Effectiveness of Endoscopic Submucosal Dissection Using Flush Knife for Esophageal Cancers

Abstract

Introduction: The development of endoscopic submucosal dissection (ESD) has enabled en-bloc resection of lesions regardless of size and shape. However, ESD is associated with a high level of technical difficulty and a high incidence of complications. In order to perform ESD more easily, safely, and efficiently, we invented water jet short needle knives (FlushKnife). Aims & Methods: We have developed FlushKnife with Fujinon having a tip portion with five projection length of 1, 1.5, 2, 2.5 and 3 mm that can emit a jet of water from the tip of a sheath. We treated 62 lesions in 52 patients (54 intramucosal cancers, 8 submucosal cancers) with ESD using FlushKnife between March 2005 and October 2006. VIO 300D (ERBE) was used for a electro surgical generator, and a 4-mm length attachment was put on the endoscope tip in order to treat as below. We marked around the lesions using 1 mm type of FlushKnife with forced coagulation mode 20w, effect 3, and performed the mucosal incision of the entire circumference using 2 mm with endo-cut I mode. Then, we dissected submucosal layer using 1, 1.5 or 2 mm with forced coagulation mode 40w, effect 2. A Hook knife was also used in situations where muscle layers were located in front. Results: En-bloc resection was performed in 61(98.4%) cases. Complete resection performed in 61 (98.4%) cases. The median size of resected specimen was 45 mm (23-80 mm) and that of tumors was 23 mm (3-72 mm). The median time of procedure was 43 minutes (20-206 minutes). Complications: No perforation was observed. All spurting bleeding were stopped by hemostatic forceps. No patients needed blood transfusion. Conclusion: Complete resection rate of ESD using FlulshKnife is extremely high and complication rate of that is low. Shortening of the projecting part of the tip of a needle knife enabled small and sharp marking, easy and safe mucosal incision and submucosal dissection. Emitting a jet of water from the tip of a sheath enables lavage of the viewing field, identification of the bleeding points and submucosal local injection without replacement of devices, which led to very efficient treatment. FlushKnife can be considered to be one of the useful operative instruments for ESD.