Endoscopic Submucosal Dissection Using Hook Knife for Gastric Neoplasms: Therapeutic Efficacy and Safety

Abstract

Background and Aims: Because Endoscopic submucosal dissection (ESD) has advantages of higher complete resection rate and lower recurrence rate than conventional methods, it has been increasingly used for the treatment of gastric neoplasms. The aim of this study was to investigate therapeutic efficacy and complication (bleeding or perforation) of ESD using hook knife in gastric neoplasms. Patients and Methods: A total of 46 patients (24 men, 22 women, age range 19-84) was included in the study. ESD using hook knife performed from June 2003 through October 2004 were retrospectively reviewed. After confirmation of the lesion by indigocarmine spraying, the margins of the lesion were marked by hook knife using coagulation current (60 W). After submucosal fluid injection, incision and dissection of the lesions using endocut mode (80 W) were attempted with the aim of achieving en bloc resection. Immediate bleeding was defined as bleeding more than sixty seconds requiring endoscopic hemostasis during the ESD procedure and late bleeding was defined as bleeding after ESD procedure. Results: Indications for hook knife ESD were dysplasia in 18 (40%), differentiated adenocarcinoma in 14 (30%), and other tumor including submucosal neoplasm in 14 (30%) patients. The mean size of lesions was 23 mm (10-42 mm) and the mean procedure time was 20 min (6.2-87.5 min). Complete resection was achieved in 41 lesions (89.1%). Among 5 patients of incomplete resection, additional ESD was performed in 3 patients of positive lateral margin. Immediate and late bleeding were occurred in 25 patients (54.3%) and 5 patients (10.9%), respectively. However, these bleedings were successfully controlled by endoscopic treatment including direct hemostasis of hook knife. Although perforation were occurred in two patients, these were managed by endoscopic hemoclipping and conservative care. No severe complications necessitating surgery or leading to major morbidity occurred. Conclusions: Because ESD using hook knife has advantages of short procedure time due to continuous performance of marking, incision, submucosal dissection, and direct hemostasis on minor bleeding, and high complete resection rate, this method is highly effective and relatively safe therapeutic modality for gastric neoplasms.