Clutch Cutter Research Articles

Short-term outcome of endoscopic submucosal dissection using a clutch cutter for subepithelial lesions within the esophagogastric submucosa: a Japanese prospective observational study.

The efficacy and safety of endoscopic submucosal dissection using a clutch cutter (ESD-CC) for subepithelial lesions within the esophagogastric submucosa (SELEGSM) has not been investigated. This study aimed to assess the efficacy and safety of ESD-CC for the treatment of SELEGSM. This prospective study included 15 consecutive patients with 18 SELEGSMs diagnosed by endoscopic ultrasonography. The primary outcomes were short-term outcomes including en bloc resection rate, R0 resection rate, procedure time, and complication rate. The secondary outcome was final histological diagnosis. Among the participants, 18 lesions were identified: 12 in the stomach (nine patients) and six in the esophagus (six patients). The en bloc resection rate was 94.4% (17/18). The R0 resection rate was 88.9% (16/18). The median operating time was 39 min, and no instances of perforation or bleeding were observed. The final diagnoses of SELEGSM included six neuroendocrine tumors (33.3%), six granular cell tumors (33.3%), two ectopic pancreases (11.1%), one inflammatory fibroid polyp (5.6%), one leiomyoma (5.6%), one lipoma (5.6%), and one leiomyosarcoma (5.6%). ESD-CC appears to be a technically efficient and safe approach for SELEGSM resection, suggesting its potential as a valuable treatment option.

Efficacy of Two Kinds of Scissor-Type Knives for Colorectal Endoscopic Submucosal Dissection: A Retrospective Comparative Study.

Scissor-type knives are spreading as safe devises in endoscopic submucosal dissection (ESD). We evaluated the efficacy of two kinds of scissor-type knives (Clutch Cutter: CC, Fujifilm Co.and SB Knife Jr2: SB, SB-KAWASUMI Laboratories. Inc.) in colorectal ESD. This single-center retrospective study analyzed 178 ESD cases treated with CC from January 2020 to August 2021 and 91 cases with SB from September 2021 to December 2023. The two groups were compared through propensity score matching. Therapeutic results, such as ESD procedure time, en bloc resection rate, perioperative bleeding frequency, and complications, were analyzed in each group. Risk factors for long ESD procedure time (≥ 90min) were also examined. After matching, 87 cases in each group were analyzed. There was no significant difference in the ESD procedure time (min, median [interquartile range]) between the CC and SB groups (54.0 [36.0-72.0] vs. 53.0 [39.0-72.0], p = 0.99). Additionally, there were no differences in the en bloc resection (100% vs. 100%, p = 1.00), perioperative perforation (1.1% vs. 1.1%, p = 1.00), or delayed bleeding (1.1% vs. 0.0%, p = 1.00). There was a significant difference in perioperative bleeding frequency (mean ± standard deviation: 1.8 ± 2.6 vs. 3.0 ± 3.5, p < 0.01). The significant risk factors (odds ratio [95% confidence interval]) for long ESD procedure time in patients treated with CC or SB were antiplatelet (7.51 [1.82-31.00]), large lesion size (1.08 [1.05-1.12]), severe fibrosis (24.30 [7.60-77.90]), and perioperative bleeding frequency (1.34 [1.14-1.56]). CC and SB in colorectal ESD enabled high en bloc resection and low complication rates. CC showed significantly less perioperative bleeding than SB.

Comparative efficacy of esomeprazole vs. rabeprazole in post-endoscopic submucosal d i s s e c t i o n g a s t r i c u l c e r s : a p r o s p e c t i v e randomized trial

Background and objectives: There is inadequate data on the clinical outcomes of proton pump inhibitors in patients with post-endoscopic submucosal dissection (ESD) gastric ulcers (PESDGU). The clinical course of PESDGU is affected by various ESD methods, including the types of devices and endoscopists’ skills. No previous reports have compared the clinical outcomes of different proton pump inhibitors for PESDGU healing in patients who underwent the same ESD method using the same device by the same well-trained endoscopist. This study aims to compare the clinical outcome of esomeprazole vs. rabeprazole in PESDGU using the same ESD method and by the same endoscopist. Methods: Sixty patients with gastric tumors participated in this randomized clinical trial. Patients who underwent ESD using the Clutch Cutter (ESDCC) method by the same endoscopist were prospectively randomly assigned to esomeprazole 20 mg (EM) or rabeprazole 20 mg (RM) monotherapy groups. All patients received 20 mg omeprazole intravenously daily for the first 2 days post-ESDCC, followed by oral administration of EM or RM for 8 weeks. All patients remained hospitalized for 7 days postoperation to monitor any ESD-related complications. Esophagogastroduodenoscopy was performed 8 weeks post-ESD to evaluate the healing status of each artificial ulcer. Results: Of the 60 patients in this study, 30 each were assigned to the EMand RM groups. Eight patients from both groups did not complete the regimen and were excluded. Exactly 52 patients completed the study, with 27 and 25 in the EM and RM groups, respectively. There were no significant differences in the demographic characteristics of the two groups. There were no post-ESD perforations in either group. Post-ESD bleeding occurred in one patient in the RM group 5 days post-ESD. Scarring rates at the endpoint 8 weeks after ESD in the EM and RM groups were 96% and 76%, respectively. There were no significant differences between the two groups in the scarring stage (S1 or S2) at 8 weeks post-ESD. Conclusion: EM and RM have equivalent therapeutic effects on PESDGUs.

Comparison of Needle Knife versus Scissors Forceps for Colorectal Endoscopic Submucosal Dissection: A Prospective Randomized Study

To evaluate the efficacy and safety of a grasping-type knife, called Clutch Cutter (CC), for colorectal endoscopic submucosal dissection (C-ESD). This was a randomized prospective study. Patients who underwent C-ESD for colorectal neoplasms >20 mm and <50 mm in size were enrolled, dividing into two groups: ESD using needle type of dual knife alone (D-group) and circumferential incision using dual knife followed by submucosal dissection using CC (CC-group). The primary outcome was the self-completion rate. The secondary outcomes were intraoperative complication rate, procedure time, and en bloc resection rate. A total of 45 patients were allocated to the D-group and 43 to the CC-group were allocated. The self-completion rate was higher in the CC-group (87% [39/45] vs. 98% [42/43]). All of the six patients with an incomplete procedure in the D-group were completely resected with CC use. The intraoperative complication rate was not significant in either group (D vs. CC: 2% vs. 0%). The mean procedure time was significantly shorter in the D-group than that in the CC-group (62.0 vs. 81.1 min; p = 0.0036). The en bloc resection rate was 100% in the D-group and 98% in the CC-group. While dual knife use is superior to CC in terms of time efficiency, the use of CC may be a safe and efficacious option for achieving complete C-ESD.

Successful Resection of a Gastric Tumor With Severe Fibrosis Using Endoscopic Submucosal Tunnel Dissection and a Picking Technique With a Clutch Cutter.

CASE REPORT Resections of gastric tumors with severe fibrosis by the endoscopic submucosal dissection (ESD) procedure are still difficult in some cases.1 Endoscopic submucosal tunnel dissection has been reported to be a good method for providing traction,2,3 and the usefulness of a picking technique with a clutch cutter (CC) for a protruding rectal tumor with the muscle-retracting sign has recently been reported.4 We report successful resection of a gastric tumor with severe fibrosis using endoscopic submucosal tunnel dissection and a picking technique with a CC. ESD was performed for a 75-year-old man with gastric adenocarcinoma in the posterior wall of the lesser curvature of the lower body of the stomach. A mucosal incision was made in the lateral side of the lesion, and the incision was then extended to create a one-half of a circumferential incision with an IT knife-2 in the anal side using the near-side approach method5 in retroflex view. During submucosal dissection, we unexpectedly observed the severe fibrosis (Figure 1). Because we could not approach the area of severe fibrosis horizontally in a retroflex view, we created a submucosal tunnel from the oral side to the anal side with a CC in a forward view as a rescue plan.Figure 1.: Figure showing the gastric tumor with severe fibrosis. (A) During submucosal dissection, we observed severe fibrosis in a retroflex view. (B) A submucosal tunnel provided good traction for the fibrosis area, and we could approach the area of severe fibrosis horizontally in a forward view.The submucosal tunnel provided good traction for the fibrosis area, and we could approach the area of severe fibrosis horizontally in a forward view (Figure 1). An appropriate dissection line was identified, and we picked, pulled, and cut with the tip of the CC (picking technique) (Figure 2). Using this technique, we released part of the severe fibrosis (Figure 2). Finally, the tumor was removed (Figure 2 and Video 1; watch the video at https://links.lww.com/ACGCR/A28). Histological examination revealed intramucosal carcinoma with negative resection margins.Figure 2.: Figure showing the picking technique after the ESTD. (A) An appropriate dissection line was identified, and we picked, pulled, and cut with the tip of the CC (picking technique). (B) Using this technique, we released the part of severe fibrosis. (C) The tumor was removed.The benefits of the picking technique may be a higher en bloc R0 resection rate and a lower perforation risk than those using conventional ESD. The reason for these possible benefits is that a severely fibrotic layer can be accurately detached by using this technique. On the other hand, the disadvantage of the picking technique may be a longer time required to complete the procedure. The reason for this is that a fibrotic layer can only be detached little by little. We consider that the picking technique is useful for severely fibrotic lesions. DISCLOSURES Author contributions: S. Abiko wrote the manuscript and is the article guarantor. K. Nakajima, K. Hirata, K. Suzuki, K. Kinoshita, K. Hatanaka, Y. Yamamoto, and H. Naruse edited the manuscript. Financial disclosures: None to report. Informed consent was obtained for this case report.

The usefulness of combining the pocket-creation method with a traction device using a scissor-type knife for colorectal endoscopic submucosal dissection.

Technical issues and long procedure time still remain a concern in colorectal endoscopic submucosal dissection (ESD). We examined the usefulness of combining the pocket-creation method (PCM) with a traction device (S-O clip; SO) using a scissor-type knife (Clutch Cutter 3.5mm; CC) for decreasing ESD procedure time. We retrospectively analyzed 95 ESD cases of PCM + SO + CC managed from August 2017 to April 2020 and 103 cases of PCM + CC treated from July 2016 to July 2017. We compared these two groups through propensity score matching. The main outcome was the analysis of the ESD procedure times under various conditions in each group. After matching, 52 cases in the PCM + SO + CC and PCM + CC groups were analyzed. The PCM + SO + CC group showed a significantly shorter ESD procedure time than the PCM + CC group (57.8 ± 31.4 vs. 81.7 ± 33.5min, p < 0.01). Additionally, the ESD procedure time was significantly shorter in the PCM + SO + CC group than in the PCM + CC group: tumor size (tumor size < 40mm: 45.6 ± 15.8 vs. 72.7 ± 22.9min, p < 0.01; tumor size ≥ 40mm: 83.1 ± 40.1 vs. 111.8 ± 45.3min, p = 0.04), tumor location (right side: 64.7 ± 33.3 vs. 81.0 ± 29.7min, p = 0.03; left side: 50.5 ± 28.0 vs. 82.3 ± 36.9min, p < 0.01), tumor morphology (polypoid: 39.2 ± 18.6 vs. 74.7 ± 28.6min, p < 0.01; nonpolypoid: 62.3 ± 32.3 vs. 84.5 ± 35.2min, p < 0.01), endoscopist (expert: 67.3 ± 41.2 vs. 91.9 ± 40.2min, p = 0.02; nonexpert: 50.4 ± 18.3 vs. 73.6 ± 24.9min, p < 0.01), and fibrosis (severe fibrosis: 82.0 ± 20.5 vs. 99.8 ± 40.4min, p = 0.169; non-severe fibrosis: 52.1 ± 23.8 vs. 75.6 ± 29.0min, p < 0.01). The combination of the PCM and SO using CC achieved a reduction in the colorectal ESD procedure time.

Endoscopic submucosal dissection for a laterally spreading ampullary carcinoma.

Video 1We performed endoscopic submucosal dissection with the patient under conscious sedation. After making markings around the lesion, we incised the mucosa from the oral side of the ampullary lesion and dissected the submucosal layer using a Clutch Cutter. We created 2 submucosal tunnels to identify the dissection line of the ampulla. After completion of the tunnels, we performed a mucosal incision circumferentially and dissected the submucosal layer except the ampulla. Subsequently, we removed the ampulla directly above the muscle layer of the duodenum using the Clutch Cutter. En bloc resection was achieved. After resecting the lesion, a biliary stent and pancreatic stent were placed into the common bile duct and pancreatic duct, respectively. Prophylactic closure of the mucosal defect was performed using endoclips and a polyglycolic acid sheet with fibrin glue to prevent delayed perforation and bleeding.

Successful resection of protruding tumor with muscle-retracting sign during rectal endoscopic submucosal dissection using isolation method and picking technique with clutch cutter.

Successful resection of protruding tumor with muscle-retracting sign during rectal endoscopic submucosal dissection using isolation method and picking technique with clutch cutter.

Effects of the combined use of a scissor-type knife and traction clip on endoscopic submucosal dissection of colorectal tumors: a propensity score-matched analysis.

Background and study aims This study evaluated the technical aspects of colorectal endoscopic submucosal dissection (ESD) with the Clutch Cutter (CC) (Fujifilm Co., Tokyo, Japan), a scissor-type knife, and the S-O clip (SO) as a traction clip, and compared the safety and efficacy to ESD using a needle-type knife. Patients and methods This was a single-center retrospective study. In Study 1, we evaluated 125 ESD patients: 60 using the SO and CC (SO group) and 65 using the CC (CC group). In Study 2, we evaluated 185 ESD patients: the CC group (N = 65) and 120 using the Flush knife BT-S (Flush group) (Fujifilm Co., Tokyo, Japan). In both studies, the clinicopathological features and therapeutic outcomes were compared using a propensity score-matched analysis. Results In 36 pairs of matched patients in Study 1, the rates of en bloc resection, R0 resection, perforation, and postoperative bleeding (POB) were 97.2 %, 88.9 %, 2.8 %, and 0 %, respectively, for the SO group and 100 %, 91.7 %, 0 %, and 0 % for the CC group (not significant). The mean procedure time for the SO group among less-experienced endoscopists was significantly shorter than in the CC group (42 vs. 65 minutes, P = 0.036). In 49 pairs of matched patients in Study 2, the rates of en bloc resection, R0 resection, perforation, and POB were 100 %, 95.8 %, 0 %, and 0 %, respectively, for the CC group and 98.0 %, 95.8 %, 0 %, and 2.0 % for the Flush group (not significant). The mean procedure time in the CC group among less-experienced endoscopists was significantly shorter than in the Flush group (52 vs. 67 minutes, P = 0.038). Conclusions CC and the combined use of CC and SO reduced colorectal ESD procedure time among less-experienced endoscopists.

Recent approach for preventing complications in upper gastrointestinal endoscopic submucosal dissection.

Although endoscopic submucosal dissection (ESD) is a minimally invasive treatment method for upper gastrointestinal (GI) tumors, patients undergoing upper GI ESD sometimes fall into a serious condition from complications. Thus, it is important to fully understand how to prevent complications when performing upper GI ESD. One of the major complications in esophageal and gastric ESD is intraoperative perforation. To prevent this complication, blind dissection should be avoided. Traction‐assisted ESD is a useful technique for maintaining good endoscopic view. This method was proven to reduce the incidence of intraoperative perforation, which would become a standard technique in esophageal and gastric ESD. In gastric ESD, delayed bleeding is the most common complication. Recently, a novel prediction model (BEST‐J score) consisting of 10 factors with four risk categories for delayed bleeding in gastric ESD was established, and a free mobile application is now available. For reducing delayed bleeding in gastric ESD, vonoprazan ≥20 mg/day is the sole reliable method in the current status. Duodenal ESD is still challenging with a much higher frequency of complications, such as perforation and delayed bleeding, than ESD in other organs. However, with the development of improved devices and techniques, the frequency of complications in duodenal ESD has been decreasing. To prevent intraoperative perforation, some ESD techniques, such as using the distal tips of the Clutch Cutter, were developed. An endoscopic mucosal defect closure technique would be mandatory for preventing delayed complications. However, several unresolved issues, including standardization of duodenal ESD, remain and further studies are demanded.

Advances in endoscopic therapy using grasping-type scissors forceps (with video).

Endoscopic submucosal dissection (ESD) is a globally accepted minimally invasive therapy for early-stage gastrointestinal tract tumors. Although numerous electrosurgical knives have been developed for ESD, technical difficulties and high complication rates (bleeding and perforation) have limited their use worldwide. The grasping-type scissors forceps [clutch cutter (CC)] is the first forceps-type resection device developed with reference to hemostatic forceps. The aim was to allow easy and safe ESD throughout the gastrointestinal tract, as a biopsy technique, using one device. The CC can grasp the target tissue accurately and pull it away from the underlying muscle layer prior to energizing the tissue, for safe and effective incision and hemostasis during ESD. Reported clinical studies showed that ESD using the CC (ESD-CC) is a safe (perforation rate: 0%-3.6%; delayed bleeding rate: 0%-4.2%), technically efficient (en-bloc resection rate: 88.9%-100%), and single-device method for dissecting early-stage gastrointestinal tract tumors. The ESD-CC technique is simple and easy to learn because it can be completed simply by repeating the grasp, pull, and coagulate and/or incise actions using an electrosurgical current. The reported self-completion rate by non-experts was significantly better with the CC than with conventional knives (61.7% vs 24.5%, respectively; P < 0.001). Furthermore, the CC is used for other endoscopic therapies, such as endoscopic polypectomy for large pedunculated polyps, endoscopic myotomy for Zenker’s diverticulum, endoscopic treatment of buried bumper syndrome, and endoscopic necrosectomy for wall-off pancreatic necrosis. The initial reports using CC for these therapies have shown favorable results. In this review, we describe the structural features of the CC, how to use the instrument, efficacies of ESD-CC, and other unique endoscopic therapies using the CC.

Assistant skill in gastric endoscopic submucosal dissection using a clutch cutter.

BACKGROUNDA clutch cutter is a scissor-type knife used in endoscopic submucosal dissection (ESD) for gastrointestinal tract tumors. The assistant during the ESD using a clutch cutter (ESD-C) needs to rotate the device and grasp the target tissue appropriately; therefore, the assistant’s skill may affect the technical outcomes of ESD-C. AIMTo determine how assistant skill level affected the technical outcomes of gastric ESD-C using an ex vivo porcine training model.METHODSIn this pilot study, mock lesions of 15-30 mm in diameter were created in the middle or lower third of the porcine stomach. A total of 32 ESD-C procedures were performed by 16 trainees. Each trainee operator performed two ESD-C procedures; one ESD-C was assisted by an expert (ESD-C-E), and the other was assisted by a non-expert (ESD-C-NE). The total procedure time of the ESD was set as the primary outcome, and en bloc resection rate, complete procedure rate, perforation rate, and each procedure time/speed for mucosal incision or submucosal dissection were set as the secondary outcomes. In addition, we investigated factors associated with the difficulty of ESD including incompletion of ESD procedure, a long procedure time (≥ 20 min) or intraoperative perforation.RESULTSThe median total procedure time of the ESD-C-E was significantly shorter than that of the ESD-C-NE (12.9 min vs 21.9 min, P = 0.001). The en bloc resection rate was 100% in both groups. Complete resection rates of the ESD-C-E and ESD-C-NE groups were 100% and 93.8%, respectively. No intraoperative perforation was observed in both groups. In the multivariate analysis, assistant skill was significantly associated with the difficulty of ESD, with the highest odds ratio of 16.5.CONCLUSIONAssistance by an expert is an important factor when trainees perform ESD-C procedures.

Safety and feasibility of same-day discharge after esophageal endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is used for treating early luminal GI cancers. ESD is the standard of care in Asia, where it results in multiday admissions for observation. The goal of our study was to evaluate the safety and feasibility of same-day discharge (SDD) after ESD. This is a retrospective cohort study of adults who underwent similar esophageal ESD with a Clutch Cutter device (DP2618DT; Fujifilm) at the Mayo Clinic (Rochester, Minn, USA) from 2017 to 2019 with a single endoscopist. The primary end point was postprocedural adverse events within 7 days of ESD. Of 96 patients (75% male, mean age, 70 ± 10.3 years) undergoing a total of 140 ESDs, 85 were SDD versus 55 admissions. Of the 55 admits, 53 were discharged within 24 hours, whereas 2 were admitted for 2 to 3 days for reasons unrelated to the ESD procedure. Admissions were more likely to have a history of antiplatelet/anticoagulant use (56.4% vs 34.1%; P= .01) and higher mean American Society of Anesthesiologists (ASA) score (3.2 vs 2.9; P= .007). Admissions had larger resections (28.6 vs 20.1mm; P< .0001) with longer procedural durations (103.4 vs 62 minutes; P< .0001). Among SDDs, no intraprocedural or postprocedural adverse events were seen. Among admissions, 1 (1.8% vs 0%; P= .39) experienced intraprocedural bleeding requiring endoscopic intervention, 1 required transfusion before discharge within 24 hours of ESD (1.8% vs 0%; P= .39), and 1 required rehospitalization and endoscopic intervention within 7 days to address an active bleed along the resection margin (1.8% vs 0%; P= .39). SDD after esophageal ESD is safe and feasible. An experienced endoscopist can determine if SDD can be considered in patients with ASA physical classification status≤2 who undergo resections off antiplatelet/anticoagulant therapy and do not experience intraprocedural adverse events.

Mo1261 THE EFFECT OF FIBROSIS ON EFFICACY OF ENDOSCOPIC SUBMUCOSAL RESECTION IN BARRETT’S ESOPHAGUS

Endoscopic submucosal dissection (ESD) is an established endoscopic resection technique used to treat superficial esophageal cancer. ESD is predominantly used in Asia where en bloc resection is often successful for esophageal squamous cell cancer or gastric adenocarcinoma due to good tissue plane delineation. It is in these lesions that early training in ESD is recommended. In comparison, most Western ESD procedures occur in the setting of Barrett’s esophagus (BE), a known inflammatory condition often treated with ablation therapy or endoscopic mucosal resection prior to ESD, making fibrosis more common. To determine the effect of submucosal fibrosis on ESD in BE. A prospectively maintained database of esophageal ESD performed in the BE unit for neoplasia was reviewed for cases of fibrosis. All procedures were performed by a single endoscopist using an Olympus H190 (Center Valley, PA) gastroscope and a Fujifilm Clutch Cutter DP2618DT device (Tokyo, Japan) at Mayo Clinic (Rochester, MN) from 2017-2018. ESD was performed after injection of epinephrine, hydroxymethylcellulose, and methylene blue to elevate the mucosa. Primary outcomes were intraprocedural or post-procedural complications up to 7 days following ESD, and R0 curative and en bloc resection. A total of 142 ESDs were performed among 97 patients (74.2% male, mean age 69.1±10.4 y). Refer to Table 1 for lesion characteristics. En bloc resection was achieved in 124 (87.3%) cases. Mean resection size was 24.0±10.8 mm, with the defect measuring a mean 27.8±14.9% (range 10-80%) of the luminal circumference. For adenocarcinoma or squamous cell carcinoma-related resections, R0 was achieved in 16 of 50 resections (32%). Fibrosis was encountered in 24 (16.9%), and of these, 2 were noted as F1, 13 as F2 per standard classification. Notably, patients with fibrosis were more likely to have had prior endoscopic resection (p 0.01) and were more likely to go on to failed en bloc ESD (p <0.0001). Mean procedure time did not differ (p 0.44). Complications were identified in 2 cases without fibrosis; 1 involved intraprocedural bleeding from a 3 mm arterial branch that was cauterized with the Clutch Cutter device and also resulted in use of topical hemostatic spray, while 1 involved need for blood transfusion within 24 hours of the procedure, followed by topical hemostatic spray and epinephrine to address bleeding along the resection margin at 5 days post-procedure. Patients were on antiplatelet/anticoagulants for 52.8% of procedures, including 30.3% on aspirin, 2.1% clopidogrel, 9.9% warfarin, 9.2% direct oral anticoagulants. ESD in BE with fibrosis is more likely to result in failed en bloc resection though complications were not increased. Fibrosis is common in patients with BE and may make lesions less ideal for training for Western endoscopists.

Mo1289 SAFETY AND FEASIBILITY OF SAME DAY DISCHARGE FOLLOWING ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION

Endoscopic submucosal dissection (ESD) is an endoscopic resection technique used for the treatment of early luminal gastrointestinal cancer. ESD has become standard of care in East Asia, where it results in a multi-day hospital admission for observation. Similarly, in the US, standard of care usually involves at least an overnight hospital stay. There is, however, limited data regarding practice in Western hospitals. To evaluate the safety and feasibility of same day discharge (SDD) following esophageal ESD. This is a retrospective cohort study of adults who underwent esophageal ESD with a Clutch Cutter device (DP2618DT; Fujifilm Corporation, Tokyo, Japan) at Mayo Clinic (Rochester, MN) from 2017-2019. The primary end point was post-procedural complications within 7 d of ESD, including need for physician phone call, Emergency Department visit, rehospitalization, and medical or endoscopic intervention. Of 96 patients (75% male, mean age 70±10.3 y) undergoing a total of 140 ESDs, 85 (60.7%) were SDDs vs 55 (39.3%) who were admitted. Of the 55 admits, 53 (96.4%) were discharged within 24 h, while 2 (3.6%) were admitted 2-3 d due to hypertensive urgency and TIA unrelated to ESD. SDD patients vs admits were similar in mean age (69.2 vs 71.4 y; p0.22) and sex (75.3% vs 71.4%; p0.84). However, admits were more likely to have a history of antiplatelet/anticoagulant (AP/AC) use (56.4% vs 34.1%; p0.01) and higher mean ASA physical status score (3.2 vs 2.9; p0.007). Admits had larger resections (28.6 vs 20.1 mm; p<0.0001) with longer durations (103.4 vs 62 min; p<0.0001). No difference in fibrosis was noted (12.7% vs 17.6%; p0.48). Among SDDs, no intraprocedural or post-procedural complications were seen. Among admits, 1 (1.8% vs 0%; p0.39) experienced intraprocedural bleeding requiring endoscopic intervention, 1 required transfusion prior to discharge within 24 h of ESD (1.8% vs 0%; p0.39), and 1 required rehospitalization and endoscopic intervention within 7 d to address an active bleed along the resection margin (1.8% vs 0%; p0.39). Overall, associated pathology was as follows: 5% had normal findings; 13.6% non-dysplastic Barrett’s esophagus (BE); 2.9% BE with indefinite dysplasia; 13.6% BE with low grade dysplasia; 20.7% BE with high grade dysplasia; 27.9% esophageal adenocarcinoma; 6.4% squamous cell carcinoma; and 10.0% had other findings, such as squamous dysplasia. Patients were on AP/AC therapy leading up to 42.9% of the procedures, including 5.7% on high dose aspirin, 2.9% clopidogrel, 6.4% warfarin, and 8.6% direct oral anticoagulants. SDD following esophageal ESD is safe and feasible. Additional prospective data will help establish more uniform criteria for low risk patients. Based on our experience, SDD can be considered in patients who are fit with ASA £2 and undergo smaller resections off AP/AC therapy.

Usefulness of a clutch cutter combined with an S-O clip in improving stability when opening the pocket in the pocket-creation method.

Usefulness of a clutch cutter combined with an S-O clip in improving stability when opening the pocket in the pocket-creation method.

Endoscopic submucosal dissection with a grasping-type scissors for early colorectal epithelial neoplasms: a large single-center experience.

Background and aimsThe Clutch Cutter (CC) can grasp, pull, coagulate, and incise targeted tissue with the use of electrosurgical current. It was developed as a biopsy technique to reduce the technical difficulty of endoscopic submucosal dissection (ESD) with knives. The aim of this study was to evaluate the efficacy and safety of ESD using the CC (ESD-CC) for early colorectal epithelial neoplasms (ECENs).MethodsIn this prospective study, we enrolled 437 consecutive patients with a diagnosis of ECEN between January 2009 and January 2018. They all satisfied the Japanese colorectal cancer treatment guidelines for ESD; namely, confirmation by preliminary endoscopy, EUS, and endoscopic biopsy. The CC was used for all steps of ESD (mucosal incision, submucosal dissection, and hemostatic treatment); therapeutic efficacy and safety were assessed.ResultsThe en bloc resection rate was 99.3% (434/437), and the R0 resection rate was 87.0% (380/437). The mean operating time was 88.3 minutes. Perforation occurred in 10 cases (2.3%) and was managed with conservative medical treatment. Post-ESD-CC bleeding occurred in 10 cases (2.3%) and was successfully treated by endoscopic hemostatic treatment.ConclusionsESD-CC is a technically efficient, safe, and easy method for resecting ECEN.

Efficacy of scissor-type knives for endoscopic mucosal dissection of superficial gastrointestinal neoplasms.

Endoscopic submucosal dissection (ESD) for superficial gastrointestinal neoplasms has become widespread. However, certain aspects of the procedure remain difficult to manage, such as intraoperative bleeding and perforation. There are two kinds of scissor-type knife: the Clutch Cutter (Fujifilm Co., Tokyo, Japan) and the SB knife (Sumitomo Bakelite Co., Tokyo, Japan). These knives have different features from other types of ESD knives and enable the performance of all ESD procedures, including mucosal incision, submucosal dissection, and hemostasis. The standard approach with scissor-type knives involves first grabbing the tissue and then incising or dissecting it. Theoretically, perforation as a result of unintentional movement should never happen with scissor-type knives compared to needle- or blade-type knives, which may induce perforation through unintentional movement. Moreover, the rates of severe bleeding and self-completion of ESD with scissor-type knives by non-experts were reported to be significantly better than for other knives. Thus, scissor-type knives can resolve these problems and help to further standardize ESD globally. In this review, we summarize reports on the efficacy of such scissor-type knives for ESD of gastrointestinal tumors. We also present the pocket-creation method and the application of traction devices, such as dental floss and S-O clips (Zeon Medical Co., Tokyo, Japan) for improving the performance of ESD with a Clutch Cutter.

Clutch Cutter knife efficacy in endoscopic submucosal dissection for early gastric neoplasms.

AIMTo compare the outcomes of endoscopic submucosal dissection (ESD) for gastric neoplasms using Clutch Cutter (ESD-C) or other knives (ESD-O).METHODSThis was a single-center retrospective study. Gastric neoplasms treated by ESD between April 2016 and October 2017 at Kitakyushu Municipal Medical Center were reviewed. Multivariate analyses and propensity score matching were used to reduce biases. Covariates included factors that might affect outcomes of ESD, including age, sex, underlying disease, anti-thrombotic drugs use, tumor location, tumor position, tumor size, tumor depth, tumor morphology, tumor histology, ulcer (scar), and operator skill. The treatment outcomes were compared among two groups. The primary outcome was ESD procedure time. Secondary outcomes were en bloc, complete, and curative resection rates, and adverse events rates including perforation and delayed bleeding.RESULTSA total of 155 patients were included in this study; 44 pairs were created by propensity score matching. Background characteristics were quite similar among two groups after matching. Procedure time was significantly shorter for ESD-C (median; 49 min) than for ESD-O (median; 88.5 min) (P < 0.01). However, there was no significant difference in treatment outcomes between ESD-C and ESD-O including en bloc resection rate (100% in both groups), complete resection rate (100% in both groups), curative resection rate (86.4% vs 88.6%, P = 0.730), delayed bleeding (2.3% vs 6.8%, P = 0.62) and perforation (0% in both groups).CONCLUSIONESD-C achieved shorter procedure time without an increase in complication risk. Therefore, ESD-C could become an effective ESD option for gastric neoplasms.

Efficacy of Clutch Cutter for Standardizing Endoscopic Submucosal Dissection for Early Gastric Cancer: A Propensity Score-Matched Analysis

Background/Aims: The purpose of this study was to evaluate the safety and efficacy of gastric endoscopic submucosal dissection (ESD) using the Clutch Cutter (CC), a scissor-type knife, compared with those of procedures using conventional devices. Methods: This single-center retrospective study evaluated 237 patients with early gastric cancer: 83 who underwent ESD using the CC group and 154 who underwent ESD using the insulated-tip knife 2 (IT2 group). Clinicopathological features and technical outcomes were compared between the 2 groups using a propensity score-matched analysis. Results: In 61 pairs of matched patients, there was no significant difference in R0 resection, perforation, or postoperative bleeding between the CC and IT2 groups. Comparisons between the 2 groups showed similar treatment outcomes for an expert endoscopist. Nevertheless, there were significant differences between the 2 groups for nonexperts in terms of self-completion (61.7 and 24.5%, respectively, p < 0.001), mean procedure times (45 and 61 min, respectively, p = 0.002), and mean numbers of intraoperative bleeding points and bleeding points requiring hemostatic forceps (3 and 0 vs. 8 and 3, respectively, p < 0.001). Conclusion: Better self-completion rates and shorter procedure times were noted for gastric ESD using the CC by nonexperts than for that using IT2, probably due to hemostatic efficacy.