Originally streamed live as part of NYU Langone's 2021 Long Island Live Endoscopy Conference - Stavros N. Stavropoulos, MD, performs an ESD on a 78 year old male patient with the assistance of DiLumen
®. hi everyone. So we'll just give a quick presentation on the fourth case and the last case for productive Stavropoulos. And so this is a 78 year old male who uh with the best, of course you have coronary disease particular disease. He was referred to us for a described four centimeter flat polyp that was thought to be in the seeker. But when I reviewed the leisure myself it was and the a sending coal and right next to the I. C. Valve, the valve was not involved. And um it was 60% of the circumference like spanning um like a flat corporate lesion spanning over two folds. The prior biopsies were cipolla adenoma. Um This is the lesion but this doesn't really um give it justice because you'll see how big that legion is. Um So now we'll just go switch to the room and dr Stavropoulos will show you the legion on endoscopy. So there's the Duluth Minn in the colon. Now I don't want I don't know if direct you want to demonstrate that the lumen outside for those that are not familiar with it? I think that's a good idea. We should see that most people are not using this. Can we have there large image of the diluting a bigger image on the main screen. That's better. Thank you. So this is the front part which has direct you want to solve the extendable balloon. I mean we hardly ever extended the money is in the back balloon that stabilizes the sheet and the scope. So the front Ballon also has futures, you can attach it to a polyp and then dialing how much traction you want. Like clip it onto the edge of the polyp. And then with that knob over there go in and out. And I just how much destruction you want like right like that or like that. But usually problems tend to be that difficult but it's going to be on turns so that doesn't work many times. And you need to use independent traction in which case you just leave the balloon retracted And inflate this balloon the back one or the front and the back and that provides stability in a tortuous kahlan right? And also facilitates instruction of the over stage if you want to shoot you that differ closed. These are two big utilities where the presentation did it w of case control study the lumen versus standard SD with matching for polyps size, previous manipulation difficult locations in the column, those being sick. Um fleck shires and signaled So after we matched them perfectly that Lumen looked like it was speeding. The asd time by say 25%. um Sergei's data showed 50% which is the 1st 70, 30 70 on a randomized study is doing I think 50% is uh you know pretty crazy. His medium speed for asd one from seven square centimeters to 15. Again mine Went from 12 square cm to 15. My interpretation is I was better at surrogate without the data lumen and the dilemma and equalized us But I don't know if he I don't know if he agrees with my interpretation. So this is the case control. We did also we looked at same day this starts after complex colony as this like this And we went from 15% to 48 same day discharge mainly because of shuttering. Right? We compared cases that were clipped two cases that standard. Yes. deal with clipping The Lumineers. Deal with future. So you know, I don't know 17% I think versus 48 same day district. So you know it's useful and you know, let's see what the legion looks like. So you can see here let's go. So how do you know several? Just go over. You put the dilution on your scope and it goes with pediatric or adult? It's a sheet. Right? So the scope goes through it all the way to the tip. Right? Right. So it goes in from here. Yeah. And then you lock it to avoid their loss all through the sheet until it's protruding from the end. And then you scope and get it wherever it is. You want to get it. Yeah. Um And then you inflate a balloon and then you do the SD. Yeah. Let's inflate the balloon. So you know, what about the what about the friction in the sheet? When you start to use special boot, a lubricant on the sheet. So you don't have to use a lot of lubrication anymore on the inside and the, the outside is you know, Pretty nice. I tell you it's 1000 times less friction than the Invesco's chief. Okay. Scientific number there. I never feel tremendous friction. There is some friction on the balloons because you see that little wrinkly but there's no friction here. Right? So there's the front balloon on the back balloon and you can inflate and deflate either one or both. Okay. All right. So now you can see the scope guide shows correct? Did a very nice short shortened loops with the assistance of the dilution. Right. You see that? Yeah, the scope guard, you know not too many pretzels and we're in the sitcom presumably. Rights and now let's go and see what we have in the second um back beyond that like the flight back like where you pull the whole sheet back or just the appendix where there's a navy m I got I don't see appendix. Are you sure? Are you sure they asked me about where? Okay, fine. Alright. Can see so I should come out more. Okay, so you deflated the balloon. Right. Hello. I need to come back a little. I think that the depot that's happened. It's okay. So I got to come, I got to pull back a little Oh I see evolve. Where are you? That's the valve approximately two. Yeah, I see Mark the majority direct market. Yes, I couldn't resist which sometimes more difficult than doing the incision. Actually a good job directors and he is the master partly in Japan. They don't let you mark until you master SD marking is considered very high level because you need to recognize where the margin should be. Right away. So yeah, it's I don't know. It's probably gonna end up bigger than four cm. Force in the middle is the way the bird bird flies. But this is all wrinkled. Dave. I bet you this final specimen on this Will be 7-8 cm. Okay, I'm there. It's next to the valve. There's gonna be a lot of fat in the sub mucosal which is also annoying because it's an insulator and even and a cat creates I rationalized part that stains the lens etcetera. So we'll see. But there's gonna be putting this up because I hear for sure. So there we are. There's a little depression there but it doesn't look too bad in terms of the pit pattern, Maybe you don't want to see a pit part than five with either If it's a more if it's a if it's an irregular pattern with big crib small crib that superficial because of invasion. Yesterday is important if you see non structural where there are no pits anymore then you need to then it's S. M. Two invasions then you need to send to surgery now I did you inflate the balloon. Well it pulled in again so just late again. Don't inflate until its area. Okay, so here let's look at the pattern. All right, and that's the standard four millimeter cap? Yes, standard four millim cap. Right. This doesn't look good but I don't know if it's trauma or biopsies or what? See this is a little bit of now. It might be trauma, but that looks like it's a cute with all the vascular salvation that Uh huh. I still don't like it because it's also in an area of depression. I don't like this here and it feels a little it's not very mobile here. So right here so we'll see. Okay, so that's an issue of concerns. Right? Right. But okay, so so here so we have to basically do a big circumferential incision. I'll start on the area of the valve which is the trickiest when when I started the area of the valve here in the tattoo and then come up the upper edge. Which is also very difficult. Then come down the left, it looks easier and then do the front incision and start dissecting front to back. Okay, so that's the plan. I don't know, I'm gonna start at whatever point you can do that. You ordinarily SD yeah. Heidi lecture and return now we're coming to you stavros. Could you sort of recap give us an overview uh from a distance and when you're ready of uh what we're looking at what we're trying to do with the strategy. I know you gave that before the break but would help just remind us. Yeah. So basically it's a huge polyp. The more we inject, the more we find. Yes. And it's unlike very uneven terrain, like really terrible terrain. See here my cat is next to the pole. If so you may think oh I don't have enough margin. But yes I do because there's a lot buried in here, you see. So this is all margin. Okay? But it's one of those, it's also completely centered on gravity. Yeah. Sorry, could you pull this go back a long view of the Sikh um and where it is relatives of the valve. Again, I'm trying to come to the water because it's completely on the gravity sides in order to see anything you need to All right, have no water right there. You see there's the hills and valleys and more hills and valleys and there's a misanthropic injections. So you want the injection to go this way but it goes that way which is the sick um The sick um is the the side for this kind of what I call on mr tropic injection you exact here and it always wants to go the other way. There's that depression in there which I'm very concerned about. Okay, like there, that area is worse. Um This area is gonna be easier. Right? So so you become detection ups off there. Yes. So I'm cutting Yes, I tried to do the back first but see it's a little problematic because the valve is in the way here. The polyp is there? The valve is there? It's just very difficult to get a good margin here. Sure, but we'll try. But this is this is this is a difficult day. I have to go towards the valve. So not exactly that. Are you using the pro knife? I'm giving the pro knife The two The 2.0. Right? And you're using dry cut and um using dry cut and precise or spray depending on how vascular it is, visit a depressed area, which is problematic really. And are you happy to be underwater on the gravity side or will this area where I can't even see the incision? Well, yeah. Right, okay. So I can try to inject their inject. I'm injecting threw the knife with our ice gel. There's a vessel here. Part of the reason that this is depressed and it read a lot and when it bleeds, it's on the on the gravity. So this is where the double red that the japanese have. And hopefully we'll have in a year would have held because the bleeding was completely under the pool of blood, inject and they start beating again because the reason it's so depressed and fiber because there is a vessel running through there also. I see. Right. So I'm trying to free it up here, but it's just so vibe robotic. Yeah, but why not drink without water? You can get an idea about where the plane is. You like that? Oh, great. So the double red reference that stavros made was to the Yeah, the scope imaging uh software in which it will uh distinguished tissue from uh bleeding. So you can I don't I haven't I heard I haven't seen it in action. Have you seen it? There's a blood go trends. It's a filter. It filters amber light um blocking green and red. So the amber light um basically let me see it reflects off the pools of blood, but it penetrates areas of vessels that are bleeding. So basically you filter that light and it's almost like it removes the pool so you can see the bleeding vessel underneath. Right? All right, okay. So this area is very worrisome there. So, I calculated the vessel. I got it all white. Which was not the intent, but I couldn't get more margin here because of the valve being there. So, that's what we have here. Okay, this is where the lead. This is where the bleed was. And I had to use a lot of it was like a massive, massive bleeding. Um, I had to use um, I had to use a lot of Qatar to stop it and use choreographer. What did you used to? Yeah, no, no, no. The forceps the forces. It was under the pool of blood. So I couldn't be very precise. I use the forceps broadly in Jack. Right. So I advise before seven. Yeah, the hotbox enforcement. Right. And you're using the the pediatric a short bending the Tawana scope. The H. L. Yes. So now I'm gonna come down here inject a little. Okay. Mhm. And Jack. Okay. So I'm approaching the other incision. But you see how uneven the situation is here. Right. Uh huh. And if you adjusted the dilution in any way or he just establish your position, know the element, the element is stable where it was at the beginning of the case and the balloon is blown up on the dilution. Yeah. Does that help keep the air also in the segment of value working in? I haven't thought of that. I'm not sure. Probably. Okay. Okay, so now I'm skin skimming around the valve here, you know, inject. I'm not sure we're seeing exactly what you see, but we don't quite see the cutting night. There we go. Okay. Yeah, that's the area around the valve here in Jack. And do you feel it's important to have a rise as opposed to just basic sailing here in the colon or I think it cuts down on muscle injury a lot. Okay, so I did the back. Right. Including this terrible sank in area there, but I'm really worried about, right, like the holy pens there. Right. I had a 5 to 10 millimeter margin. But I got a road that by this bleeding vessels. That's why should always make extra margin. But I don't like the pit patton here and how far and depressed it is. Yeah. Yeah. Okay. Um Okay. Now we are going to proceed on the bottom side. Like I think we did this. It's all sunken in. Right? Yeah. Do we have a little bit have a great job. Yeah. Yeah. In fact. Okay. Okay. Little bridge. Uh huh. I'm using spray because when you see bridges like that where the month there were the knife skip. Usually there's a vessel that caused that if you go it looks inject. It looks pretty inviting to do a cut cut here with cutting carbon. But I'm giving spray because I bet you there's a vessel causing the depression there. Okay. Okay, that's it. Okay, so that's it. We we cleared up this bridge here right now. We are down here Now. This gets a little tricky because there's another another valley and a tall mountain and then another valley on this side. And the polyp is right here. And I don't see, I have to say, I don't I'm not sure. I don't see directs marks. So we have to put new marks trying to estimate where the polyp ends. So the polyp ends. It's a pretty subtle one. I think that is the ads right. But it's all very dup. So I think where do we put the marks? I think I can continue here. Right. Ash. It looks like you can continue their right. What? Well there is another fault but we're that's that marks it guide. That's right. We have to write that fold then pass through that mark. All right. And then we have to make some more marks. We lost a mark already in the fall. And this is a true church. What happened to my mike? No, I don't know there. I'm gonna put another mark here. You know what? Maybe you can try to inject a little. How are you going, Jack and Jack until the injection is not coming towards us unfortunately. Okay, so now what? Those what? Okay, so where does it go? Yeah. Ah So it starts with the FBI. You go back to normal light. He dives in here. Now. Is this the market? Right? There's one mark to the right. Right, so an original mark on the right always with this water cable on the way. Haven't open. There was a question about a single or a double channel gastro scope being used. Um I think we can just do it. I'm disgusting. Even with the illumination. The short bending kaleidoscope is uh probably because I can't trust them. Yeah. Little little off camera drama fellow Putin's Youtube causes bleeding in the nose, which means I can put a bridle. Now I'll call you wanted to see what happened? Yeah. Sorry. My complication with the complication of the complication complications from the N. G. Tube placement. Oh fantastic. And Jack uh the original mark that was put in right. I'm hoping. I think so. Oh it's a stray mark but it looks like it's in the right place in Jack. See there may be another vessel in here. Now inject. Okay. Yeah I think there is a vessel and the vessels leaving the depressions. You gotta be careful. Right And the patient is left lateral. Yes. Okay. Okay. Now where do we go from here? So we're standing there. Oh I see marks there. This marks there. Question is are they far enough from the pole? So the polyp is here. All right. Right. Yeah I think they're okay this marks but that would mean I would have to start to initiate a dissection in the crevice. Do I want to do that? I don't think you'll initiating the credit smell but they want to start somewhere. Let's see how it lived exact. You can give yourself a wider berth flying outside the market. I'm just gonna go outside the dots. Right And I'm going a little bit give yourself more room. I mean obviously when the japanese do is the critical for the japanese methodology to of all the marks on the specimen that's removed. So they always detect outside the marks to ensure that they have everything removed that they want inject. And Jack. Mhm. Oh and Jacked. I notice you're injecting moving along. Do you feel do you sort of go back and have a look to make sure it's not too deep or not. Do that after Jack time. I have some reason here. I better maintain it. Yeah, that's a few of the next market. So there it is now. And Jack again. Yeah. I'm covered with his dirty water inject. Oh God. Right, okay. The mark looks like it deviates. Is that a mark? Oh yeah. So well getting close to potential cuts. So I could get instead of cutting over there, I could cut closer to here. Right? Yeah, you can bring them back down and Jack. Yeah. Um Okay, this marks. These marks are too close to the polyp. See the polyp is right there. Yeah. If I get any bleeding again, by the time you calculate that goes your margin. So I think I'm just gonna keep I'm gonna give this out or I'm gonna come down from here where I was going originally. Right, right. And just keep going across. Yeah. And Jacked. Jack and Jack and Jack. So the injection is going in front of me instead of under the flap. Right? It just, it basically goes away from the musical love. Okay, so we got to make this transition here, but I'm not gonna inject again because it keeps going the wrong way. Right. Yeah. So the nice thing about the pro knife and also the dual, I suppose is the knob on the tip helps you to pull you closer away or pull it out as you cut, gives you added protection. Tried to inject their inject? Uh slim pickings injector and you have an effort of the injection? I'm sorry. There's been nothing in the injection. I can't hear you. Do you have epinephrine but never in a I don't usually put now inject okay. Very close to bringing those two together now. Mm. Project yeah inject yeah. Okay. Okay. Okay. We're finished with the incision I think. Yes. So now we need to uh now we need to dissect which should be easier than the incision at least initially. You have to decide on your entry point. How are you going to decide where to go in? Let's start where it's easy for now. Mhm. You're going to see where you get your best lift. Mhm. Which is usually what we do. We want to make sure we have a clear access point, the area or the flat that lifts most easily. And I noticed you you're staying underwater here stavros mm Not entirely intentionally. The minute the minute I wash all the water stays here. So the only way to do this dry is to never use water cause I'm right on gravity. So you know you got to pick your poison. If every time I was I'm covered in fluid I might as well go underwater and enjoy. Right or you turn the patient over to the other side. Yes. I I already warned the team here about that eventuality. Right. But you know it's it's a pain. Yeah. Is there any difficulty with the lumen and turning the patients? I guess it's just the difficulty of turning a patient under G. A. Right. I was at a meeting in Copenhagen and uh every time they needed to turn a patient they called a special aide who happened to be a weightlifter, he was six ft 10", £300 and he could lift a £300 patient single handedly turn them over. So I think that I think we have to advise our endoscopy divisions to hire an aid uh weightlifter when it's on my to do with viking genes. Exactly from Copenhagen. Uh huh. Uh Yeah. Yeah. Come on there. Water pressure inject see to stop. I notice you're not using the Fuji cap which surprises me. Um These difficult entry points, the two issues with it is bubbles inject underwater together. More bubbles than the Olympus. And they can be very difficult to clear. Like every time you use undercut you have a bubble right in front of you that you have to move the scope to get rid of. So that's one issue. The other issue is it's a it's a sharp cup. So you know in the colon I've seen it because because of you know, tears and bleeding and things like that. So I would use it if it was really, I mean if now I could magically change my cup to fuji right now without needing to bring the scope out and stuff. I would do it right now. Right? But you just have to pick a priority what you want. I think so, I picked this one now. I'm stuck with it. Yeah, but you have great visibility, a better visibility, less bubbles, but harder time getting under the flat. But getting under the flap is I think the list of our problems I can use try if it gets really difficult, I could use traction. Right? And and Jack, do you think rep reflection is affected by the developments are made easier or not? Because you don't get looping? Yeah, it's easier because you don't get looper. Right? Yeah. And did you try rep reflection with this lesion to see what the access was like? No. Yeah. On the other side, is that depressed area? And that's no place to try and get under a flat. This is gonna be ugly here. I don't know if somebody took a lot of biopsies or I'm worried that there's something there. A depressed area. I'm really worried we'll see what it looks like from underneath. So let's continue. Give me some Actually I know it's uh absolutely outlandish to think that we would use a hybrid technique, but if you dissected everything else off except for that small 1 to 2 centimeter area, you can then use a full thickness resection and remove that. In fact Uhh one word, yikes ha ha Well, let's see the yikes that come out of you when you get there. I'd rather just save off the upper part of the muscle and have a nice art. zero specimen. Well, the interesting thing is with the hybrid full thickness. The cancers that are in the polyps are usually less than two centimeters are usually nine. I mean the ones you decide that are eligible for E. S. D. That have an invasive cancer, It's usually very small segments so you can least get vertical roo margin please. And the lateral of course the hybrid is always positive. Yeah. Well, having read that study that try to use over stitch, two states early cancers or cure them. And the results were pretty disastrous. So I don't know what are zero. They had r zero cases. Quite a few that then had the local recurrence. How can you get a local recurrence? And I'm talking about maybe 10%. 15%. How can you get a local recurrence from an R. Zero resection? And it's all very suspicious. That's true. You know the german multi center trial where they just focused on cancers. Very disappointing. I think a bit dangerous because it may induce people to take a cancer and play with it as opposed to doing a very precise csd or sending a person to surgery. Yeah, because the idea is like, well we don't care if it's still 1 81 B. We're just gonna take the Athabasca and basically do a full thickness resection to the degree that we can and then if deep margin is positive the person goes to surgery but it didn't work quite that way. And you can cause perforations and you can cause perforations in a cancer. And I don't know I think cancer should not be played with. You just have your best thought the first time you go there I think he S. D. Has it. You can't even do a very superficial almost the FDR like you have a cancer that is starting the muscle. You can just take a little bit of the muscle very superficially And preserve the sorrows and you can still get a deeper zero and then you can discuss the patient what the risk of lymph nodes is and say okay you want to do a collector me Risk of mortality 7% in a risk of in Jack. Risk of severe complications, leaks 10 to 14%. You want that or you know a 20% risk that live notes there. I think that's better. So I'm progressing here slowly but surely. Yeah you're getting a ton of getting that three point which is great. But you see the arise creates a pretty nice broad cushion there. Yeah I was hoping for a quicker colonies. Data based on the time concerns And I thought four cm. Okay this is not exactly what I intended inject. I don't have any doubt that we'll get it on block and are zero. Unless there is a t to cancer in the but it's not it might not be like a three hour years. Days, maybe more like a five hours a day. You may have to hold the fort with the asians At five p.m. Which is a bomber. I really want to see the laparoscope. The endoscopic alas hysterectomy. Well, if you give me privileges quickly I'll come and take over. Good, good. Okay. I like it. Give me a little break with cancer. Uh huh. Yeah. And Jack sea ice. I switched to undercut now because I couldn't stand how the dry cat was lagging at doing any serious cutting. The problem is if I accidentally hit a vessel that I didn't see it's gonna be quite a blade with God I may get some kind of warning. All right let's work on this side. That looks like a vein. Mm. I think it's a vein. Yeah, inject. I mean do you have to see if there's any pulsation there or not? I can use Yeah. I'm not sure. Maybe it's a not Jack. I'm just gonna do a forster calculation now. Yeah. A little bit of forced to cook it. Right. Yeah. Then uh before you got a little more forced while you're it up and down the vessel before you transact it. Okay let's see what it looks like. Um Okay let me take this up in your cause our first and let's see I don't know if it's dead yet. Think it's pretending. Well we need a little more yeah maybe from the other side on the other side. I would be too tangential because I'm very oblique here. Okay. Yeah and it needs a lot. You see how you see how robust it is even after all this burning it's still it's still holding. Do I dare cut the most? Let's pull away and have a look. I think it's still drinking myself because I hear badly I think I'm gonna cut I don't want to count that yet. You've got flow underneath it. What do you use precise to cut? Well I'll end up. God yeah. Okay. All right that's every year old. More sure. Oh yeah. Uh huh. See it's not done. Did you see the bleeding? You know time isn't done and started using You can you can see it's still there. The lumen are a little more forced. Yeah one problems of underwater with a Kelowna scope is you can't see the tip of your knife as you see. Yeah. Right there's a question that came up with a tunnel or park it meant to be faster here. This is effectively a tunnel method. We're creating a tunnel into the sub mucosal plan. This is just the entry point at this point. So we're just trying to create an entry point for the top. Okay a little bit more force collide there. Yeah. More forced gulag. All right okay and transact, okay. I think I can go back to precise. Right, okay. I can't say I'm in love with precise for coagulation even though it's promoted that way. I find it sparks a lot. Um, and it limits the dispersion of the energy and for smaller vessels that will coagulate. But I still think for larger vessels you have to use the methods that you've shown right where small vessels is good for big vessels. I think we still need a forced yeah. Oh good. Okay. And I look good. You're getting underneath which is lovely. Yeah. So do you have a formulaic way of adding methylene blue like a quarter CC for 20 CCs of or an eighth of a sky blue sky blue sky blue. But, but to be honest I use a lot of our eyes gel. I used to drive the apple starch. Uh 6%. Yeah, that was my go to for like 56 years until the rice jail came along. And then I said I'm going to use the gel only on the difficult ones in Jack, but it's just so useful. I can't stop myself and it has much better lift on the head to start. I've done hundreds of colonias. This would hurt a starts. It was really my go to for 5, 6 years but it's just all right, john is better. Is it? You feel just sustains the lift longer or Oh yeah. Like when I, when I get to the back of the bullet, the injection, I used to do the back circumferential incision is still there lifting for me to complete the, to complete the dissection at the back of the polyps. So yeah, it just stays there for hours. And what volume of arise gel do you think you'll use for a policy like this? You don't want to know my answer to that? I do guys can be a scary answer. You know, you know, let's put it this way. A significant amount. He asked how much. Alright, I'm a need for it, difficulty as you like this. A lot. A lot. A lot. Yeah, but I think even if you prevent a few micro perforations that may result injecting a few extra days of observation, you may recoup a lot of that cost. Sure of course. But I would say with, you know, large G. M. R. S or I think you have options. That's a, that's a bald. I got too close to uphold, what do you think that if you look to the right there, do you think that goes all the way around? So I went, there's a, there's a reads in the middle that fall that can fool you. So I I think the muscle slightly there, but nothing major inject. It's difficult to keep the plane here because it goes up and down and around and then next to the musical valve, it's just, you know, 10 different planes. So it's very difficult. It's all about maintaining the plane of detection. You have to constantly remind yourself where the muscle is, where the yukos is. Make sure you're in the middle and duct. My God, look at this. There's also a Sprinkle of tattoo now in here, right, we're getting to santa too. I'm having trouble deciding on your plane right here. Well, there's a circular muscle that I exposed a little. So this signing fiber, it's part of it. So it runs here and goes all the way around. So you see, I exposed it are very much trouble getting up there. I mean a terrible, terrible angle. I can't even lift enough without using the lateral dial here, but I can't show you. It's a circumferential, it starts there, you see those five birds and then goes all the way around in a circle. Right, right. How are we looking from the outside? So the top, I may need to do some traction there because it's in a terrible occasion. I can barely keep the scope to reach there. One thing you can do is change to Augusta scope, right? I can't think gas to scope. Um that's obviously a major time investment. Uh, maybe maybe just a little bit of traction will do it. So I will work on the bottom for now and when I'm ready for that, we should try to bring it down with traction. Um let's hope it might work, but for now we can work here. Okay. And what's the length of the dilution? 1 35. So for a gastro scope you have to cut into the side. Yeah. Yeah. You have to cut into the side. Right? That's what I'm saying. I don't want to commit you to something like that. Inject because then you may lose the air, you know the downsides. Yeah, inject. Okay. Um staying right off that muscle there, right, it goes circularly. You say it tries to get in my way all the way around, look at it. There's like a uh very bad location. Okay, let's work on this now. And Jack. Okay. Yeah. Okay. Well I'd say we're about 25. done. Yeah. That's uh not bad considering a the crazy angles and multiple hills and valleys. Okay, okay. Inject there. Okay. Oh wow. More muscles. So it extends like a seal in the other way there. See I'm I'm barely missing it again and again. And Jack. And that's a big pulsating at a Now is that close to where the bound down area is? Well, uh we're that area is at the back end of the polyp when we hit it will be almost almost close to getting done. I don't think so, exact. But the problem here is this artery is bad, huge. There's this there's this very next to it. But this artery. I mean you see it's the size of the people of the knife and that made them look out there. That's words coming. His word penetrate. Yeah, I'm very unhappy. It's a part where I'm exposed muscle. I cannot reach very inconvenient location. Yeah. Okay. Well let we'll keep exposing it and try not to hit that muscle. And then you're going to work. Take your coat. Grasshopper, Grasshopper or the are the forced four steps on that artery? Um forced forced calculation now. Oh yeah. Yeah. It looks pretty big for that. I don't know if I calculate with I have such a delicate plane. If I put the four steps here and coagulate, it's gonna collapse. All my sub miracles are playing right next to that muscle. And I'm just curving. I'm gonna curve, curving, curving, curving. If I eliminate my plane, I'm gonna run into the muscle. So let me try the forced inject. Okay, I just don't want to cook a big chunk of the sub mucosa there. No. Okay, let's let's try to get underneath it. Right. It's a nasty one. Okay, you're forced. So you're lifting up with the tip of the knife and you need it for Yeah, avoiding the model. Reid right now. The risk I'm gonna make a hole in my specimen because the people of the knife is pointing on the folded specimen. Right? I was doing Let's see. No. Okay. Uh huh. This was the artery right. Us Butler is anesthesia? The paralysis on cooler or God inject dr peddler is an anesthesia star. I covered that on my welcome. Are you sitting right there? Not quite horizontal but trying to get horizontal. Uh huh. Oh boy. So it's fired. Inject. Okay. Did we get through it or not? Quiet? I don't think. Quite yet. Not quite. Oh close a little more sizzle. Uh huh. Uh huh. Yes. I've seen a inject a little there. Okay. Can I cut it yet? I don't think so. Not yet. I'm being very hard on you. No. Well now I think you're there. I'm cutting. Yeah that no I wasn't there yet. Okay give me spray or something. I remember, you know. Okay. No. Oh boy. That muscle is right there to your right. Yeah. The muzzle was sitting there ready to trick us. Very difficult. I still have forced. Right Yeah. See how structurally sound the other is. Don't give up I guess. I can't you cannot get through the forest. It's still there. Right still there. Yeah, they're still there and maybe it's another one. I don't know. Yeah. Oh God. Oh I can't see because of this piece. I think we have to work on the top of the piece because it's in my way we have to work on this top here. Um Yeah, you miss spray. Come on. Okay. Inject. Okay. A couple of questions came up which all address. Uh Somebody was uncertain as to what knife you were using. This is the pro knife which has um injection capability through the barrel of the needles. And this is a two millimeter needle use comes in three sizes 1.5 2 and three millimeters. Um and it says why not use spray for dissection? Which is being used in Japan for last year's asd Jst. So the question is uh at least the volume in my ear. I can't, I can't hear. Yeah question was using spring Greg. Can you turn towards the table? Has this far microphone that is hard to talk to. Can you turn towards the table and talk towards that central microphone there? But I can hear you in the distance. I can't, I can't catch everything you're saying. Is that why don't you you spray for dissection because in japan and then I couldn't hear open. Right? So the question was uh there was a suggestion I guess at last year's um meeting of the J. S. G. E. And the A. S. G. Uh at least this particular person is suggesting that spray was used for dissection. And um I don't do you have a comment on that? Yeah, they use, I mean many people you spray when they make a tunnel on poem. I think he knew he was using it in the beginning to, I don't know if you're still using it like basically you go down and puff puff puff puff puff puff, they use pray to vaporize because as they do the tunnel and that I think you know the risk of heating up them you cause up to at least glancing it or not, making it purple is significant. So but it's very easy for beginners. I don't have any SD experience. Let's say you're a thoracic surgeon that daisy um are and then wants to do poem and doesn't do much SD you don't have the movements on the scope where you know I say I'm gonna cut from here. Point A. To point B. C. I can do PP. Pp. Pp PP. So you need you need movement. You need to know the movements to cut as if it were a scalpel. So instead they use it like a like a blaster by making little holes in the sub mucosa adjacent lee. And the end result is almost like you cut through. It's like boom boom boom, you blast the sub mucosa consecutive points. So you know for beginners, I don't have the movements to do sweeps. Long sweeps of cutting, you can use the vaporization in consecutive points to create a line. I don't see I think the 4000V can go anywhere. If the if the if the mucosa inject if the mucosa of the tunnel is touching the opposite wall in the esophagus. You can actually have the 4000V jump and burned the opposite wall and the proximal wall in kissing kissing white blood spots because of how high the voltages. So you know I'm not too big and dissecting now as you saw the FDR in the duodenum the whole time that I was using spread to dissect on the risk of vessels was high. So you can use it when there's a, you know when you're underwater and you need a powerful coagulating current when there are a lot of vessels and you're worried. But you just have to know that it can go very deep and very far. It's the most it's 3000 votes more than every other current on the urbane or almost inject. Yeah. Spring regulation was originally introduced by anyway, the very original poems for the first three years where he taught everybody you spray now spray was being used a lot and with the T. T knife and with spray it jumps ahead of you a little bit so it is more powerful, a little bit more dangerous. Actually 7000 I believe to be compared to force the regulations don't was in the room but he left. I thought it was 4000 on the old value. It's 4000 on the new value. I'm not sure. So there's less chance for forced to jump and cause contre coup burns or jump across to the mucosa Cosby Colin burns. So spread is much more powerful. Uh but I think uh as you said have been working underwater then you'll need it because the energy gets dispersed immediately by the by the water. Okay, I'm working on the top now, fortunately without traction and Jack. Okay. Right. Any other questions? Uh, let's have a look here. Um well there are questions on actually um reimbursement which I cannot answer. Maybe you can. But it says the poem Cpt are the you is 13. Yeah. Well thank you. Thank you Societies for cutting my poem reimbursement to almost half. Thank you. Thank you all. I wasn't involved in any of those negotiations Only do like 110 poems a year and I'm talking about this of a deal poems. I do not including G points and I was never consulted. I filled out that survey that they sent. But the proper, I was with the enlisted code. It was 22 are we used which is the same as a laparoscopic heller. And now the negotiator 13 There goes nine RV use. Yeah, that's what happened. They're on the muzzle. Yeah. Yeah. Oh done days here. So what's the big voltage for spray? 40 200 V. Okay. I was wrong. I said peak to peak was 7000 John right Well if it's 40 200 I'm happy. Oh good inject and Jack. Okay that Again, got control of the top two. So that's very good news. Now the only problem is that depressed area and what it might represent and how deep it is and blah blah blah. Yeah, strawberry when you have a moment when you're changing planes. Can you pull back and give us another overview of the total dissection up until now is to get a sense of where we're at. Yeah, we fanatically as deep people don't like doing that. I know because I have such sounds a good rhythm going here. I want to work in my little box. Well, no, if you have a good plane, you don't want to give it up. Old things once you have the second is so finished. Remember I couldn't I couldn't reach the top before so I don't do I don't want to move back and give it right now. Don't give it up. Yeah. See I receive that top. Boom done. That's that's the muscle fold here. You see it coming in. So I went in the trough over the fold and out into the next valley. That's good stuff. I'm afraid. I don't want to change any dynamics in the colon inject when I had the case where remember who was in the room? I left the room to go help somebody in another room and I come back. And then the orientation. I was like totally different inject right? Because I think some people, the system is not like a dad. So you leave it there or you pull back it straightens the scope. Suddenly you can't reach the top again inject. Mhm. That's especially true for the sigma. one of the tricks of the signals. If you can't reach is go all the way to the transfers and come back and suddenly the he s becomes a lot easier. It's straightened again. Like slowly. You lose the straight orientation and you need to go deep in come out and then it straightens it again using dilute and that's not an issue. Right? Let me show you. Let me there. So a little so uh it's it's so big that you know, I have to come back a lot. Yeah. And it's not it's not floating that much. But we have done maybe 35%. I don't know. I mean it looks good. Right? You're more 45. Uh huh. Let's see. I mean it all depends now what what what that depressed by broderick area looked like. And let's hope we're getting there and Jack. But yeah, I inject liberally. That's I mean, so far if I didn't have a right jail, those things in the muscle may have been actually deeper things in deck. The gel protects you. But as soon as getting anxious because see the muscle is following me now. It may be down here. Right? That's a hill not going to the valley. What's going on here. What's going on here? Uh and there. It's got this issue. What is this? Unless it's the vessels. You know what? No, it's the vessels are coagulated because yeah. Yeah. I would say the yard. I was afraid. Male male cancer that we reached. Inject, inject inject underwater. Seems awfully bright. Okay, so I'm following the muscle here and Jack. Okay. Yeah, so now I'm dissecting with end of God because I want very precise cutting underwater. And Jack. Okay, you're using endo cut here. Yes. What do you use? Welcome that one with duration for like, what's that like? Well, we're on the via three justice and look at one. Yeah, Direction, Duration three. Okay, operation too. Okay. Okay. We're doing good now here, down here, is that that same season? Right? Steve. Okay, project now the depressed segment is at the other end at the last part of the problem on the other and we'll see what happens with that. Okay now yeah, you almost have that corner. Uh huh. Let's go there. Mhm. See when you want, when you get impatient you want to cut more. I think that's where precise sect is. Good because I want to grab tissue with the entire knife now because I want to speed up. But if there is a vessel in there, you don't want to do this with and a cot. So give me precise again. Oh, what did I do? I guess I really tried to rush is basically the lesson of this story because there's a substantial vessel here close. Okay, give me what spray or something are there underwater. I think you need to spray here. Yeah. How does you spray work? Okay open? Yeah. Uh huh. Okay, steve inject Oh come on, come on. And Jackson, Jack. Okay. Okay, so how are we doing on this bottom area? It's a little folded up. Okay, inject. Okay. You're getting a nice plane there. Which is always yeah, I think we're getting to the five broderick area. You see that, that greeny scholar here. I think maybe we're getting there inject. It's a little weird underwater here. I don't know. Is it my color? Maybe my very green. Okay. There you go. Thank you. See this is the scar here. I think I'm hoping in Jack. Okay, so I'm just going to inject the either side of it. All right, inject now that's the most difficult part you're coming up to. There is a big vessel underneath. Yeah, but it does look like there is a plane that's why I brought it here. Although I think you can get underneath that. Give me a closer there. I think it's okay. Yeah, it looks okay there. Nice. Beautiful. Maybe we can avoid the vessel very much above it. And Jack, you don't have a lot of rooms. Oh good. Don't you find that a little bit too bright? Yeah, because of the water. It is all too bright. But on the other hand, I have a studio light reflecting off the ceilings. You know, if I make it any darker, I'm not gonna be able to see anything. Right? Have a big studio light. Like creating a a daylight environment in here. Okay, we can try, you know, try to lower the go to the middle there. Is it better now? I think it's a little bit looks a little better for identifying the plans. Yeah, I like that a little bit better. And Jack. Okay. Okay. Yeah. You see, the muscle is pulled is pulled into the pole if there where the scar is. Right, Let's see. Um Do you think those strands are muscle fibers? The shiny ones? Yeah, Well, that vessels right underneath you. Yeah, I'd be careful there. Oh, maybe. Dammit. Uh Let's see. Did it go through? I don't know about that. The problem is, I don't think I don't think we can get the bullet without going through here. Well, it looks like you're still all right. Uh Jack. It's such a difficult. That's that's a nasty scar. That's a nasty scar. If he did this with the Bobbsey forceps, you know? That's so sad. Really? Yeah, That's that's that's like that is fused here. Yeah. Why don't you do everything else and come back to that at the end. That's exactly what I was thinking. Because if I make a hole, at least it will be at the end. Well, exactly. So, you get a whole you're almost I leave you got that big vessel right beside where he's going to cut. All right. So, we're gonna we're gonna work at the top again. Right? And get everything else done, leave that to the end. And Jack. Okay? And Jack. Mhm. And Jack. Oh God. The nice part of where you are, if you have the cap pushing the flap of mucosa behind you and you have your detracting knife right at five o'clock there. So it's 5 30. So it's uh that's a good plane to be working. And yeah, just I'm again at the end of my dials up here, like that's as high as I can get you up down dire. Right, right, right, that's a little awkward. And see that's muscle hiding there at the totally unexpected plane. Yeah. Right. Um well, so we have to follow the muscle here. So let's start from here. Uh huh. Well, I could use traction by such a complicated paulie. Once I put traction, even complicate things inject. Yeah, I mean, you're gonna need so many different axes of traction, Right? And you put one arm and you have to change it. Yeah, I think I just need a little patience until I get lower. Mm. Yeah, mm. Maybe dissect a little closer than your clothes, are there? Uh huh. I mean, everything about SD is getting the plane of dissection once your stability in a plane, you're ready to go getting the stability and getting the plane. That's the challenge. Okay, injector. Okay, I'm going to spray here. You're going to go right through it right through and Zach. And are you back on and do cover? You want dry handle cut. I need very precise cutting because I'm I'm almost touching the specimen, I don't want to get current everywhere. I'm really I'm writing the heads of the specimen here. If I burn it it will start tearing and fraying. See it's already getting unhappy. Yeah. Okay. At least you see the plane. Nice way. At least. I mean and check okay, once this flap gets to the middle of the pole it will be much better. I'm having trouble open anything so high here. I mean I have both my dials crunched to be able to get over that slab and I keep losing it. Uh Do you want to try retro reflection to see what happens or you feel there's no way this is on this side of the valve. So if a retro flex I'll be looking on the other side of the valve and dr and drugged. Yeah, I'm touching the specimen here and we're kind of the whole because I'm sitting on the specimen because of the awkward position here. Yeah, I really need to free once I free that area there it will be so much better I think. Yeah. Coming in from this angle would be very helpful. Yeah. There we go. Yeah, I'm burning the specimen. It's getting unhappy. Yeah. Getting unhappy. See I can see now the mucosa from the other side. Yeah mm. And that uh not helping me. Arabs and Jack. Okay, well I started to open up a bit. Okay. Uh huh. Oh almost tore into the specimen. What were you pulling back or pushing? Yeah, I was pulling back and then the dial gave and almost jar and yeah, and Jack, that's a good plan right there. Yeah. So would you ever think of Icty nano? You feel it's just too large and to uncontrollable? Yeah. To poor control. Yeah, I mean here you see, it's like micro surgical. I pick fiber, cut fiber, pick another fiber, cut it. Yeah. No, no. I always compare this to retinal surgery. I feel that you know, it's fiber by fiber, you have to see perfectly clearly everything. Okay. A big problem with the denies is the bleeding. You often get leading if you're going blindly underneath the mucosa. Yeah, there is much harder to control that exact. Oh, so you know, for the people in the audience that wonder why we're killing ourselves here. Um because I'd be like, why don't you do a piece million mar Well, number one, as you mentioned with the Levesque. Yeah. Peace merely um are will not work here because that depressed area that is vibrate IQ um unless you pay for it, you are not going to get and then you're gonna do hot avulsion or something, right? I'm talking about typically um are practitioner and then that would be, that would be me. Well, you would do a vesco at least trying to get the complete clean cut of that. But most of the people would just hold that version that would do a pc I've had people use the end or rot or you know, like any creative craziness that can come up with. And then what happened if you have cancer, you have basically no guarantee for the patient that you removed it. You can send it for him, collect on me really. If it's not cancer, You're gonna have at least uh I mean on Michael Burke series for Polish bigger than 35 mm. His recurrence at 18 months was 35%. Right? So you're gonna get 30 cars of at least 35% because this is way above 35 mm. Yeah. And then you're looking at salvage your mar ablation. And he says that 7% of the time and that Michael Burke 7% of the time. He fails to oblate a recurrence completely and needs surgery. So, basically after surveillance and further ablation. And I am are you have a seven? If you are one of the people that record You have a 7% chance of ending up with surgery anyway, because the eradication fails after multiple attempts reasonably exact. So if you add all this up, it's substantial like this patient, We'll have an R0 resection. Right? Even for such a ridiculous polyps. So, So he has an R0 resection. Then we are looking at goal, No surveillance. You're done. Right. Well, that's true. If you have our own reception. The margins are clear. Yeah. R. Zero resection means zero chance of recurrence for years day. So basically if you have an S. M. one cancer you were saved from surgery. And if you have an R. Zero resection which you know my my rate in the last 300 years this is 97% for R. Zero resection in the colon. Then you're done. Done one procedure 97% sense never to be seen again except for regular surveillance. Say at three years. Whereas if you do it by um are Everybody gets to surveillances sc one sc 2 at six months and 18 months. 35% get a lot more because they recur so you know nothing about every patient to more colonoscopies. And one third of patients at least for a public decides several maybe more colonoscopies because even if you do one salvage CMR and clear the polyp then you re set a clock to sc one sc two. So even if you americans that is completely treated, most people would not read it at the same session. That would take the bumps and come back. So you get surveillance surveillance, they find a recurrence. You got brought back to remove the recurrence and then you get another surveillance surveillance. And that is if you're successful at removing the recurrence in one session. So the you know I want my polyp removed this way. Sure. How about you Greg but and I'll be asleep for me that time is absolutely worth it. I don't know about the doctor though. And especially with reimbursement like the asd reimbursement. What do you think about that? I mean you need to you need to um ah Bill creatively. Which I don't think for example you can do in private practice institutions can build more creatively. I think like I inject right you can use similar coach to surgery, things like that. Which I think is what the bill is due here. I'm a salaried position so it's not like a major I'm not sure what the reimbursement is like for the S. D. In the colon or what we're getting at this point. I'm sure it does not reflect the time and the effort that's involved. You know it's all about it's always about case selection. It's always about picking the highest risk case for S. D. And you know I think it's a lateral spreading tumor if it's granular I don't care what size it is. You know if the topographic features are favorable uh then you know extensive EMR is still the most practical effective way to do it. And even if you have a recurrence rate in a large lesion. I think it's fairly safe and quick to go back. So you know I think there's a good argument for usd and the high risk leisure that's basically and then of course you know the level of risk that you will undertake with VSD depends on your experience. But the problem I have with this reasoning is let's say this did not have a depressed area and was this gigantic polyp next to the logical volume and Jack, I mean what I said applies to that policy. The 35% recurrence, bringing back surveillance upon surveillance, salvage treatment, more surveillance. Like frankly, if I had a polyp like this without a depression concerning for cancer, I would find somebody to do this as opposed to a peace million mile. Like let's say I could go to Australia and have a piece. Million mark by Michael Burke was the best practitioner or I could go to Japan. I have your head. You do this. There's no doubt in my mind what I would do. I mean, I don't know what you will do, but I know exactly what I would do without, even without any risk factors for malignancy. Just this, this 56 centimeter flat polyp in a difficult area next to the, your cycle valve. Just this without concern about malignancy. Yeah. But the other single valve is protective. You have a very big fat pad is the risk of perforation around the alias eagle valve. In fact, it's less than a sequel poll. So in my mind, I mean it doesn't bother me that it's around the area. Cycle valve. All that active. No, I'm saying just difficult, somewhat difficult location, which would be even less likely that the EMR will be very clean. That's what I'm saying. I'm thinking about, I'm thinking about vs. Csd you have to be tactical with them are the same way you have to be with the S. D. You have to adjust the location. You gotta, you have to turn the patient over. Oftentimes in the paddock lecture, we have to have a right. That's not the question. That question is we have a big 456 and the metropolitan. Forget it. Let's say in the middle of the ascending colon. Okay. Well what would you do? Would you put the champion of EMR to do your case or would you put the champion of VSD to do your guys? No, I'm very happy with the M. R. If there are no negative right guys. Okay. I wouldn't be fine. Sorry. I don't want to do a surveillance at six months or at 18 months. I don't want to 35% recurrence rate and then more messing with my polyp. I'm sorry, but I don't, I mean what we do with all the large polyps that we do, we have more, we do a 6 to 12 months follow up and it's better do you follow up at 12 months because you'll you'll find more of the recurrence. Is that six months? You'll get 80% of the recurrence in the 12 months to get another 20%. Just do it in 12 months. That's provided there's no high grade dysplasia. It doesn't matter. You need to do one short term surveillance and then because there are stragglers that recur later, you have to do a long term surveillance. And okay, if you do four and 16, if you do six and 18. But you know, Michael Berg says, you know, you will get some recurrences on the long term surveillance that you didn't catch on the sword. So you need to destroy extra post resection surveillances. Yeah, but my point is, you don't have to do that. That was done in their research studies. But if there's no high grade dysplasia and you are, you know that at least macroscopic. Well, you've got the whole thing that there's no problem waiting one year. There's no problem. And if there's a recurrence of one year, which maybe 5, 10 or 15% depending on how you treat the margin. You treat the recurrence of one year and then And depending on what it is and then you go back three years later. So I don't follow this principle of six months, 18 months. Well, okay, so you saved you. Well, I don't know if one year surveillance has been proven adequate meaning that then you can tell this pace and see you in three years. Inject. I find I had when I used to do um other had plenty of recurrences that happened after one year. Um So you're saying I'll do it on one year. And if it's negative, I'll put myself in the back and tell that person to come back in three years, Jack. No, but I generally I really I go like like that I don't go like this. Mhm. No, I don't. Yeah, listen, I of course um I have a huge experience and we do a follow up with, you know, we're involved in a couple of perspective trials. We've looked at our recurrence rates and you know, if you do careful examination under near focus of the peripheral margin and you make sure that there is no macroscopic residual uh poem. I'm not even sure that you have to do uh marginal treatment that Michael Berg recommends with narrative. Yeah, that is a science fiction. I think. Okay, I don't I think there is a little bit of a message there. Um but I think it's the most important thing is to microscopically evaluate the entire margin under near focus and also the central areas, because you'll still get recurrences based on uh unrestricted macroscopic adenoma in the in the base of the lesion. But I'm still not convinced that given the time, the skill and the effort that's required. That prognostic, like if there are no negative prognostic signs, I still would not favor is deep. Uh This is different. You've got depressed. You've got this area. This is a different ball appear well, it seems everything I get is about that kind of polyps. So no, of course. You know, it's it's your referral basis? That's what you're getting? Uh huh. And exact are you coming closer to that area of where it's Now the top, the top is all the way down to that area too. So the side is all the way to the, to the top is all we are closing in on it. Oh God. Um let's see what time it is. 4:24. Yeah. So this is that area. What does this? Well, thanks, what, what happened here? So this area is the problem area. And look at this. It has tattoo in two. Thank you very much for that people. Uh Yeah, so the scar has tattoo and has a bunch of blood vessels. But this is the problem area right here. Right, well, let's continue advancing this. Uh Oh, okay. So this is this is a this is a problem area here. Um Yeah, yeah. I need to go from the side. If I go from the top, there's a high risk, I'm gonna perforate the specimen. I need to go from the side again and Jack. Okay, how can I do this steve hook knife? Is it time for the hook knife? Uh huh. I think. And then should we do traction or not? Yeah, I don't know. Um We need to change the hook knife here and Jack. All right, mm hmm. What do we have? This is nasty. That's very nasty. I have to cut a little muscle here. Hopefully. Just a little what's on the other side of that piece you dissected from the other side. Now, The other side is the end resection. I'm hoping because look this is so this is the other side. Uh We are here in that depressed area. Right? Where are we? Okay, right there. Wait um Not sure. I think you know, higher up maybe you're right where that little dimple goes in right there. So we have we have this to dissect still. Yeah, but now this is not the sort is be here. Right. Uh So so several. I'm just trying to uh factor in the one other lecture. We have uh the lecture from Professor joe. Um That's a that's a prerecorded lecture. Right. When would you like when would you like that? You wanted to get that in now while you're working there or? Yeah, that was the original plan and deck. Because then we'll have to look at the nice colors stacked on me. Right sections live at around I guess 5:00. So unfortunately back and forth. Yeah. I mean normally the other Long Island lives are pretty loose at the end of the day. But here we have a whole other program starting at five. So, so I think we have to go to the lecture then. Maybe you can saw my little glimpse of where I am then. Yeah. And then if we can pull it, we'll go through the chinese age and day. If we can pull it, I can show you the end of this in a little edited video. Right? Sure. Sure. But I don't know how else to do it. I think that might be in a way the way to go. Um And Jack, I'm just looking this over now where the general schedule for the support the power and Mhm. It's more like the lecture schedule if I could. Yeah. Um And you're still man and Jack. Because we have um Professor jones lecture. But we have also the poet presentation. Now the boy starts at five Haru will be there at five. So, you know, we have to sell the lecture from Joe which is 30 minutes. Okay. Okay. All right. We'll do that now. So Well, we'll have to leave you stavros. Well, I'm just gonna be picking out this dance scar here. I know now. I mean it's nice. You're going to stick with pro tonight. I'm going to switch to the hook knife in Jack. I'm going to switch to the hook knife now. It's just Impenetrable scar there. So, I think at this point we'll leave you and we'll come back after the lecture for five minutes after the lecture. Right? Right. We'll come back. We'd like to see what's happened. All right, Well, you know, great stamina. Great work. Uh Rose. Keep it up. Keep it up. So, I think at this point what we'd like to do is to go back and see how uh stavros is doing with his resection of the S. D. In the colon following that. We'll have the presentation of the Poet procedure uh video and then the discussion by professor in a way. And then we would Professor Usagi can stay with us. Uh We would love to have his commentary on that. Absolutely astounding demonstration of uh duodenal es de beyond ending. My imagination would have thought. Very humble but unbelievably talented presentation. So we look forward to uh speaking to Professor Harvey as well. So let's go move now to uh Scarborough to see what's happened with the uh Kalanick S. D. Okay, so listen, we are slowly getting through this amazingly pillar. We're alive. So we are we are we are digging through this extensive scar tissue. We have uh we were taking a little bit of the muscle of to make sure that we don't that we don't injure the specimen. Right? So yeah, you see, you see what's going on here, right? We have isolated this area. Somebody put a tattoo obviously right in there and they may have bob's. He does. Well, I don't know, I think this is man made. I'm not sure that it's cancer here, but look what they did to this area. It's like it's a turn. So when you say you cut the muscle, did you get a preparation or just, you know, these are muscle fibers that are stuck to the mucosa. So just remove them with a hook knife, right like that. You see that I do that. Right. I mean these people really these people in the middle of the bullet and all the way through the muscular is appropriate. Right? And I don't understand is what a polyp that can easily be described as a huge polyp next to the ecological love. Yeah. I don't know what the tattoo is for even a surgeon tattoos and it's absolutely, it makes no sense whatsoever. They would do a right chemical looked on me. Right. So, yeah, well, look at this. I mean, what is this for? What is this for? You want to do that? Why don't you do it not inside the bullet. And what about that duffel which is in that strand. How are you going to handle that? What? I'm sorry. Is that a vessel right there in the middle here are their vessels in here. And then the flap. You see the rest of the flap all the way here, it's free. This This is good. Sub mucosa here. We won't have a problem here. There's some vessels to deal with. But the big problem is digging through here trying to don't not make a full thickness perforation. So I see you got to cut the superficial part of the muscle basically, but not all the way through. We're digging tattoo out of there. You see, you see that muscle fibers being pulled by the tattoo. Yes. And you're using again and don't cut you. Yeah, I'm using and a cat because I would have to be very sorry with this. Um get turned to Xena please. So I need to I need to mom come on. Okay. The bottom part of the endoscopic images being cut off by the way it's being framed. Is there any way to see more of the bottom part of the end of scott? It's cut off. If the bottom is cut off, then you're missing all the fun. I know that's what I'm worried about. I never want to miss the fun. Why? Why are we missing the bottom? Yes. You're missing the bottom there. Right, are you? We can just barely see the tip of the hook by the way, it's framed on the transmission notice you see better now. Yeah, I think so. Let's just have a look here. We can see the knife scenario. I'm almost through the tattoo and maybe through the scar here. I'm hoping so. I think we have to go on with the rest of the program. I mean, but you see the idea is like you use the hook knife too slowly. Um see sometimes the jail creates these puffed up areas that makes seeing difficult. What you can do is then basically cut into them and that releases the jail like this this part here that is sticking out. You can just put the knife then, you know, kind of deflated a little. So it's not in the way. So before you leave stavros, did you give us one overview of the entire lesion? Yeah. So this time student tattoo and you see I'm seeing something mucosa again. So here I'm done. So this was the most difficult part of the reception. I can't go really fast because we found the subject cause are playing again. Yeah, and it doesn't look like cancer. Somebody just put a tattoo in the you're not really easy to continue. Do not dissect any muscles. So so this is the this is that that was the c that's that area here. That was the problem right there. Okay, so now I mean it's a big I put traction there, right? So so this is, I don't know how to give you, I don't have time to suckle the water out an inch of flow. But on the right, is that completely you have more dissection on the right there. It's all clear sailing because it's all it's all intact mucosa here. Right, okay, so this is gonna be easy to, you know, extend to the backyard with very easy like this like really cutting cutting all the way straight and then in the middle we're gonna go with the back incision which is all made and the top is already free also down to the incision. So so I'm gonna use it probably a second traction um if necessary for this part over here. Uh Are you sick of water pressure either way. So that and then I'll show you, I mean that was that was the problem. This this area here. But now we are all nice puff tops of mucosa. So yes, I'll continue straight through and finish it and future. And hopefully I can show you this during the program that starts. Now let me come say hello. Um, so I'll see you at the conference room For the next 30 minutes. Okay. All right. Wonderful work sorrows. Usually a masterful day ending with the most challenging leisure. I mean, so, so so was your camera here so you can speak to the camera and my nose strand left Hanging there. The destruction on one side. Afghanistan is sitting there to be cut and I can go to the kurds because I was just playing with. I was playing with my food a little bit. I was happy. I was enjoying that time. I've got a final moment. I was enjoying it too much. So it keeps to the actual cut there. So we cut it and there is a defect. It's not an easy position for the end of life for the overseas to close because at 12 o'clock, okay? You like your closes at six o'clock if you can't help it. But at 12 o'clock. And personally you have to work it. You ever think about turning the patient over. Mm hmm. Yeah, I can make it really bigger from where I don't see out here. Hold on. Okay. Now now I'll show you the future in itself As with their # two. And what we do is we basically make a hole in the dilution because it's too long for the overseas to get that are versus is a gastro spoke. So we make a hole in the lumen. I'm trying to get rid of the piece that is stuck to the overseas because the piece we remove at the end when we come out. So there and then I'm shoot you in here. I'll show you towards the end of the future. So here is here I'm getting from I started on the left hand and went all the way to the right hand. This all adds approximately this alleged approximately and then uh I'm removing that. Speak with them. Yeah, I'm about to shoot you sent it. Thank you so close and then we can discuss the patient home today even though this was thought out maybe a 5.5 hour you d there's no problem. We only got gas. So as long as soon as he urinates because with middle aged men who have urinary retention we can go home. So here we are. See again the the metal needs to be buried into the tissue. So I massage slowly. You see the metal detox going into the pleasure. If I finally went into the tissue, that's what you want to see. And then you you basically thank you. That's advanced a little bit and I think I sent it. All right. Big. I'm trying to show the final picture. So this, since I should have left it alone, is what I think I hear you. See. You see that's that's it, itself close completely enough to worry about any delayed problems. Beautiful. Okay. And now we remove the peace and I'll show you. But basically, we grabbed the piece with a grasshopper and we have come out with everything that the illuminati oversees the reception piece altogether. And then finally, I'll show you the final video, which shows the piece itself all nicely pain complete on block reception. There it is. You can see the pink area. Is that the norma? I'm showing all the way around. It's definitely are zero. We got, I think in one area we got close, um, like they're 65:00, but it's all completely removed.