We're already into our case. I'll explain one a second. But first, I want to thank everyone at Mayo for allowing this to happen. Thank the patient, of course, and certainly the ASG and UMO for allowing us to participate. Importantly, I've got Dr. Mia Mizrahi from Tampa, Lago Medical Center in Tampa, who is a co-endoscopist expert in ESD. And so he will introduce the case. If we can have a slide up for the case, please. Good morning, everyone. Thank you for having me here. And I'm happy to perform this case together with Dr. Kumbawi. Today, we have a case of a 50 years old Caucasian male that was in a colonoscopy for screening and was found to have a six centimeter rectal polyp that actually involving the anal canal and the dented line. His past medical history is obstructive sleep apnea, hypertension, and rheumatoid arthritis. And he's having a few alcoholic drinks a week. Next slide, please. Resection. We plan for a resection using the Fuji system, the ELOX system with a dual channel scope with the track motion device that we will give a full explanation and we'll show you the whole device system when we are going to use it. The knives that we will use in this procedure today will be a dual J knife and the made by Olympus and the Erby knife made by Erby company. With this, one slide on the traction device that we are going to use today. It's called track motion and it was developed by Fuji and I had the honor to work with the prototype and actually help with the development of this device. It's a device that helps us to grasp the tissue and pull it away and give some traction. You can open and close as many times as you want. To be able to use this kind of traction device, you actually need to use a dual channel scope and the device itself can be assembled on different types of dual channel scopes by Fuji or Olympus. So I will pass the microphone to Dr. Kumbhari to go ahead with the case and show you our case. Well, actually, let's thank you so much. We have some videos saved when the case started to show us and the audience need lap please to show us what we've got. Jason, can you play the original videos, please? Those four videos that we took. So since we started the case earlier today, we took some videos to show you the actual polyp. As you can see here, this is a very large laterally spreading polyp of the granular type and the granular portion of this polyp is actually right at the anal canal and the dented line and you will see it within a second. Here it is. So we investigated the polyp very carefully to try and figure out also what is the pit pattern and which kind of resection would be the best for this patient. So since we are using a Fuji scope, we are using a LBI to be able to investigate the pit pattern of the polyp. Can we see the second video, please? So this is a lesion in retroflexion. So this is the lesion in retroflexion. You can see very carefully we are testing to see the maneuverability of the scope which is a portion very important before you start the ESD to be able to see if you can actually complete the circumferential dissection incision and then the dissection very carefully. As you can see in this video, we have a very very good stability in retroflexion and part of the major part of the procedure is going to be done in a retroflexion mode which we will show you further on. As you can see, this is a special scope. It's the zoom Fuji scope. You can see that we can zoom in very very deep into the villi and you can actually appreciate the vessels and the pit pattern inside the lesion and actually even see red blood cells moving, actively moving, inside those tiny vessels. After a careful investigation, we decided that our approach to this lesion will be with ESD and the reason is when we applied the crudo classification, it seems like to be like a 3L which is a low-grade dysplasia polyp but with some components of high-grade dysplasia mainly in the granular area. Here we are showing you another type of chromatoscopy that we used with indigo carmine sprayed on the polyp to be able to find the margins very accurately because it was very very subtle to find the end and the margins of this polyp. Here we are back at the lesion. We're just doing a release here so let's take you through what we've done. We've been at this for about an hour and a half. This is what we've done. We initially did a release of the anal side here. Basically, it's using a sort of traditional EST technique. We've been using the combination of injection with 6% head of starch, methylene blue and we've basically, we took the dentate line intentionally. It's highly vascular, really miserable encountering all these vessels. So again, dentate line, dentate line, dentate line. We took a lot of dentate here and now we're coming up into the lesion here. Our plan was to just release a little more on this left side here and then we were going to address the fecal side. Amol, Amrita, hi and any comments as to what we've been doing so far? Good morning, Vivek. A beautiful demonstration so far. Definitely looks like a challenge, especially starting on that dentate line and even see some kind of hemorrhoidal vessels there. What's your approach in terms of anticipating those large vessels? Did you use a little epinephrine in this initial injection, particularly knowing that you were going to start on the dentate side? Yeah, we did. I'll let Mia comment. We did and we used certain settings with our electrosurgical generator. Maybe you can show it behind you, Mia. We can zoom in on the room camera. Actually, we tackle those vessels in different ways. One of the ways that we use, of course, is to use the precise dissection. When we encounter those big vessels, especially at the anal verge, what we do is we start the dissection with a precise dissection slightly away from the lesion and from the vessel. We take our time, as Dr. Koubari is doing right now, and we burn those vessels. This technique is very useful and saves some time without the need of putting the coagulator in and out all the time for those big vessels. Yes, we used a little bit of epinephrine, especially in the anal canal initial injection. Go ahead. Sorry, Amita. Go ahead. I was just going to say if you could comment just for a moment. Precise setting is a new setting, I believe, on the VIO3 processor. Could you comment a little bit about that setting? Because it's not a setting that I think a lot of people are familiar with. It's actually on just the VIO300 option. What it gives us, it's a slightly more precise cauterization. What happens and the difference that you can see from precise dissection to the previous modes is that you see less charcoal injury. You see less of the black carbonization of the tissue using the precise dissection. All right. Vivek, hi there. Amol here. Wonderful case. Really well demonstrated with those videos also. I'm sure you must have really struggled for that one and a half hour before this. Quite a challenging case. I suspect I'll struggle for the remainder of this case as well. No worries. I'm sure you're going to get fine. A couple of points. You've got a lot of, you know, you've got a long incision on the dentate line. Do you anticipate any pain in the post-procedure period, you know, in this patient? Do you also anticipate any stricture or fibrosis over there, which may require dilation at some point in time in future? That's a great question. We actually spoke about it a few minutes ago because we recently did a few cases of big polyps like this one on the anal canal and the dentate line area, including suturing. And surprisingly, I have to say, most of patients woke up without severe pain or any different requirements from any other resection. I also have a question. Fabulous control of the scope, but I do notice sometimes that both your hands are up by the processor. Is someone holding the scope for you? It's a very tricky position. You know, even with the air, the scope can get pushed out and that's beautiful control that you have over the scope right now. Yeah, I am. As you can imagine, there's about, you know, three centimeters of scope or four centimeters of scope in the patient. And so, we're very unstable, which is exactly what's going on. And plus, my sort of movements are mostly torque as opposed to a wheel. And yeah, so sort of I'm working hard to manage this sort of the stability issue. And are you using an upper scope or a colonoscope? Yeah, go ahead. As for now, we are using the upper endoscope, the new version, which is also a zoom scope, as we showed you earlier, to evaluate the actual lesion. But after we will finish the circumferential cut, we are going to switch to the dual channel scope, upper endoscope, and try and use the retro, the truck motion device on the dual channel. Yes. Which part of the rectum is this? On which wall? Is it on the posterior wall, anterior wall? I couldn't really figure it out. I believe the patient is in a left lateral position. So, do you anticipate having to change the position of the patient during the procedure at some point in time? Actually, with this location, we are very, very lucky, I have to say. The gravity is completely on the other side. And actually, Dr. Kumbari can show you how the gravity is already making, you can see where the water are, the liquid are, and you can see how the gravity already making its job, pulling the whole tissue away from the muscle. Wonderful. That's very important for, I think, all the attendees to know that one has to use gravity to one's advantage when one needs retraction, because that's one very easy way of getting tissue retraction and making sure that you get the right plane. And there's a couple of questions, I think. Let me see over here. Yeah, so there are a lot of various ways that you can get retraction in these patients. So, there is a pocket creation method, there is a tunneling ESD, and then plus you have, you can have clip and line techniques, and there are also some special clips or the rubber band clips or the SO clip, which we've have some experience on. So, now, what is so special about this device that you're going to show? And, you know, what is your opinion about doing a tunneling kind of, you know, a dissection in this patient? Because this is a pretty large lesion, six centimeters, and, you know, that's something, you know, you know, I believe it could be possible in this case. So, yeah, so I think a tunneling technique would have been quite reasonable. We thought that just because of the width of the lesion, you know, I'll try and show you in retroflexion that it really does go, and I would say it, yeah, you know, and it's sort of more of a hemicircumferential. So, we thought that, yes, you could do sort of multiple pockets and join. I think that'd be a very reasonable approach, but in light of TrackMotion, we thought that we could try that. For now, we thought, you know, as you cut away to other cases, what we wanted to do now is the sort of SQL side release, let's inject team, and then release the SQL side with a jewel, and then we were going to go to TrackMotion. So, what are your thoughts about that strategy? I think, you know, I haven't seen the TrackMotion device in action, actually, in motion, but I believe getting a proximal SQL side incision and release would be important from both point of view, even for a tunneling ESD if we have to do that. So, I think we need mucosal incisions on both sides before we actually can get the tunnel through, and then that's important. So, one needs to know. Actually, by releasing the oval side, all this lesion, I expect it will tend to flip down, and since we have a good, if you can show them, if we have a very good release of the anal area, I hope, as you can see here, I hope we will be able to dissect this lesion pretty fast, even with this size. Yeah. Right. Perfect. That looks perfect. Okay. One question on the anal, you know, from the dentate line, when you're releasing it from the dentate line, do you anticipate fibrosis over there? Because typically, the mucosa is very densely adherent to the muscle layer, and finding the right plane can sometimes do, does become challenging, particularly along with the vessels out there, which is very vascular area, and then that can make things a little bit tricky sometimes. So, any comments on that? So, yeah, definitely, we didn't take, we took around 50 percent of the area of the anal canal or dentate line, and he might most probably have some kind of distortion of the lumen, let's say that. Not sure as far as, not sure as far as having a stricture. I can tell you something from my own experience. I didn't check it yet as for, you know, study-wise, but on all of my rectal ESDs, since I had one or two cases where big, big lesions like this one, or even more than this one, stricture down, pretty, pretty big stricture, let's say that. So, what I started to do is I give them like mesalamine suppositors, and I have to say in the last 10 cases that I've done, I didn't encounter any kind of stricturing. So, that might be a good case also here to think about that. That's a good start. Thank you, Dr. Kumbari. That is great demonstration of this technology. So, we will come back to you after as you make progress. So, we'll, we've been working hard here. That was a nice work, Suwani and Moeen. So, so your comment about the hemorrhoids with Suwani is well received, as you can tell right here. We have constant ooze from these vessels. But regardless, this is where we were initially. We've been working hard on the cecal end, as you can tell here. So, we've done a circumferential release all the way out. You can see this amazing Fujiscope, what it can do in retroflexion. It's phenomenal. So, there we go. We've done the release there, coming across, coming across here. And we're going to show you. Oh, well, thank you. Yeah, we, we, we've been sort of cooking here and working hard. We, I wanted to point out a couple of things. You know, one comment from the moderators about this and this. Now, I did this in retroflexion. So, as you know, when you push on the cap, you start to make the muscularis propria become perpendicular. You see that? And so, there were some areas of scarring and I dinged the muscle. So, maybe we'll just hold comment on that because I want to run some, some videos, please, Jason. We're going to show you some videos. So, here's a video of us sort of doing the release. I know we haven't showed you a whole lot of that. So, basically, we take it, we take the injection, do that same dynamic lift, just hit the marks. And then, we've been using the dual knife J for the circumferential release. You could use the OBI knife, no problem. But we've been using the, the head span and the, the dual J. And so, in this particular instance, we're going from normal towards lesion. So, we're actually bringing the, we're pushing the scope forward, if you can imagine, and sort of torquing the scope using dry cut. So, slowly tapping away with dry cut to get that mucosal release. This is a 1.5 dual J. I think that's the, that's the way to go here. So, showing you where we, where we sort of drop the scope and the knife. And then, you just, just keep going. You know, they talk about not really needing to mark the lesion in, in, in rectal ESD. I think, to me, it sort of helps here as well. So, just tapping away here, nice and slow. And then, we'll connect. And then, we'll show you a second video. So, you can see how we connect here. See, dry cut, there's a bit more coag, but we've got, our markers were way away from the lesion itself. So, no problems there. So, let's go to the next video, please, Jason. So, here's some submucosal dissection and retroflexion. That's what I was talking about. It's very challenging to get underneath the lesion, to not drag muscle up. So, one, one of the things that we can add in this area of going in beneath the lesion is using actually water, the water jet, and try to make the flap going up. And then, you can, might insert your needle right, your knife right beneath the flap. Or, if you use the dual, the dual J knife, you know that with a ceramic white area that you can still see it, then the option of perforation is very, very low. So. And so, have a look here. Look what happened there. Yes. Did you see that movement? So, we could not see the tip of the knife, that white portion, and I dinged muscle. So, I think that's a very nice lesson here. We'll show you very quickly a third video. This is sort of a lesion release on the, going from cecum to the sort of anal canal. Sort of different technique where you're sort of having to drag the scope back rather than push forward, because this is all retroflexion. So, you may say, why did you bother doing this in retroflexion? Why not the forward view? It had to do with the torque, the position of the lesion. I would have required excessive torque and go forward. I was actually much more stable in retroflexion. I think if you've got a good scope, that's able to retroflex. Doing a lot of this in retroflexion, even up to, again, the anal canal is done. Let's come back live here with us, please, Jason. So, again, you can see what we've done. So, this is just some trimming here. So, I want to show you some challenges we had trimming the sides and why we think track motion is going to be helpful. So, now we've spoken about track motion a lot. You haven't seen it yet. But, yeah, so we actually had some trouble sort of trimming these edges. I couldn't get the scope underneath here. Really had a lot of trouble there. I kept sort of getting very close to muscle, particularly on this side here. But we have done a full circumferential release. So, let's, yeah, go ahead, please. I was going to say a couple comments on the videos that you showed and, in general, you know, some changes. I think there's more of a movement or there's a movement towards having a larger margin, I think, for multiple reasons. You know, I think it definitely allows for traction methods of all types. We're looking forward to seeing the one you're going to show us. There's also, you know, I think when you go through more normal tissue for your initial incision, that really helps you establish your ability to get underneath the lesion. And I think the closer you are to the actual lesion itself, the more one struggles. And then the other is that, as you just demonstrated, I mean, in general, the teaching has been not to move towards muscle, you know, not to push the scope and the knife towards the muscle, but rather away from. But when you have a really nice lift and you're far enough away from the lesion itself, then doing that maneuver that you just did is actually quite safe. If you did have a perforation like you did, it's very much on the edge of your lesion. There's no need to stop the procedure to treat it. And, you know, you're at less risk for kind of having to abort and run into issues with that. So it's a nice demonstration. Thanks. So I think we'll show the track motion now. So let's get the room lights up. And so let's focus on Dr. Mizrahi, and can someone hold the mic to him, please? I got it. So while he's doing, so basically, this is a dynamic traction system. So you need a double channel scope. You can use it with the Olympus 180 double channel or the Fuji double channel. I like the Fuji, and you'll see why. I suspect, we haven't tried it, I suspect we'll be able to use the track motion system in retroflexing. Yes, sir, if you say you're going to move just when we show track motion, there'll be tears. Right, Dr. Kumbari, why don't you set up everything? Because Dr. Haber is ready. So let us go to Dr. Haber in NYU, and we'll come back to you after. So you can see, we've been busy here. This is the track motion system. Don't worry, we've got some really nice videos to show you. But let me just show you this in vivo. So this is the, so remember, I've got a double channel scope. I'm fully retroflexed here, and I still am able to get right where I want. I have a large device for a working channel, so it can jut out a long way, comes back. This will, the jaws open. And it's quite amazing, this atraumatic grip you can get. So we grasp the lesion here, push forward, close the grasper, and then we rotate. So one of the nice things about the traction, track motion device is that you need one operator, and you can handle everything by yourself, including the change of the position of the flap, as you can see here, done by Dr. Kumbari. We are actually almost done with this lesion, and so what we'll do is we might actually show you a video. We've actually taken some nice videos, so Jason, and while we are watching the video, we'll comment, but I'm going to be treating some of these hemorrhoids. I just want to show you how easy you can grasp, lift, turn, and look how close I can still get. The maneuverability is amazing. Now, what you need to be careful of is lifting up the muscle, too. The traction is so powerful. And again, look, I let go, absolutely atraumatic. So let's go to the video, guys. With the atraumatic aspect, do you target the mucosa side or the submucosa? Yeah, we can. We'll do both, actually. So let's, Mia, can you comment on the video, please? You should be able to hear me. Yeah, so as we comment, we are using a dual channel scope, Fuji scope, and you can see that the track motion device is mounted on the larger channel, the 3.7 channel. And when you're talking about this handle, you can see it looks pretty big. And guess what? When I used it initially, I thought that we would have a lot of issues with the weight of the handle and everything. But no, it's pretty surprisingly not heavy and does not give you a lot of issues after the procedure due to different weight. Now, as you can see on the video, by advancing down the handle, I can advance my traction device out of the scope. And by opening and closing the handle, the forceps will open, and then we can grab the tissue. And then after closing the handle and gripping the tissue, we can move and rotate 160 degrees with the retraction device and actually reposition over and over again how many times that we want. One thing that Dr. Kumbhari mentioned and I wanted to emphasize a little bit more is the fact that by using this traction device, you actually can walk very close to the lesion, something that, for me, it's very important. When we use retraction devices, a lot of times you need to go away from the lesion. And here we can walk very, very closely, as you can see. So now let's go to the second video. So this is us getting started here. So you can see here the track motion. We can go. Yeah, you can see the track motion. It's so nice to have the side-by-side video. Great work, Jason and Michael. So you can see here we grasp the lesion. And remember, this is the part that I wasn't able to easily dissect. Remember, I said I was struggling to trim this area. Watch this grasp. We elevate. And you can see how it's pulling the muscle of it. You've got to be careful with using the injection. Now, the other thing that's a little clunky is that you see the knife is moving in and out on the left-hand side, because it's a double-channel scope. But watch. We've got good views here using the Irby iKnife precise setting. Again, this was rather tethered down. I couldn't get the cap underneath. Now, watch what happens here. My memory serves me correct. This should just blast away here. And you can sort of, you can. So not only does the track motion give you traction, it actually gives you some scope stability. You'll remember, Amrita, you quite nicely pointed out that I had to have someone holding the scope. That's not the case now. Then we can come back again. It's not, you don't have to continue to re-grasp. You can actually stay where you are using the precise setting, the slightly bigger iKnife as compared to some of the others. You just go through. Use that traction. It keeps you away from muscle. You can be confident working your way through there. And again, you don't need to reposition the track motion all the time. It has wonderful sort of flexibility. You saw on the ex vivo demonstration how much it can actually angle up. In fact, it can almost come behind the scope, if you know what I mean. Any comments? Amrita said I'm all about distraction system. I think it's a game changer. Yeah, you know, it's a beautiful demonstration. I think it shows nicely how it frees up your hands to deal with just pulling the knife in and out, especially with the adjustable tip knives when you have to deal with that. It brings to mind one thing about training. You know, it really is changing the way you are doing the ESD. I think we've seen some variable demonstrate, various different types of demonstrations. We saw a very different demonstration of the rectal lesion with Swani. How early do you think these type of traction methods should be introduced in one's training for ESD? Yeah, I mean, I'll have a go on the last, Amir, but it's a different approach. One could argue that the cap is unhelpful here. I'm so much farther away than what we would think. The scope management is different. You know, obviously, I'm still learning this. This is relatively new. But the way we maneuver a distance from lesion and the fact that, you know, I would normally have done a pocket technique for this, and now we don't really need to because we have traction. So to me, it's an entirely new training sort of platform, Amir. Yeah, and I think just to take it a further step ahead, I think that using traction device, you need to insert it very early in the training because it's completely different. Like, as I always say, when I do ESD, I always like to have the natural, let's say, gravity retraction just because that's how I was trained. But doing those cases more and more, you can see that you can achieve different, let's say, different advantages by using it. But it needs to be, in my opinion, inserted pretty early in your training for ESD and third spacing, yes. Yeah, and I think that's not particular to this device itself. You know, it's probably the issue of traction in general and learning different methods of traction, but I think it really can sharpen the learning curve quite a bit and decrease issues with complications, perforations, and bleeding management early on. Very exciting. So now we might go live, but you can see here, you really can just blast away. This is all live, of course. I mean, it's recorded, but it's in real time. So Jason, let's come back to us here live, please. So here we go. We've got a bit of mucus that's taunting us, but we'll get rid of that. So here we go. So hopefully we'll be able to take this home now. So we've got, now, just the nuances here is, if you grab too far underneath the lesion, watch what happens to the muscle layer. You sort of ride it up. That's not bad, but sometimes, and as you can see, again, how it just doesn't fall off. You know, it's not this dinky thing. It's very stable. Knife out, please. Also, we need to be careful of the mucosa behind it. Again, fully retroflexed team. We're a couple of centimeters from the anus inches, whatever you say in America, but you can see here. See what you can do with some comfort. Now, you know, do I need to re-grasp? Probably not. Probably not here. I think we're okay. I've got a little bit of sag of the tissue. I could re-grasp, but I think we've got just a small window here to allow us to cut through. We're so far away. What setting are you on in the video here? Or you're live, sorry. We're live now, yeah. We're precise. Precise sex 5.6. So I think we're almost through there. So you can see the maneuverability. I'm just going to open up the track motion here. A little different. You can see how torqued we are. We actually twisted the lesion on it and saw that before we were released, but really have a lot of swing. Very stable, sort of doesn't whip a whole lot. You know, you'd think it would whip more than this. So now we can, you know, we can think about actually going into forward view and seeing what this does. It's a little, so you, this is what we got. Yeah, so, you know, one could argue that traction's not desperately needed here, but so now, just to demonstrate, we come across here. Let's see what we've got. So I'm actually almost twisted this a little too much. So we'll un-rotate that. Knife out, please. So I'll try and clean the lens a bit. And now we'll just. So coming, coming, coming home. You know, there's some balloons that I believe will drop from the ceiling, I hope. But. There'll be a lot of applause for sure. That's what we got. Oh, this is, this is really unfair here. But again, you can see what we can do with the lesion now. Interestingly, in this particular case, and we'll suture this up. But it looks like, see, the magic of Fuji traction is even if the traction system's off, the lesion will always give you traction. Just feels it owes you a favor, you know? So that's our lesion there. So we'll, so we'll sort of just quickly retroflex here and then we'll, you might want to cut away and then we can, we can suture this up. So remember, I'm keeping this device in the scope and I'm going to retroflex. Sorry about the lens being a little foggy, but. So what we're, what we're seeing here. Yeah, so he's a nice job. So you may wish to cut away and, or we can discuss and then we. Yeah, that was great demonstration. We'll go to Dr. Haber from NYU. Here you go. So what you can see is we're sort of closing this lesion here. This is what we've ended up with. We do have a lumen, as you can tell. It ain't, it ain't huge, but it's there. So price to pay for a big lesion. So what we're going to do is we're going to take you back to this. Actually, I might just show you how we're going to continue here. We'll show you in rewind. We'll do a replay of how it started later on. So we're suturing using the overstitch, double channel, sorry, overstitch generation two suturing system with the double channel, Fuji double channel scope. Let's get the helix, please. I think what you might see is at the outset, I probably took my bites too far away from the edge of the lesion, which has caused this sort of heaped up formation and the lumen to be potentially unnecessarily narrow. But I think it's important to learn- Are you planning to close it oral to anal side or do you plan to close it side to side? Oral to, I don't know. So we're closing it side to side, but yes, starting at the oral end and then coming back. So, I think we'll go through the suturing technique here, but if there is time, you see we've crossed. I'd love to talk about, would you suture? How does everybody feel about suturing at the dentate line through these hemorrhoids? Will there be a traction sensation for this patient? Et cetera. For me, it's sort of a bleeding prevention aspect that sort of encouraged me to suture here, but I'm interested in your thoughts and Mia's. Yeah, I was actually gonna ask the same question is are you suturing all of your rectal lesions? Because we asked that question of Sawani as well, who has chosen to leave her lesion open. Yeah, so you were going to mention your answer. I'm interested to hear as well. Yeah, Mia, go ahead. Yeah, so personally, I don't close all of my lesions post ESD, the main thing that I would close might be in the right colon. And then it would be challenging to bring the device over there. But I wanted to hear you moderator about the defects that we had in this procedure, the muscle defect, and if you would have do something differently like a different closure or even not closure based on the defect that you have seen, the tiny defect that we have. Mayor, I think we are in the distal rectum and defects which we did see were quite superficial muscle. So I don't really see a need to close those defects or be really worried about any leakage from those defects because it's distal rectum, this is extra peritoneal and that's going to heal in no time. Having said that, in fact, we don't close our rectal lesions or in fact, majority of the lesions unless these patients have a risk of bleeding or when we have gone through the muscle really deep and then we are concerned about a perforation. So those are the only situations when we would close. One important aspect is, there is a study which they have mentioned that even with clip closure of the muscle defects or something of that sort, if clips are applied on top of the ESD defect, when healing occurs, the scarring makes subsequent evaluation of the scar evaluation more difficult and one can miss recurrent lesions if there is additional scarring because of some kind of a closure technique. So when we don't close, actually the mucosa heals back so nicely and smoothly. It may take a few weeks, but when it heals, it really heals very well without any scar and you can barely identify the scar and that's really nice. So I would probably leave this alone unless this patient had risk of bleeding or something of that sort. What about you, Amrita? I think mine is a little similar in the sense that I wouldn't categorically close all ESD defects. I think that there is a little bit of a defect here and what you worry about is sort of in a few days, if the patient is aggressive with their diet and or there's some constipation, I think there is risk for bleeding and potentially for that to worsen. So I think where closure is easy to do and like in this situation and there's a lot of room to maneuver, you can easily access it with a good closure method. I would normally close this. I would probably in the rectum or in the colon, I try to do more oral to anal as opposed to side to side, but I think here you do have a situation where you wanna put as few bites as possible in this, through these hemorrhoids. And yeah, but in general, I think that the other area where I find closure is helpful to prevent delayed bleeding is in the cecum, anywhere where there's really potential for a lot of fluid and contents to sort of reflux over the area and delay healing. So I try when possible to close lesions there as well. So one of the things, definitely if I leave patients with no closure, especially definitely in the colon, I will give them smooth softeners for two or three weeks after the procedure, just that I don't want them any strain, anything like, you know, pushing and causing bleeding, delayed bleeding or even perforation. Me and Dr. Kumbari here on this case, we definitely didn't think that we need to close based on the defect, the muscle defect that we had, but mainly to try and prevent further bleeding due to the hemorrhoids and the anal canal area. Yeah, so we might, while we come out and have a look at the gastroscope, let's go back to the video, please, Jason. Yeah, so we're just gonna go back to the video. So we'll show you how we thought about our approach to closure. And again, you know, what could have been potentially improved. Right, just a quick question, Vivek, how long is this, you know, track motion device and can you use it for the right colon? Yeah, so excellent question. So right now it's only available for the double channel scopes. It's been around since July, August this year, you know, it had a limited launch, I think to the people who were involved in its development. So me, Petros Benais and Mia Mizrahi, and there may be some others that the Fuji folks know about. So we've been working on it back for about three years now. So we're very excited to get our hands on it and put it to clinical use. But I suspect it's going to be ready. Let's run the video. I suspect it's going to be available commercially to everyone even now or shortly. It just works particularly well with the Fuji double channel scope, which recently got, the current version got approved through regulatory this year. So this is a Helix. So I think here I arguably went a little too far away from the edge, which has caused some of that luminal compromise. And I basically did this pattern where I went from the left side of the screen to right through a sort of multi-byte technique to avoid sort of sutures swinging across the screen. Obviously we'll keep him on some stool softeners and maybe a bit of lactulose as well. You'll see just out of interest for those who haven't had much experience with suturing on the Fuji double channel, the placement of the alignment tube is a little different than the Olympus. And so you just need to be mindful of that as you do your procedure and do the anchor exchange. So that's sort of our technique there. I just wanted to show you how we got started. And if you want, we can just wrap up. See Vivek, would you want to do a mucosa to mucosa position or would you want to do a full thickness? Because again, you would be just placating the muscle if you do a full thickness. I agree. I think here I was just interested in going mucosa to mucosa to really... And actually I took a lot of bites close together as you can tell. Maybe Jason will stay on that video. I will stay on that video, please. But you can see here the mucosal apposition that we've got with our current technique. So you can see we actually took bites very close together. So Vivek, this is a great demonstration of suturing. If you, I think we're ready to go anyway. If you can give us some final comments overall on this case was really very well done, beautiful demonstration of this new technology. Yeah, thanks. So, I think, sorry, this is just the final appearance here. So we have some room to sort of guess the scope. Very nice. There's your stint. So I think it's close. So if this patient feels okay, I'm going to send her home. I think with the advent of sort of active injection, now dynamic traction, I think ESD is going to become much easier with these technologies from a speed perspective. When we did some ex-viva work, we found it was about 40% faster and from a safety perspective and a sort of R0 restriction perspective. Mia, just to sign off. Yeah, so I think that was a great case and the track motion, definitely, I think it's a great technology that can add a lot and shorten the time of our ESDs and maybe facilitate like other type of reduction devices. This reduction device, as I said, we really, I'm bonded to it because we developed it from scratches actually, from prototypes. And here you can see the length of the lesion without being pinned yet. And we are talking about- When we pin this, it's probably going to be- Nine centimeters before pinning. So at least 10 centimeters. When we pin this, it's going to be about 25 centimeters. Not suspect. So, right, I think we are ready to go to NYU now. And thank you so much for this wonderful demonstration. It was fantastic. Excited to see this new technology. Excited, thank you, Tom. Thank you. Thank you very much, have a nice day.

ESD procedure

rectal polyp

Fuji system

dual-channel scope

track motion device

tissue traction

investigation

dissection