, I would also point that you should angle away from the muscle and the specimen so you're going into open space. As we go, oh, yes, Dr. Draganoff. For me, there is two crucial things that is make it or break it. Where people get burn is they'll keep doing the mucosal incision and they say, well, I'm doing great, and they'll keep cutting and keep cutting. And the key of flap creation is to create it early because if you open the mucosa too much with the needle knife, then fluid starts leaking out. So as Dennis correctly pointed out, the first movement is puncture. It's not lateral move. You puncture once you're in the submucosa, then you start with your lateral move, and then you immediately repeat what you have done. So you trace your initial incision two or three times until you create the flap rather than keep cutting. So that's one thing. The second key component that I find that usually people run into trouble, for most of ESD, we work up close. The cap is against the tissue. With one exception, when you're creating the flap. Because if your cap is against the tissue, you're pushing the flap down with the cap. And actually you're closing your space. So that is one time where you wanna be a little bit away from the tissue and work from a bit of distance until you're retracing from a distance without the cap touching the tissue during the retracement. During the mucosal incision, you want the cap on the tissue. So those are my two main things that I have noticed over the years that people get into trouble with that initial flap creation. I think that there is a concern about leakage of the solution because when you cut too much of the mucosa. I think it was true many years ago before the knives, combinational knives had become available. Now you can add all the time. You don't even need to use longer lasting solution. When you were in the past, when the longer lasting solution were expensive and then you were trying to save on it, then yes, it makes sense to work in the sector and then to put an aim on decreasing the amount of the leakage. But now you can add all the time at liberty with those knives and you don't even have to use more expensive solution. You can just do with normal scaling. So I say that make no sense trying to prevent that leakage and work in sector. I prefer my personal preferences to make circumferential incision and then to use some traction device to pull everything up. And if you don't do circumferential incision, later on you will be struggling on the opposite side, especially if it is under the gravity and all the fluid is collected there. So you have to think of that and you may want to start in the most difficult part of the lesion so that later on it will not become your problem when you exacerbate it by making all this. It's almost like you read my slides. I love it. It's great. Yeah, one other quick thing. So all of us here are beginners learning how to do this. One of the things that helped me a lot in the beginning, it's very similar to what Peter said. That flap is your key. Make sure that you're generous. A lot of time people are afraid and they make their marking very close to the specimen and they start close to the specimen. In the U.S., a lot of these lesions are biopsied so many times, played with so many times. Amazing how when you start at a far distance, don't be afraid. In a normal mucosa, it makes things so much easier. You have this nice, big, open mouth and then it just, you go on from there. I love it. It sounds like everybody saw my slides. Great. So Dr. Akimoto, would you tell me in Japan, with flaps, are you keeping a tighter incision and conserving for fluid retention or are you doing a circumferential initially, like Dr. Kansavo is mentioning? How are you approaching? In Keio University, we use water pressure method to make the mucosa flap. I will show you the water pressure method in the hands-on training. Several years ago, we performed that. We make the mucosa flap before circumferential incision to keep the good lift of the sub-mucosa layer. However, now this underwater condition, it's very lower pressure of the gastrointestinal lumen. So we perform the mucosal incision for the distal side. After that, in the lower pressure, the gastrointestinal lumen, and in the underwater, and we make the proximal incision and immediately making the sub-mucosal flap in the water and using the water pressure. I see. So in case you didn't hear back there, making a circumferential incision underwater and using water pressure to help with that flap, making a proximal and a distal flap. In this case, it'd be proximal coming from rectal, for rectal ESD, and then proceeding. Yes, sir. I wanted to expand on Sergei's comment, which is a great one, that traction makes a difference. But to apply traction, you still need a flap. I mean, because you need space where to attach whatever traction device you're needing. You may not need that big of a flap, but still you need some degree of a flap. Yeah, I just, you mentioned it earlier, but for everyone, the comment that Peter said right now, this is one of the most crucial thing when you're starting ESD. You dissect, and now you have separation. You have mucosa, and you have the rest of the legion. And now you are going by your knife, and we teach that you have to dissect deeper. You cannot dissect deep at the beginning. Actually, you have to be barreled to the mucosa, just under the mucosa, because you're still blind. You cannot see what's behind you. If you just go deeper, you're gonna cut the muscle. And sometimes, no matter how experienced you are, you can perforate from the first cut if you just go so deep, once you make the first mucosal incision. So you can inject as much as you can to prevent perforation till you make the mucosal incision. The next step is the most critical one. You wanna be a little bit further away, and then you're gonna advance your knife and go barrel to the mucosa. And repeat it like two, three times till you create this flap. Then you can start going in and go deeper. But if you try to go deeper from the beginning, you will end up just hitting the muscle. And that's, I feel like, one of the most important principles. Once you do that and create the flap, then you can use traction, use tunneling, use bucket, whatever it is, but that's the most critical step. Love it, love it. That's great feedback. So from everybody, I really appreciate helping me get through my presentation because this makes it easier for me. Thank you. Okay, yes, sir. Just wanted to emphasize what Peter and Ken Sufoy say. For traction to work, there needs to be separation of the lesion from the surrounding mucosa. The muscularis mucosa needs to be cut through. The lesion has to be floating and separate from the surrounding before you put traction on. A lot of the times we see traction fail. It's when people put it on too early before making that mucosal flap. And the term usually used is trimming. You need to trim the lesion before you deploy whatever traction method. But Alex, so the beauty of this course is that I personally learn all the time. And what I learned today is that I'm in a bind. I can come up to the podium and let the other faculty make the decision. Well done, Alex. Look, I'm here to learn as well. This is perfect. Okay, so I've got a few slides. And actually, you guys are gonna see that everything that's been discussed here are in the next couple of slides. So I could have just run through this, sat back down, enjoyed my coffee. But why not interact with your friends? Love it. So our cap insertion under the mucosal flap is what we've talked about. And we're gonna do that trimming. We're gonna get under superficially and then widen that space carefully so we're not getting that deep injury that we're looking at. We can use that cap to tamponade and then prevent or manage our bleeding. But really, this is the most important step of your procedure. Yes, there's many critical steps. Why is this very important? Because it's technically challenging. You're doing this blind. And you've gotta get that flap and get the cap under there. And it may take a while. The whole point, you're not in a rush. Get this part safely and get under there. And then you're gonna go ahead and be able to follow through with your ESD. But this is gonna set the tone for your entire procedure. So it's the start of the case. You want a safe entry. And then again, you wanna be able to make sure that you're not doing that immediate perforation like Dr. Othman was mentioning. You wanna get in there, do your tracing, get your cap under. And then whether you're doing a circumferential or a wide incision and then retaining the fluid or you're doing it underwater and doing water pressure, those are all techniques that you're gonna see. As well as introducing traction. So here we're talking about cap traction, gravity. And then eventually using other devices, making sure that that flap, telling you, you guys read the slides. Making sure that that flap is nice and wide. So some pitfalls that you could run into while you're creating your mucosal flap. Fibrosis or bleeding, right? So as Dr. Yang had mentioned, as you get in there, you might see some bleeding and you don't wanna have to over-treat. So you wanna get into the submucosal space but then again, prevent that perforation. So take a wide circumferential incision. Thank you, that was a great comment. You wanna make sure that you're wide. You don't wanna be right at the edge of your lesion because then it folds. You could get, your pathologist could say that the edge is not, you have a thermal marking there and indeterminate on the edge. So you want a wider edge with normal mucosa so that you can differentiate as well as you're not ripping the specimen. So plan for traction with margins that will allow you to apply your traction devices. And that starts with your mucosal flap. Bleeding can occur as we mentioned. We're dealing with those superficial vessels, various caps that we've talked about and we saw some earlier in the presentation by Dr. Fukami. So those, whether it be tapered or straight will be your preference. And then as, and you'll see how you wanna use those caps. So our take-homes. First of all, this plan varies with the lesion location. So whether you're doing an ESD in the esophagus, the stomach, the colon, in the rectum, or left or right side, you're gonna have variation, right? So you're gonna, whether you're doing a proximal or a distal flap for stabilizing, say in the rectum, you might wanna go in and do the oral side first and then utilize that for your traction site versus going in and doing the anal side first. But again, so location matters. Esophageal versus gastric, all these things are gonna come into play. So your approach matters. Assessing and making sure that you've got gravity in these things on your side and that your approach is gonna be stable, I think is the key point there. And that's what we've got in that next margin. And we talked about the oral or anal side. And then whether you're injecting and what's gonna happen to this lesion. Is it gonna flop left or right and where are you gonna go with that? So kind of plan for these things. I personally, I like to use extra injection in the beginning to make sure I have a nice big lift. And if it costs me an entire syringe of solution, that's what it costs. The rest of the procedure I can do with my injectable knife. But here's where I want a nice big injection so that I can get through my procedure without dealing with issues, at least immediately. And then our incision, we want it in normal mucosa. And I think that's key. We really wanna make sure we've got that nice periphery so that we're gonna get a lift and get our cap under there. And then utilize the techniques we discussed. And then I've got a big red line through the duodenum. Just don't do it, not yet. Just stop. Wait, talk to the experts. It is being done. There are plenty of folks in other parts, you know, in Japan that do these things. And I wouldn't make this your first or even your early ESD. I would focus on places that you can do this safely and the duodenum's not it. So that's a big red line for me. I'd like to thank everyone for their participation. Thank you.

Endoscopic Submucosal Dissection

mucosal flap creation

lesion handling

incision technique

bleeding management

traction application