We will next go to Dr. Gregory Haber from New York University. Dr. Haber, so you're online, please go ahead with your case presentation and introductions. First of all, I just wanted to say that I think this is a tremendous idea on the part of ASG and hats off to Moen for pulling this off, bringing us all together for this discussion. It's a great learning experience for all of us to see how we operate and how we do things and so I hope this, for all of our audience, this turns out to be a very educational experience. What I thought I would do to start with, because I've heard on these initial questions with Vivek and the team from Florida about what solutions, what knives, all that sort of thing. So I wanted to give you a little bit of an overview. The first thing that I'm concerned about, beside me I have my advanced fellow, Ahmad Altai, who's been fantastic. The first thing that I am concerned about, when I do, you can lay it down there, endoscopy, is that we know that with ESD, 50% or more of ESDs, 80% are often done in the retroflex position. And this is critically important. So what determines how well you do retroflexion is how well your scope will retroflex. And so I'm going to give you an example of, you can go in close on this one, and here's two different scopes. And you can see how we have one which is really 210, 220 degrees, the other is 180. I always check all of my scopes, this is the scope that I want to have for ESD. So I always check my scopes from the point of view of retroflexion, and make sure that I have adequate retroflexion, because I know if I don't, I'm going to be totally frustrated. So that's one of the first things. The next thing, we talked a little bit about solutions, and you have the viscous and the non-viscous. In general, for let's say the esophagus or even the colon, saline is adequate to stretch out the submucosal space. When you're in the stomach, or if you have fibrosis, or you have a tight submucosal space, we like viscous solutions. And on the viscous side, traditionally the Japanese have used muco up, which is hyaluronic acid or glycerol and fructose. We haven't used that in the West. In the West we've tended to use, although we have used hyaluronic acid here for the first few years, but we're tending more to the starch solutions. And I know Amrita mentioned head of starch. So we use, just to give you an idea, we have a bag of head of starch. This has different brand names, by the way, but it's 6% hydroxyethyl starch. So we take a 500 cc bag of the head of starch, and you can take this either full strength, or if you want a little less viscous, you can do it half strength at 3%. What we add to the head of starch is we add 1 in 10,000 epi. So the way we make our solution is we take a half a cc per 100 ml. So we use two and a half cc's of the 1 in 10,000 epi in a 500 cc bag. And then we add, you can add methylene blue, you can add indigo carmine. In fact, if you wanted to, you could probably ask any food coloring or if you want, but this is what we use. And, you know, it's always hard to get the right amount. So we take about one cc of the methylene blue in a 500 cc bag. And when we do that, we get sort of a solution of this color. You know, it's a kind of sky blue, azure blue. People have their own preference, a little lighter, a little darker. But that's how we do it. So we use the head of starch. Now, there are proprietary solutions, obviously, which make it a lot easier for people. It's prepackaged, etc. So we can take a product like Orize, which is a proprietary gel, a very viscous solution. The only issue, it's not an issue, really, but you cannot mix epinephrine with Orize. It's a little bit too gelatinous, a little bit too viscous. So if you want epi, you'll have to inject it separately from the syringe, which has the Orize gel. I don't have a package of Elevue to show you. It's similarly a proprietary product, which is prepackaged for you. Elevue is a little bit less viscous. You can mix epinephrine with the Elevue. So we're always set up. We're set up now with saline, epinephrine, and methylene blue, which is what I'm going to use in the esophageal case. If I have trouble, I'll move over to the head of starch, probably the 6%. Now, the only thing to remember is that when you're going to inject, don't forget that if you're using saline, you need this 25 gauge needle. If viscous solutions, you need 23 gauge. So pay attention to the needle you're using, depending on the solution that you're using. Now, the next question you have is what knife am I going to use? So traditionally, let's just take the hybrid knife from Irvi. Here it is here. Now, there we go. We'll focus in on that. This is a hybrid knife from Irvi. I believe that's what they're using in Vivek's case. You can see that the needle length is about 5 millimeters, and the shaft size is, I can't remember, I think it's about 1.2 millimeters, something like that. I don't remember exactly. So it's a long knife, but it has the advantage of a very fine dissecting stream for injection. You won't be able to see it. It comes out of the tip of the knife. It's about 120 microns. It's a powerful sort of cutting force of fluid, if you like. So it's very good if you have a very restrictive or fibrotic submucosal space, because you can also change the pressure of injection. So it's standard set at 30 millimeters of mercury, or maybe 30. I don't remember what the metric is, but you can go to 35, 40, 45, whatever you need to improve the dissection force. So I think that's something to remember if you want that. The disadvantage of that knife is that it's very thick. It's a long knife. I don't think it's very good for, let's say, fibrotic areas. We want a very precise dissection. So the two knives that we are using now, and let's have these brought up. Yeah, there's one, and we'll take the other. And they're open. We'll get a close-up of these. Now, these two knives, one on the blue one is the Pro knife from Boston, and the other one is the Microtech knife with a little bit of a gold band and a gold tip. These are very similar hybrid knives, if you like. The injection stream is out through the needle. I don't have a flush knife, which has been around for a long time with a very similar design from Fuji. I can't show you that, but it is similar. But the advantage of these knives, of course, and the Dual knife, and you'll see Dual J being used, I believe, is that they have a precise length of the knife. So generally, these knives are available in 1.5, 2.0, and 3.0 millimeters. Now, why is that important? Well, if you have a very thin mucosa, as in the esophagus or colon, we almost always use a 1.5 millimeter knife. With a thicker mucosa, especially in the distal stomach, you need a longer knife, a 2 and occasionally a 3 millimeter long knife. So the only difference between these knives and the Dual J is that in the Dual J, the fluid comes from the catheter. So it's alongside the knife, where in these particular knives, the fluid comes out the needle a little bit more precise. Now, with these knives, you have to inject the fluid from the handle. So for instance, here, you can either hook up from this handle. This is the Pro knife. You can either hook on a syringe or a pump to inject your fluid. And the same is true, let's see, of the Gould knife. Let's see, it's a very similar fluid injection for this knife as well. So those are the knives that we use. The other thing, I guess, which I've got here is, which I should have mentioned a little bit earlier, is the type of cap that you put on the scope. And I think most of us now, we have two choices. Of course, we have the traditional Olympus 4 millimeter cap. And then you have the tapered Fuji caps and the ST Hood and the other Fuji caps, which have a conical tip. Now, the advantage, there's advantage and disadvantage of a conical tip. The conical tip, of course, helps you gain entry into the submucosal plane after your mucosotomy. On the other hand, the larger, let's say, the Olympus cap, let's say if you're doing a poem, it's better at separating structures. So it's a little better at keeping the mucosa away from where you're dissecting, reducing the risk of mucosal perforation. So there's pros and cons. In general, I would say the, we're going to have a close up, but you can see these two tips. The only thing I would say is a little different is the light transmission with the Fuji is a little bit better than with the Olympus cap. So you'll see that. We'll be using these and you'll see this in the course of the study. What else do I have to tell you? I should. Greg, this is an amazing tutorial and I think really demonstrates how you have to be prepared with a lot of different instruments, the variety. Just wondering, when you're choosing your knife, are there any restrictions with regards to the liquid that you're going to, the fluid that you're going to use? For example, can you use the Hexan in all of the knives or is that something that you have to think about before starting? And the other variable length of the instruments, do they all come in a sort of one size fits all, or is that something that you have to consider? I work for the office. I got to love my screen. Yeah. So most of them, that's a very good question. And when we use the viscous solutions, especially with the smaller needles that I showed you, the Microtech or the Boston knife, you do really have to inject firmly and forcefully to get the viscous solutions in. So it is an issue, but the solutions, even the Arise, et cetera, which is maybe a little more viscous, will go through all of these knives. Now, the advantage, of course, is the Irby knife. It's all done by the Irby hybrid injector. So you don't have to push it with your hand, but they all will go through. Now, a couple of things I want to mention while I'm here is what do you do with your specimen? So I think a grid is a great thing to pin out a specimen. So with these grids, there are different grids. But when you pin them down, I think it's a very nice way to get an accurate measure of what you've done in sending it to pathology. I also should mention that like the pins that you use, let's see here, we also use cork. We have lots of cork. But the pins that come, you got to use a very thin pin with the tissue. And people don't pay attention to that, but I'll see if I can show the difference. Here's a couple of pins. You can see that the thin one is the one you want. So I don't want to get down into too much detail, but we use a very thin pin. OK, let's move on to cleaning. Very important. Now, you may think this is for me so that before I present to a big national audience, I have a nice clean breath. But no, this is to clean the knives. So after I inject, our nurses always have a toothbrush to clean our knives. Very, very important. If you're wondering if you use soft, medium, or hard, I'd go with the hard. OK, there you go. Now, let's go over to Irving. So we have a preset for our ESD. I'll put it on here. Let's see. So you have a choice of all the presets that we have on the VIO3. So we go to ESD poem, and this is what comes up. A lot of people are, we're going to go with, let's say, a monopolar instrument. And let's go with dissection. So people have different choices with this equipment as to how to dissect. Now, traditionally, what I've used for mucosotomy is endocut I, and I use it at a setting of 2, 2, and 3. So intensity 2, duration 2, interval 3. I like this. I'm used to it. I've used it with all the Olympus knives and the newer knives. I find it very good. Now, a lot of people, and the Japanese have sort of led the change in the trend. They don't go to endocut I. They like dry cut. So they'll go to a dry cut, and they'll set it at around 2, 2 to 3, which we'll set here. Let's say the advantage of a dry cut has more coagulation and less cutting. The only thing about dry cut, it doesn't have the interval setting. So it depends on tapping on the pedal. And I find that a little bit more difficult to tap just the right amount of tap. The thing I like about endocut, it gives you that interval. You can sort of cut through slowly. So we have a little choice there between endocut and dry cut. As I said, I like dry cut, but I'm not a great fan, even though that's the popular trend today. What about Precisec? Amrita, you mentioned that. Well done. Oh, they told me I have two minutes left. OK. Anyway, with the Precisec, the advantage is it's supposed to coagulate even vessels up to one millimeter as you dissect. I actually don't find it does that that well. And hats off to Mike Mack, who's been a fantastic assistant. A lot of people like Precisec. I'm not a great fan. You can control how much. I've tried six, five, four to see what gives me the best effect. But again, I'm not a convert yet, but maybe next year I will be. So what I use instead of Precisec, I like force coagulation. Force coagulation on the vial, I usually go down to about a two and a half. So my own personal preference. So and I go, as I said, I don't like dry cut as much as I like my endocut. So that's my setting for dissection. The last thing I want to mention is coagulation. Because you have to have the coagulation available. So we know about the coagulation. The thing that you may not know is that we use a hot biopsy forcep here, often under the same coagulation setting. It's a much wider cup. And we close it here. And we just use it for against, close the cup of the, you have the closed cup, and we just push that against the tissue. And we use the setting of six. Okay, I think I've spent enough time doing that. We'll get our case going. So I'd like to introduce our fellow, Ahmad Altaieh, who will present the case. All right. Go ahead. Thank you, Dr. Haber. So our patient today is a 64-year-old female with a history of long-segment bariatric esophagus, who presented for upper endoscopy for surveillance. Upper endoscopy showed long-segment bariatric esophagus classified as C3M4, as per PREG classification. In addition, a three-centimeter nodular area of salmon-colored mucosa was noted. Biopsies of that area revealed moderately differentiated invasive adenocarcinoma. Upper EUS was performed and showed that nodular area was confined to the superficial mucosal layer, also known as layer 1. In addition, a 9-by-4-millimeter mediastinal lymph node was noted. Fine needle aspiration showed reactive lymphoid tissue without any evidence of malignancy. Patient had a PET-CT scan that showed FDG-avid thickening of the distal esophagus just above the GE junction, with no evidence of nodal or metastatic disease. And our plan today is to perform endoscopic submucosal dissection for superficial esophageal adenocarcinoma. Good. Thanks very much, Ahmad. So first of all, of course, I want to introduce the team here. We have a tremendous group who are assisting us. Katrina is our medical physician. Edis is our nurse. Susan, our anesthetist. And our tech team, Sean, Roger, and Sophia, my administrator. So everybody's worked hard to put this together. So this is the lesion. We'll go to the endoscopic view for the audience. And it's sort of slightly raised. We'll just blow this up here and give you a good view. Just trying to blow this up a bit. Now, you'll see this in a minute. There we go. And it's this raised edge here. Of course, we have the close mag. It's not easy to see that. But you can see the irregular vascular pattern. And then in the central area, the total loss of the vessels, a suggestion of malignancy there. And then we'll go off of the mag. And we're going to take a fairly wide margin on this lesion. Down at the GE junction, several studies have shown that the submucosal extension of the lesion is up to about 5 millimeters beyond what you see with endoscopic definition of the topography of the lesion. So we tend to take a wide margin. I'm going to go fairly far down here below it. And we're going to come around to this side. And we'll start our dissection. So what I do here is I like to do my mucosotomy, tackling the most difficult side first. So we've marked it up. So I'm going to start with the caudal end, if you like, the distal end of the lesion, and try to get my mucosotomy across here. So we'll start with injection. And what I'm going to use is just a saline solution. We'll see how that works for the lift. It's got a little bit of methylene blue and epi. What I also do here is, if we show the audience the view of my hands, I'll take the tape. And what we always do is, I'm not sure if we can give the audience that, but we basically place tape at the end of the whatever device or accessory we're using. So we know when we go back and forth that we're in the right spot. So we'll just put the tape on here. So every time I go down with that needle, I know that this is down at the tip of the scope. OK, we're going to go back to the full end of view. Great, great. Just one question. I see you've made a pretty wide marking on this. And it actually is beyond the hemicircumference of the esophagus. Do you anticipate, or are you worried about any stricturing over here after the ESD? Yeah, very much a problem in the esophagus. And so we try to limit it, if we can, to less than 75% of the circumference. But of course, the principal directive here is to have an RO resection margin. So we will deal, even if we have to do circumferential resection, that's a whole separate discussion of steroids, stents, or other measures that people use to prevent it. But in this case, I think we're still under the 75%. This is one line, and the other line is over here. So I think that we're probably more in the 50% range. So I think we'll be all right. You can discuss what, Amol, it's a great time if you want to discuss what you do for strictures. Needle out. I think we do use topical steroids as well as oral steroids, a combination of both. So we do inject topical steroids at the end of the ESD into the submucosa. And we also put these patients on steroids for about four to six weeks on oral steroids. And with that, most of these patients don't develop strictures. Those who still go on to develop strictures that we do have to dilate. And important thing is we need to call these patients in every couple of weeks to scope them. And if there is a stricture forming there, dilate before the stricture gets really hard. The longer you wait, the harder the stricture gets, and then it's more tough to dilate that. We use stents very sparingly. We have used it only on two or three occasions when we had to do a very long segment circumferential resection in the esophagus. But otherwise, we try not to use stents in these patients. Okay, dual knife 1.5. Greg, while you're injecting, I have a question. What will be your approach and how do you think about that? Are you planning to tunnel in this case or do a full circumferential incision and a more classic conventional ESD? Yeah, so basically, in this case, I'll do more of a classical approach. The only problem you get into with lesions which are down at the lower end of the esophagus is if you dissect from the top and then go down to the bottom of the lesion or you tunnel through, you sometimes get a problem with the top end of the lesion prolapsing down below the GE junction of the stomach. It's hard to identify the bottom end of the lesion. So what I like to do is to make a clear entry point at the bottom of the lesion. When I do the subucosal dissection, I sometimes leave the top end of the lesion tethered down. I don't completely necessarily dissect that. So we'll hold the lesion as I tunnel down through. So it's kind of a, not a complete tunnel approach. It's leaving a little bit of the lesion tethered at the upper end to hold it in place. For some traction, yeah. Reload. So we have, now we're using the dual 1.5. Needle out, yeah. And what's the patient's position right now? Supine or? Left lateral. Left lateral. And is that something you'll consider changing as the procedure progresses? I'll see if it becomes a problem with respect to the fluid, yes. We'll change as we have to. Okay. At the gastroesophageal junction, do you anticipate that changing the position really helps, Amrita? We found that the benefit is less as compared to rectal lesions or colonic lesions. But yes, sometimes it does get, you know, you might have some benefit, but. Yeah, I agree. I think that now, especially with different traction methods available, sometimes the positioning is not as critical and may just increase delay in the procedure. I think the important part is what Greg has talked about was kind of going after the most difficult part for the mucosal incision first so that you're not struggling and the lesion isn't kind of flopping over when you're trying to do the mucosal incision and you have difficulty with visualization and there's increased risk for early perforation. So I think that's an important thing to think about. Yeah, that's true. And what is your take, Greg, on doing the distal incision in a retroflex manner, particularly for G-junction lesions like this? Would you prefer to do it? So this part of the incision, you know, we're in the tubular esophagus, so I don't generally retroflex here. It's more important when we cross the G-junction. But in this case, we're gonna do it prograde mostly. Yeah. And you can see, it's critical to control bleeding right off the bat. If I have trouble, I generally go in with the hot biopsy forceps and just lay it in there. I think we're okay at the moment. The only thing with saline, let's just clean off the end of the knife. With saline, you have to sort of re-inject a little bit more often. It doesn't stay elevated as often as long as the viscous solutions. Okay, just give me the hot biopsy forceps quickly. So I'm just gonna get rid of this little annoyance. So even though this is sort of the most tedious part of the procedure, I think it's very important the nucleoside may become really the most important part. Actually, close the device, please. Okay, we're gonna use the closed cup of the hot biopsy. It's very easy. And we just use soft flag, bio three setting six. And we're just gonna go against that vessel and just- Dr. Haber, that is nice demonstration. So we will, while you're working on this, we will go to Dr. Kashyap for a few minutes as he wants to show his complete product. And we'll come back to you after. Well, let me show you what I've done just to get a little catch up. Basically, we've done the mucosotomy all around. We're just gonna start our dissection at the top end of the lesion. But we've basically created, there's a little bit more muscularis mucosa in the cup there. But we've gone all the way around the lesion. Again, muscularis mucosa, that sheet-like area, which we will cut through when we inject a little bit more. So one of the things that we always do is we always suck out the stomach every opportunity we get because we're constantly filling it up with CO2. So let's come back. Well, now we're gonna use the pro knife on the upper end here. And we have our Fuji cap. And we're gonna create a tunnel now going down through the lesion. I'll leave the corners at the left and the right for now. And we'll see how the dissection goes when we get underneath the cancer. So this is the two pro knife two, needle out. You can see that. And it's got a little knob on the end. There's about 0.5 millimeter shaft and about a 0.8 or 9 millimeter knob so you can catch tissue. And we'll go in here. Now what we'll do is just a little bit of a lift, inject. There's a manual inject. Stop. So you hear Katrina happily telling me what we're doing. And now we'll use a little bit of a coag for this vessel. Go through there. And now we'll go underneath here. And once you've got a good mucosotomy, the rest hopefully comes easy. If I have vessels, I'll use, I'm using force coag there. And now for my cut, I'm using endo-cut. You hear that? And now we have a little bit of bleeding. It's really important at all times to control the bleeding. That's about 80% of ESD is keeping a dry field, seeing where the blood's coming from. And we're looking at these vessels, looking to see if we can find the, take it when we put pressure on, of course, we stop the bleeding. And then when we want to just, just gently, it's coming down from the left there. I can see it, but we'll come down to that spot. Now let's see, we've got some more bleeding on the right. Here's a vessel here, a little arterial. I'm not sure if this is enough to do it. We may, we may take our hot biopsy forceps, which we've been using. We'll see how that goes. But again, everything has to be totally dry as we go. All right. So I believe there's some new technology, Greg. I believe there's some new technology from Olympus regarding the RDI technology with the red, you know, where they have a mode where you can identify bleeding vessels and you can identify them easily. Unfortunately, we don't have that technology. It looks amazing. Would give us the ability to see where the bleeding vessel is coming from. So now we have to use old traditional techniques. All right. So we'll just, do you have it Amol? We just started it. So we did a few cases with that. We don't have it in our unit yet. We played around with it for a few cases. It looks pretty challenging. Again, impressive. It's very nice, but probably you need to get some more experience because you see so many types of colors. So you need to be familiar with all those colors. Otherwise, you know, it's all looking very nice, but then you still need to see the clinical utility of it. And Greg, what are your settings right now? Sorry, stop. The settings? Yes. Yeah, we're using a force coag. I don't know if Roger can show them anyway. Basically a setting of three on the vial, vial three and endocut two, two, two, endocut I or two, two, three. So again, I'm not choosing the precise or the dry at the moment. Now we've got these bubbles. I don't know if the bubbles are different with the different solutions. It's often was said that hyaluronic acid gave you a lot of bubbles. This is starch, whether this is more of a starch thing. Now we get to this, coagulate through. So we're just gonna work our way underneath. At this point, we'll have a good dissection plane. Okay. So Greg, are you going to tunnel your way through all throughout from oral to the gastric side? Sorry, what was the question? Yeah, so will you be tunneling your way through from the oral to the gastric side and come out? And then probably try and join the edges. We've already seen a couple of, you know, three different types of techniques. I think Vivek is using the track motion as a retracting device. And Sahwani is performing a conventional ESD and Greg is doing a tunneling ESD. So many different techniques. And so, you know, Greg, maybe you want to take that up or maybe Amrita, you can answer that question. How do you choose which technique you use in which situation? So because for a person who wants to start doing ESDs, you can't do all at one time. So how do you choose? Well, it's a very good point. I mean, Amrita can speak to this, but I mean, traction is a critical part of improving the efficiency of ESD. Now, in this case, in the esophagus, it's a little bit different. You don't really need traction. You can tunnel underneath it fairly well, but there are, you know, Professor Eineway has shown us different techniques with a snare, a soft snare that he uses to attach to the top of the lesion and pull it up or a hard snare to push it down. Of course, we have elastic bands and sutures and other different traction devices. I think certainly in the stomach and in the colon, traction is going to be very attractive. Here at this point, I don't think I need it. We have it available if we want it, but at this point, I'm happy as long as I can get a good plane of dissection. That's a critical thing. You want to be able to see well and have a plane of dissection, good control of the scope. So in the esophagus, maybe I've got the easiest task of all our demonstrators today, because I feel that this is sort of an easier type of dissection compared to the colon. I had the beautiful experience of doing a five-hour ESD yesterday on a transverse colon follow-up that had three prior attempts at removal with EMR, and it was like going through cement. So there's all kinds of different scenarios. Amrit, anybody want to comment while I carry on dissection? Yeah, sure. No, I think that's the point there. I think in general, traction is definitely the way to go of some type. Now, with that said, there's everything from natural traction from gravity to traction from, as you mentioned earlier, kind of cutting the mucosa, but leaving a thin layer of submucosa available to create traction. And now to newer devices, we're looking forward to seeing the one that we're going to use in the rectum, but rubber bands. You have to think about a few things. Where is your location? For example, in the esophagus, we can use more of a clip-in line where we're actually putting traction from the mouth, or in the rectum, you can do the same. But when you're in the colon and farther away, you have to look at devices or traction methods that you can use very local to the lesion without having to do anything outside. And I think in the esophagus, the tunnel is a very reasonable approach. Although the one thing that I think you have to make sure is that you're not doing a poem, right? So in the poem, you can get very close to the muscle and there's no worries. And so when you think about tunneling, sometimes you adjust your method that way. But in ESD, it's critical that we are not getting that close to the muscle itself. And so if you're going to tunnel, you really have to have enough room in the submucosa to be able to do that safely. And I think it ultimately comes down to what you're comfortable with. Again, ability to change the position of a patient is important. If you have a very large patient or that's not going to help so much, then you have to think of other traction methods because gravity is not going to help in that situation. And I think the only other thing to say is to think a little bit, to plan ahead. Clearly, you need to know if you're going to do a tunneling method, then you don't want to create, you don't want to keep going on the mucosal incision. And sometimes when you're doing that and it's going very smoothly and well, there's a tendency to just keep going. And it's important to remember that if you're going to use a tunneling method, you need to stop. The anal incision is very, very important because as Greg mentioned, there is a tendency to lose your orientation when you get to the distal end of a lesion and keep tunneling under the actual place where you want to have the distal margin. So thank you, Dr. Haywood, that was nice demonstration. So basically I've held off here for the last little while so that we don't finish up, but essentially you can see from the overview here, we've left the corners tethered. This corner and this corner. So they're holding the specimen high up. The other thing I did was, as I got down towards the bottom of my dissection here towards the muscle, I was a little bit worried I might undermine the distal fold, which can happen. So I came back and kind of looked at the measurements, see where we were, figuring we're about here. So then I decided to open it up a little bit more at the bottom to make sure, and we'll do that now, to make sure that we don't overshoot, that you go, and obviously from the comments, you can understand that early on, we overshot a few times. So we're gonna open this up a little bit more so that we'll enter that space and then we'll work on the sides. So let's just have a needle out. I was gonna ask Vivek, when he was a kid, did he play with dinky toys? Dinky is a word we don't hear very often. I was just curious, he said it was sort of a dinky device or something. Okay, inject. So we're just gonna open this up, that's good, that's fine. And then we'll, just cut through here. What happens is you often, when you do your mucosotomy, you may leave a little sheet of muscularis mucosa when you're being a little bit more cautious. So I think that's what happened here with some of this dissection. Gotta be careful here, there's a little vessel. We'll just use cautery to go through. And there we go there. So I think we'll probably be able to recognize this side as we come underneath it. We'll probably dissect through here. And as you can see here, there's a cancer, so one of the critical issues for me is to try to stay low, stay close to the muscle. I definitely want a vertical RO margin. So we'll just complete the end now through here. Okay, inject. Stop. You notice how Katrina keeps telling me exactly how much is injected at all times, communication at all times. We'll just, I think I might've asked you this question before. Are you still using the Hexstan solution? No, we went to the, we went to Hespan, yeah. Okay. We did a little bit of saline on the edges, but now we've gone to Hespan. Inject, please. Injection, injection one. Stop. That's okay, okay. And usually one of the things I point out as always is that dissection, submuscular dissection is always a left or right or lateral movement. It's never a forward to distal movement. Otherwise you hit all kinds of things you're not aware of, big vessels, et cetera. I try to emphasize that a dry field is critical for good ESD. And so that's why I'm using, you know, a coagulation current here. This is forced coagulation. And we'll just carry on down through here. Hopefully we don't undermine it, but. Side to side. That's an interesting point about a dry field because we've seen some nice demonstrations from Ken Binmuller and others of a lot of underwater resection. What do you think of those? Any comments on those types of methods? You know, listen, it's gotten great press, especially for difficult EMR, floating up tissue, grabbing it. Even the cold snare world now loves cold snare underwater. I don't know, I just haven't adopted it yet. I don't know why, whether I'm slow to change or whether, I mean, I do find it a little bit difficult. I mean, I find it filling it up, room temperature water, filling up the whole lumen. So I don't think I'm the best one to speak to it. I haven't really adopted it yet, but maybe you have, or maybe people in your group. No, we haven't either. And I think, you know, maybe for classic dissection methods when you're doing ESD, that's a hard transition to make. I think there has been really nice demonstrations with EMR as I think you were saying, but in the ESD techniques, you know, I think in terms of visualization, I oftentimes do have difficulty really filling and staying clear with the fluid, and at the same time using the instruments, getting the bubbling from the cutting, the currents and whatnot, and especially when there's bleeding that occurs, but definitely a different approach. So we can see here muscle here, so being very careful. There's muscle and muscle down underneath there. So we're watching all of that. So I think I'm, the reason I'm focusing on this bottom end is I think I'm almost through. There's our lesion. And I'm expecting to pop through here any moment. There we go. We just popped there. Oh, yes. So we'll just open this up here to complete the tunnel. Light at the end of the tunnel. Light at the end. It's especially important when you're using coag graspers because oftentimes your view is just blood or fluid and it can be difficult to see exactly when the coag grasper comes out. So thanks, Dr. Haber. So that was a nice demonstration. We'll go to Dr. Peshaw because he's finishing up his Z-perm. Then we'll come back to you after. OK, well, we've been on hold here to show you this last little bit. I did hear the conversation. We do also tell our patients in New York that they shouldn't strain, but straining for the New Yorkers is I don't want them to run a marathon and I don't want them to go on a weightlifting contest. Everything else is fine in New York. They don't worry about the bowel movement straining. Anyway, as you can see here, aside from a little bit of humor, we've basically, I can't remember where I left you off, but we went through, we created our tunnel. Then what I did is I worked my way laterally from distal coming proximally along that cut edge to make sure. And then as we come up here, we see we have this little bit tethered down on this side and I've left a little bit tethered down here as well. And that creates our own sort of traction. The other thing we did with this patient, you won't notice it from the camera, but essentially we did notice that there was pooling of a little bit too much liquid on the left hand side. So we moved the patient over to her stomach. And so this lesion is basically posterior and it's hanging down for us. So we did move the patient around to make it a little bit easier. Okay, so now we're gonna just finish this off if we need a load. You can see the mucosa. One question is, do you do both edges one after the other and do you go all through on one side and then go to the other side or do you do it bit by bit on both sides? Right. You know, I do like to go on the dependent side first so it hangs down on that side as a preference. In this case, it's falling directly anteriorly so it doesn't really matter. So I'm going left and right. I do like to leave a little bit of tether on each side when I'm working underneath in a tunnel. So it helps to maintain the tunnel without the lesion flopping away. Okay, need a load. All right, inject. Stop. It is sometimes difficult to see the edges when we do this. So you gotta come back, remind myself where I am and the plane that I wanna cut over towards this margin. And the other thing we have handy if we need it, I mean, a little extravagant, but we do have, you can cut down the sides with an SV knife or the IT2, I think, is nice in this situation too. So there's a little bit of brown, which is maybe old blood sitting there. So I'm gonna just try to inject underneath, inject. The white is the mucosa above. Stop. So we'll just cut through this. You can hear the difference when I hit the coagulation. When you get towards the edge, there's a lot of vessels you sometimes don't suspect. And so we're almost through on this one side. Inject, please. Stop. So, Greg, there is a lot of discussion about, you know, the direction of your cut towards the muscle, away from the muscle, towards the mucosa, towards the edge or from center to periphery or the other way around. So how do you choose that? Well, I mean, listen, I think you wanna be parallel to the muscle. So, I mean, look, the challenge of ESD is always getting the scope into the right position. It's not the knife, it's not the solution, it's not, the trick is managing the scope and trying to get into the plane of dissection. So that's always the challenge. So, you know, we obviously try not to direct down or up, but parallel with the muscle plane. Right. So sometimes the swing of the knife when you're going from periphery to center can go and hit the muscle. So that's something that one needs to be careful about. I can see how Greg is being so careful and meticulous about opening up the edge before he gets his knife in position to do that. I'm using the scope, obviously, for my traction, lifting up on that edge. So, I'm using the scope, obviously, That's that side, and now we'll just take the other side off, and in this case I'll start from the top down, I mean, it's just easier to see it, injection, stop. Sometimes these last moments can be the longest ones of the procedure, I think it's really important to just maintain, as you are, just steadfast patience. I think there's one important aspect of ESD that one needs to mention, that's patience of the endoscopist, and the entire team, not just the endoscopist, probably at least the endoscopist is doing something very actively, but the rest of the team in the room, the supporting team is, you know, having that patience is very important. Yeah, and to take that another step further, I mean, we haven't really talked about that in any of these rooms, but you know, the aspect of the team, their knowledge of your techniques, you pointed out a few times, the sort of calling out of how much is being injected, when it's being injected, I think all of that is absolutely critical, especially when you're starting off and establishing your practice. You know, Craig, you have a fantastic team there. Stop. I mean, the other thing I like to emphasize with the fellows and everybody else, make sure you see the tip of your needle as much as you can, especially if you're in fibrotic or difficult dissection, this is not so difficult, it's very important to be able to see the tip of that needle, don't get lost, buried in there somewhere where you don't see where you're going. So I think it's never about speed, it's always about accuracy and good visibility. Yeah, that's even more important here because, you know, you're cutting up towards the anterior wall of the esophagus, and it's a little hard to tell exactly how much room you have, you know, because ideally you're going to be completing this incision entirely. So I think that's really critical, particularly at this moment. Right. And one can see how the tip of the knife within the scope is not moving at all, it's not going in and out. And Greg is moving the scope. So that's a very critical maneuver during ESD because one needs to work with the scope shaft, the torquing and pulling and pushing of the shaft, rather than pulling and pushing the knife within the scope. That's very critical. Yeah, Amal, I think that's a critical point that you made. It's all about controlling the scope and you just lay the knife about two or three millimeters beyond the cap. And then, as you say, you have complete control, you move your, it's all with your hand, your right hand on the shaft of the scope, so you can direct what's going on. Right. That way one can maintain the depth of the cutting and the dissection much better, because with the pulling and pushing of the knife, that can really, you know, you can cut deeper. So Greg, as you're completing this, do you think this patient, you're going to give this patient some steroids or you think it's not needed? Yeah, no, I wouldn't put this patient on steroids. I mean, the overview is that we've got about, you know, maybe 50% here. So, you know, I would not put this patient on steroids. You know, I don't know what the right thing is with steroids. The Japanese reported on, you know, 40 to 60 milligrams a day or the Germans of oral steroid or injecting small amounts into the muscle at the end of dissection or the bottom of the submucosa, little aliquots all along the dissection area. I'm not sure. I think the easiest, of course, is oral steroids. And then, of course, very early endoscopy to look at what's at the lumen. So we had a gal today, we just dilated. She had two hyperplastic polyps, a menetriase with hyperplastic polyps of inlet patches that were obstructing her lumen. And she, you know, we brought her back very early on about one week later to start dilating, you know, to try to make sure she stays open. So I think that's the other critical thing is to get the patients back early and tell them that they might require several dilations. It's not a one-shot deal. And Greg, we were having a discussion with Vivek about closure of rectal lesions. When, if ever, do you feel the need to close esophageal lesions? And what would be your method, particularly if there's a, you know, a muscle defect or concern for that? Right. Well, this patient has a little bit of a muscle defect. I'll show you, at least through the circular. And so in this case, we're going to use short, small clips, 11 millimeter clips. The risk you run into with clips is you can tear the muscle, so it's a little bit difficult. I'm a little bit reluctant to close the esophagus with suturing if it's this degree of dissection. I think you could compromise the lumen. So I'm more in favor of clips if we have to use them. Okay. Almost there. Inject. Amit, I think it's practically impossible to close esophageal defects, you know, because the tension on the mucosa and the lumen is pretty high, and there is a significant chance of, you know, causing stricturing and restricting the lumen. So if there is some muscle defect, you can put a few clips, but otherwise I would be reluctant to do that. Yeah, I have had experience with, you know, a lot of concern I had for a potential defect. I did in that situation, and the lesion was semi-circumferential. I did close it with sutures a little bit more loosely, and then I actually placed a stent just for a very short amount of time just to, you know, deal with a potential luminal obstruction that I may have caused. And in these situations, like for example, this defect, we'll see how he'll clip it, but one might consider, again, getting part of the mucosa and then clipping that over to a sort of submucosa and covering that area. So I think there's, you know, different strategies, but I agree, in general, esophagus is a hard thing to close. This is a great demonstration, Dr. Haber. So we are going to Dr. Kashyap soon. Do you have any final comments? Yeah. Okay. Greg, do you have any final comments on your case? We'll be shifting over soon and probably not coming back. Well, thanks very much. Listen, I think that basically we're tethered here. We'll take that down. I carefully inspect all the vessels and coagulate anything I see with any tiny bit of pulsation, and I'll use on that one little sort of circular muscle defect here, I'm going to use a small clip and I'll try to get it sort of, you know, top to bottom here. So that's going to be the, and then patient, this kind of patient I'll admit probably overnight on clear fluids. And then tomorrow, keep them on fluids for five to seven days, double dose PPI, of course, and possibly sucral fate as well. So that's the game plan. And thanks for all the great commentating, Amrita and Amol, that's, it's so great to get your input as always. So enjoyed this very much and thanks to Mohan again. Thanks Greg. Thanks Greg. Wonderful case. Excellent. We can go to Hopkins again.

endoscopic submucosal dissection

ESD

esophageal adenocarcinoma

retroflexion capacity

submucosal space stretching

hybrid knife

Pro knife

traction methods

post-ESD strictures