Chapters Transcript Video Duodenal ESD Naohisa Yahagi, MD, PhD gives a presentation on Endoscopic Submucosal Dissection of Duodenal Lesion. So uh you know the technique you demonstrate is really amazing and you mentioned of course the high preparation rate that we often see uh are the perforations ones that you worry about or because of your closure techniques, you anticipate micro preparation but you know when you close that it's not a problem. I don't afraid of uh immediate cooperation during the procedure because we can easily crip and cross uh after prying and the clip, it's usually disturb the smooth procedure after crossing the uh that's why I don't want to have any preparation during my procedure, although I can quote large defect after a complete resection of the tumor and it is mandatory to cross raj defect after a complete resection of that. You are who avoided the complication? Right, right. I was surprised that you showed incredible cases with very large reception and yet you were able to close them and there's no problem with stenosis or or compromise of the lumen. Uh Yes, that's a very good question. Uh In case of having a circumferential reception in the second part of the uh duodenum, it's mandatory to close large defect in order to avoid delayed complications such as the population and also stricture formation. But if we can cruise large defects using string Crips featuring method, we can avoid stricture formation. I already conducted more than 500 ordinary cases, we experience the only two stricture formation feature. Okada in the gardena about because uh if we perform circumferential resection in the second part of the duodenum, we can close it by using string crips blistering method. But if we remove big legion in the duty in about it is almost impossible to cross because of the difference of the anatomical structure. Therefore we usually don't cross the defense in the both. As a result it's sometimes called stricture formation but we can control it by balloon dilatation. Right right. We can see the gate now on the other. Yeah. Yeah. You know he S. D. Go to the cabo do it. Sorry. I would like to show you actual procedure of water pressure method to remove middle size the dude in a region uh which size four cents meta in the greatest dementia and located at the outer side of imperial judy no angle. And after complete resection of that region. I would like to close that the large mucosal defect using string crypts featuring method. Today I'm going to use this or incarcerated therapeutic endoscope which is G. I. F. H. 290 T. Uh This endoscope is relatively uh stream that has 3.2 millimeter working channel which is located at seven o'clock. And the water irrigation channel is located at 6:00 PMclock uh which is very convenient when we encounter active reading during the procedure. And today I can use or incarcerated. The endoscope system which is uh X. One. Uh We can use our D. I. In case of having active bleeding and also I can use bright N. B. Before starting SD procedure. Now I'm introducing and those scopes to the lumen. And this is ironic clean. I usually don't separate C. 02 gas too much in order to avoid the bending of the endoscope within the gastric lumen. So I try to approach uh straightly to the duodenum. Now we can see the target lesion which is located at the outside of the Imperial do Dina. Whoa and I always rush the lumen using summit con solution because uh green environment is very important before starting actually inspection. Now I can use T. X. I. Which is a rapist or impasse technology. Of course the bright N. B. I. Is also wonderful with babies X. One switching on the T. X. I. We can has self structure textured uh keratin and brightest are brightness. Uh Of course when we use T. X. I. One it becomes unnatural. Therefore if you want to have a much natural carol we can use T. Excite too. Which is very similar to the fight right? But for the detailed observation using magnification still uh N. B. I. Is much better than TX I. Uh So I usually use TX I for the screening purpose but for the detailed observation I usually use N. B. I. And I prefer to use uh indeed will come and die to perform promote endoscopy. I still uh I'm still using from our endoscopy because uh we can check the gravity as well. Now uh spread in the goal coming go to 2:00 side that this is the gravity died. And of course uh integral coming uh it's difficult to get in the United States but in our country it's very cheap material. It's just to uh U. S. Dollar for a single ambulance. Mhm. Well I always use uh for my uh do Dean RsD procedure. I usually use standard uh fujifilm SD food because there is a small throat instrument. Therefore, uh initially I introduced injection needle to the working channel and align the ST uh just uh in front of the working channel and fix it with the tape and use the uh rents cleaner to avoid uh the to avoid the okay difficult situation with the dirty materials. Then go back to the lumen. Carefree introduced cap attached to the endoscope and again avoid inflating the CO. Two gas too much. This is already second part of the duodenum and suck the air as far as possible. And use the water. Education. I always immerse the target vision using normal saline and wash the room. And again in order to remove the indigo coming and to have clear visibility of the target lesion. And of course straight and Oscar position is very important for the smooth BSD procedure of the duodenum. Therefore we should avoid over in separation or over thrashing of the normal satellite. Now I'm checking the border of the target lesion, we can recognize the border very Cleary because we can magnify the target lesion within the underwater condition. Now I'm going to inject solution to the southern Gaza ria Using needle master or impasse. I prefer to use grizzle solution for my procedure because it's relatively cheap and easy to handle. Griselda is unique solution which is a mixture of 10% reselling 5% fructose and their .9% sodium provide. And I always include small amount of integral. Coming to visualize the southern cause Arria as a blue carrot rare. I usually inject 3-5 ml of resale solution. Often we punctured the target tissues then move on to the lateral side. I always start injection and the initial because our incision from the outside in order to make it sure that in the point of the southern coastal dissection because of the happiness of the target tissue is in the uh duodenal women. The maneuverability of that and the scope becomes very poor. But still it is possible to control everything underwater condition is very effective to visualize the target uh tissue within the underwater condition. Now I'm introducing dual knife. J. Picture is 1.5 millimeter metric tip. Please don't use two millimeter. Do all night for judy no es de or chronic pTSD because uh master radia is very sin. Uh We will make cooperation easily if we use uh Now I am going to make those are incision using bio three. Uh dry cut. 2.0. It's good enough for making uh for making the decision. Of course there is no interval for dry cat mode. Therefore we should step the foot pedal intermittent re and check the incision line by using water irrigation. Then took the edge of the initial because our incision with the rhetoric tip of the knife and go to father left side by checking the mucosa incision if there is lemonade because a bridge, I can cut it and took the edge once more again carefree, catch their edge, then come to the front side, putting back. Yeah. And those scope a little bit. We should control the endoscope very gently in order to avoid uh serious complications complications such as immediate cooperation or serious breeding because they are rich vascular network within the southern cause Arria. Therefore we should make them cause our incision as shallow as possible. At the beginning of the procedure. Now we can see the mucosal bleach remaining at the A no side catching the edge of the remaining mucosa. Then gentry conduct because our incision using dry cat mode, fortunately there's no bleeding at all. Although they are rich vascular network within the southern coastal area. Again catch the edge with the small metric tip of that. You and I and go to the light side Using Dry Cat Mode 2.0. It is very effective to make very smooth because our incision of course you may use and you got if you want. But for myself I prefer to use strikeout mode because I can control everything regarding the duration of the uh cutting and in to bob. So carefree talking my list to the light side. I can go to the right side then secretary remaining mucosa here uh cutting longitudinal direction is a little bit difficult because of the front the situation of the endoscope in the gardena. So catch the target tissue. Is the tip of your life. And carefully cut the mucosa by pushing my and uh we can inject the additional some cause of reeducation at any time through the knife if it is necessary. Uh This is a very convenient way to keep the safety of the procedure. And carefully continued because our incision by pushing endoscopes throughout the in outside. We should visualize the target lesion by using water. Education if there is lots of bubbles, who inside the cap visibility becomes very poor. Therefore I frequently press the hood better of water education and it is mandatory to use no monastery for the water education if we use just the scale the water, we cannot cut the tissue well because electric current doesn't conduct well to the target tissue. If we use uh the scale of the water uh electorate is very important to conduct the electric current to the target tissue. That's why I always use normal sarah. And for a water education. Now incision line is nicely connected to the end outside a few of the circumference already. Uh uh uh incised I carefully check the incision line and if there is a minor breathing, we can easily stop it by uh prying cruise tip of you all night. In this case we usually use Spray Quach. 1.2 very low setting of spray drug is very effective to stop the bleeding. Using cross tip of your life. We don't have to use cooperation. Forceps such as formula meta koa, grasp our just using pro step of your life is good enough. Now I'm going to inject additional for education to the horror side. It is necessary to make a small hole to give additional uh for education using drone attack J. Because power of uh injection of donald J is not strong uh as compared with hybrid knife. Therefore we should make a tiny hole on the healthy mucosa. Then we can smooth reinject additional solution to the southern cause Arabia. But I always check the lifting sign of the healthy mucosa when I make a small uh puncture. Otherwise it will cause perspiration when we make a small hole. So we should check the condition of the because our rifting all the time. Now I'm making a longitudinal uh decision also on the light side by pushing manner and using water. Education we can check the uh because our incision and if it is necessary, I usually switch to the swift Quach because they are rich vascular network within the southern coastal area. Now I'm going to the left side because there is uh enough seven Cozaar fruit cushion. I'm continuing because our incision on the left side for the remaining uh because our area on the left side and check the remaining koza. And I decided to inject a little bit more solution in order to make it sure the safety of the procedure after creating enough sudden cause of education I can make a safe because our incision on the left side, carefree, catch the target tissue is the tip of your life. I can easily make a nice mucosa incision to the left side by pushing manner country uh attached to the target tissue with the tip of your life. Uh now I encounter minor breathing again I used close tip of daily life and used to 1.2 uh spread quite. It was nice re stop and then quickly continue the decision to the upper side to complete the second french and cause our decision new ability of the endoscope was rid of it. Sure, that's why I minimized my movement of the endoscope and improvised uh the less pilot re movement. I gently controlled my endoscope towards the upper side and flushing the no more saline. Who first carried out air bubbles from the cap. Then finally I could connect the incision line to the upper side. Now I completed the circumferential because our incision then quickly inject the additional from education to the some cause Arria and trace the image of the incision line using sweet quark. As I mentioned that there are rich vascular network within the southern coastal area. Therefore I always use sweet quirk for the initial Southern Gaza dissection when we opened the southern coastal space and the war uh pressure vessel is always very effective to open the southern coast of space by flushing normal saline to the incision line. We can open the southern cause a real like this. Uh Then following sudden goes out dissection becomes quite safe. And uh the easy and of course if there is active bleeding, we can use our the R. D. I. R. B. I. Is a new narrowed band uh imaging of orange bas uh we can find the bleeding point much easily uh than using quite right because we use the to narrow the band. Uh light peachy is red and amber and usually amber, light largely absorbed to the uh concentrate consent higher concentration of hemoglobin. Therefore we can easily uh reading point Now we can see the breathing point and upright across tip of do our life and use the 1.2 of spray quirk. I could easily stop that bleeding even though it was actively bleeding from the artery uh breeding already stopped and sit back to the white. Right? And I found the sick blood vessel again. Uh therefore I decided to cooperate it before cutting here in in this purpose. I always use very low setting of four squad features. They're .3 with open tip of dual knife. This is very effective way to operate the sick blood vessel within the southern courtyard area. We don't have to use quad grass by in this situation just catch the uh sick blood vessel with the open tip of our life. And they use uh they're 0.3 of post quack. And of course if there is some breeding and breeding we can stop it using cross tip of their life. Okay. The uh minor breathing already stopped, then switch back to the white right and continue the southern goes out dissection on the left side. Okay Now I found another breathing vessel. So upright cross type of dual life. And used to 1.2 of Swift Quirk and it was nice re stopped then approach to the edge of the inner side and Phuket and cut with the swift quack and the left side is almost finished. This is the edge of the in inside and it already go to the in our edge and the checking the blood vessels. And again I used cross tip of the knife to stop the minor bleeding. As I mentioned, there are rich vascular network who is in the southern cause a rare and it's very convenient to use cross step up due to our life rather than using switching to choreograph spa. So I larry use cooperation forceps for my procedure. Now I can mostly control breeding occasion by using your life Close, close at your life and touch to the breathing point. And they use 1.2 of uh spray quack. Now it's completely stopped. Well I already finished half of the southern coastal dissection on the left side. Therefore I'm going to on that dissection on the light side. Again I injected Greece all solution to the Southern cause a rare and using water pressure method. Opened the Southern cause a space And the conduct seven causal dissection. Using 3.0 of sweet quack. And for the breathing occasion I usually use R. D. I. To visualize the breathing point and upright. Cruise skip of their life. And use 1.2 of spray quirk and speech back to the white right and continue to sub mucosal dissection. Using swift quirk. Water pressure method is always very effective to open the Southern cause a space. We can easily visualize the remaining seven cause a tissue by using uh brushing of normal saline and checking the remaining southern gaza tissue. And of course it is possible to inject additional solution to the southern cause a rare Here's another broad vessel. So carefree. Catch the edge of the remaining seven cause a tissue at the or outside. The maneuverability of the endoscope was really bit unstable. It becomes property so I carefully check the remaining tissue and the control the lens of the see some of the dear life gentry. Catch the edge and go to the right side by talking my list. After injecting some solution to the southern. Cause a rare and carefree, dissect some causal tissue using swift quirk. Oh again that's breathing. And switching to R. D. I. And try to find the bleeding point. And if it is very difficult to find out the bleeding point within the uh underwater condition, I sometimes in separate C. 02 gas. Then I can easily find the bleeding point and check the situation of breeding once more again irrigating normal saline. And this is the bleeding point. Touch to the blood vessel. Then A Pry 1.2 of spray quack. Now it's nice to be stopped. Then switch back to the sweet clark and continue the southern cause of dissection to us. The roaming outside and open here once more again. And I found the sick blood vessel here. So injecting additional solution to uh make a group color border remaining Southern Gaza tissue and dissect some cause a tissue about the sick blood vessel. It is a little bit dangerous situation but it was okay no breeding and again approaching to the southern coastal area about the vascular network and try to dissect The seven cause of tissue. Now we can see the brought basil here about touching blood vessel. I try to dissect the remaining sub mucosal tissue. After injecting additional resell solution. Can't re conduct the sub mucosal dissection using sweet quirk. Yeah. Now it's completely opened. Dissect the tissue very carefully. Now I should open the oral side. Otherwise it becomes very difficult situation. Therefore I'm injecting additional solution to the remaining seven. Cause a tissue at the R. O. C. And try to catch the edge of the remaining tissue at the or aside and cut here to open the door our side. It was very difficult to open here because of the property situation. But we don't have to hurry. We can go relatively story but safely catching the edge and dissect little by little. Now it become possible to visualize all the southern cause. Already here catch the remaining sub mucosal tissue and go to safer side. But it becomes really pop and Decorah approach here. It's really bit difficult. Two open here. So I think it's much better to approach here from the from the other side. So I tried to approach to the remaining seven called uh tissue from the proximal side. Inside the rhetoric tip to the remaining seven cause diarrhea and hook it and dissected towards the safer side. Now it becomes possible to open here again from the southern cause outside. I can catch the remaining tissue, Then conduct seven causal dissection. It's really for a peace situation. But it's okay look here and go to safe aside by talking my list to the light side. I can't control right left direction. This is a little bit dangerous situation. Therefore I minimized my movement of my list and control my uh movement of the right Mr barrick. Uh Jeffrey. Yes. Now it's start opening here. It becomes much better situation and injecting through carol grease oil solution. It becomes a relatively safer condition. Now it's complete reopened, gets here and dissect the remaining southern gaza tissue. And by you to rising water pressure. I can visualize remaining something called a tissue and fuck the edge here by the metric tip of the life and go to the safer side. The sub mucosal dissection is very slow here but safety is much important than fast cutting. Therefore I cut some causal tissue. Leader by leader. Now it becomes possible to completely open the oral side and quickly dissect the remaining southern causal tissue to the upper side. It completely opened. Okay I can see the uh the point of the someone goes out dissection. I can see the edge of the incision line at the inn outside. But still there are some because of tissue remaining within the southern cause of layer. Therefore I Going to inject additional seven Koza for education to the remaining some cause a rare and conduct some causal dissection to the safer side controlling my list to the upper side. Using light left channel. Together with the talk of my list. I can control the light left direction, relatively smooth. Three. And by crushing that like it I can flush away the bubbles from the cap and fuck the remaining tissue here. And this is the edge of the inner side and this is remaining tissue at the bottom of the some cause a rare and catch the remaining tissue and carefully conduct sub mucosal dissection. This is nearly the end of a sudden causal dissection. Carefree conduct. Someone goes out dissection. Step by step. Now we can see the end point here. Hook here and go to right side by taking my list to the light side. Very carefully and this is the edge of the light side injecting solution to make it safety safer and the catch stage and go to safer side and open the edge. And uh if there is breeding again, we can probably close step up to our life using spray squawk we can easily stop it. And even for the homeostasis, I usually step the hood barrel intermittent re to control the electric current much precisely. Okay, this is remaining tissue catching the edge and go to safer side. A new ability of the endoscope is really poor. So we should be careful not to make a cooperation during the last step of the southern coastal dissection. Yeah. Take here and finish the light side and checking the remaining southern Gaza rare and for good. And go to the left side out here and open the space and check the remaining tissue using water education of normal sarin and catch the tissue. It is really the end of my procedure that's fear and go to rest side and what and tiny remnant tissue can be easily detached by the pressure of the food. Now reception is finished and ready to leap. Resected specimen using suction. And this is resected specimen. No, he's uh I wonder if we could take another small break. So now we would love to see your technique for closure. Thank you. So we'll join you again. Okay, after the reception, it's mandatory to cross the large defect. I always cross the large defect to using. I in this technique, I usually use uh Or impasse reloadable and a crip and 40 Nylon socks. Workers who just read We need 1.5 metre long surgical threat and make a loop and apply it on the partially opened uh rhetoric arm of short sized and the clip and tight tree uh close it and another to make it sure. Uh We uh make another note using tweezers. And this is a sad note. And the tight re close it and cut the tail of the a threat. Using cesar's for uh caesar's. And to go back to the reception bed and introduce the massage. Go thread and crypt together through the working channel for this purpose. It is mandatory to have at least 3.2 millimeter working channel. If you use 2.8 millimeter standard working channel, creep. Undermine usually stacks within the narrow room in of the working channel. Therefore we should prepare a wider working channel for this procedure just in front of the reception. Bet carefree opened the and the creek and the change that direction And approach to the an outside 1st. And I always try to capture both because our age and part of the Masseria together and the sector air read a bit in order to uh make relax the Masseria and carefree carefree cross the in the grip to anchor the faster in the crypt at the inn outside. Now you can see the ankle then decrypt at the inn outside And catch this rind using 2nd end Grip. Now my assistant gave me a second shot sites two reloadable and the crib and carefully introduced the end grip. And I took the such cars threat to my fifth finger of my left hand. And uh carefree. Opened the short cites the end grip again and catch the surgical threat with the rhetoric arm of the end crypt and approach to the poorer side and again try to catch both mucosa edge and part of the masseria together. It's mandatory to capture the masseria in order to have uh thank you a closure of the large mucosal defect. Now both inside and approximate side already captured by the end of creek and preparing sound and grip which is long sized reloadable or impasse and grip and open it just beside the two and the crips. I'm now approaching to the left side. First carefree into the southern end quick and open it very carefree at the approach from outside and rotate it to one o'clock position and approach to the N. Outside. And by pulling the strength using my fifth finger of my left hand. I can approach me too large opening very easily now. Roger opening is completely approximated and toward the south and the grip then suck the air once more again in order to make muscle really docks and capture both edge together with part of the masseria. Then we can completely cross the large defect. And of course part of the masseria also included within the metarie crip. So this is really secure Kuroda. And I'm going to approach to the light side. And the surgical uh string is really helpful because we can change the direction of the target tissue by playing the string before capturing the target tissue, carefully opened the end of grip and make it available crock and putting the threat to the approach my side and suck air and close it. And light side is also tightly grossed. This is really uh safe condition now. And I I apply additional and the crips for the to cross remaining because our defect. I always use or impassively rollover. And the quick because this is very convenient and the price of finger grip is relatively cheap. We can get a single grip at the price of uh $6 at my institution. I mean, so it is reasonable cost even if we usually use multiple. And the clips for this technique now force and the crib upright, it becomes really nice situation and I'm going to apply another and the grip introducing and the grip carefree and open it and change direction and productive string and suck a little bit and close it now last year opening already closed. So after closing the last defects, we should cut the line using cesar's prospects. This is still in the grip. I love right at the left side edge. Okay, noted to 2:00 PM and crazy. Okay, left side already completely close now. Yeah, totally. Okay. I think it's time to cut the line because it becomes easy situation to cross everything using additional and the clip on the light side, it's not necessary to use uh oh, still I'm applying additional in the crypt. Okay, close here by sucking air and pushing what the and the scope a little bit. Okay. It becomes very nice situation. I believe that this is scissors forceps maybe please don't Israel Qatar for cutting this kind of line. It usually stacks. Who is the job of loop kata scissors. Forceps is the best option to cut this line to quit and push forward. Then we can easily cut up this line. So I'm going to apply additional and and the groups to close the because of a defect completely on the light side. I'm introducing short sites to end the clip and adjust the angle to 11. Uh still I'm trying additional grip on the left side. I'm sorry, but it's really secure condition completely cross here. Okay then probably I'm going to approach to the light side. So even if we use multiple and the crips the total price of the used to creep is relatively cheap. Therefore I prepared to use reloadable and the grip for this procedure, adjust the angle of inside it and the crypt a tale Bachrach and the proximal edge. Oh, it's frippery but it's okay sucking air and fix it cross it. Uh proximal edge slipped away from the rhetoric arm. But it's okay because Masseria and uh this storage was completely captured by this and the clip so I speak to the long sides. The end the clip in order to make it sure that capturing of the all our side, This is wrong size in the clip, a little bit stronger than before. Okay, and make it 10:00 I guess. Yes. Okay, then took the proximal edge and bring it to the inner side little bit. Okay. And pushed toward the endoscope a little bit and find the best position. Okay, looks fine and suck air and twist my list to the light side to have stable conditions and fire it. Okay. It looks very nice and I will give a final and the quick crowd start last part of the because our defect. Okay, open again. This is short size and quick. Okay, and catch the crooks marriage and push towards the endoscope and suck the air. Play back to the light side. You play back over now. Large defect is completely closed with string creep stuttering missile. This is really convenient And actually I used 11 and the clips to cross this large defect. But even though I use the 11 and the crips total price is restaurant $100 the US dollars. So it's quite reasonable technique and this is resected specimen. Resected size was nearly six centim in the greatest diameter. And of course it was free of uh imagine was completely free from tumor. And I checked the selfish structure using bright N. B. And we can see the difference of the surface structure uh here. So I believe this is causing cancer and uh of course I believe uh this is complete curative resection. Okay this is the end of my procedure. I always check the resected specimen and take a hot shot and finish my procedure. Okay? Thank you very much. Well yeah now he's a beautifully done, wonderful wonderful demonstration but very clear teaching as well which is extremely helpful to all of us. Um Maybe a couple of questions would be for the beginner for doing Geely sc. Could you list uh the easiest location and then middle difficulty and most difficult location. Okay basically I don't want to uh recommend to the do dinner es de for the beginning because it's really risky sometimes really dangerous procedure as comparing with other es de procedure such as castro Gsd or correct R. E. S. T. Because of the poor maneuverability of the endoscope and also very single of building. Um uh We make a really serious complication but usually outer side of the second part of the duodenum is relatively easy part because of the easy approach on. The contrast in the side is really difficult because of the maneuverability. And of course the upper side of the second part of the duodenum is much more difficult and underrated parts such as inner side of the inferior. Do dino angle is the most challenging part to the E. S. T. Because uh approach to the inner side at the underrated area is really difficult. And the closure of the mucosal defect after successful reception is also very difficult at the inner side of inferior. Do Dina angle. So the priests uh not to try uh difficult procedure at the beginning and in case of having complications, you should switch to the standard E. M. R. And quickly cross the uh cooperated area or serious. Uh uh You should stop the serious bleeding immediately after making complication. Yes. Yes. Well your advice is well heated. You know, of course it's going to be extremely difficult and only as you say, super experts should really begin to do that. Let me ask you one other question about The endoscope, you showed us your specialized endoscope with the 3.2 channel. Um Is that a gastro scope length or is that like a PCF modified PCF? Uh it's a gastro scope GIFH 290 T probably or impasse previously launched. GIFH 190 90 t. 190 t in the United States and european countries. So probably you have some kind of an endoscope. Yes, I guess the outer diameter, maybe a little bit larger than yours. Uh I think so. And probably you have 3.7 millimeter working channel for the therapeutic single channel and telescope in the United States from orange glass. Okay, well now he's a it's been a fantastic presentation. I think we have to leave you again to uh switch over to Professor joe. But uh on behalf of stavros uh I want to thank you enormously for your contributions, which have been so wonderful and uh so educational for all of us. So I hope you have a good day in Japan and certainly uh it's a pleasure to see you as always. Thank you very much for your kind comment and it was a really great honor to have a chance to attend this meeting and I really hope that to have another chance to attend the meeting in person next year. Yes, that would that would be so exciting. Thank you so much. Thank you very much. Bye for now Published August 5, 2021 Created by
