Dual Knife Research Articles

Esophageal bronchogenic cyst treated with submucosal tunneling endoscopic resection: two case reports

IntroductionAlthough esophageal bronchogenic cysts are benign diseases, they may be accompanied by serious complications and have the possibility of recurrence. Therefore, once confirmed, it is necessary to treat the esophagobronchial cyst when the contraindication is excluded. Endoscopic treatment is usually used for lesions with small diameter and shallow origin, and has the advantages of small surgical trauma and risk, which can reduce the psychological burden of patients to a certain extent, help them to recover quickly, and lower hospital costs.Case presentationCase 1 is a 54-year-old Han Chinese man admitted to our hospital who complained of difficulty swallowing in the past 6 months. Case 2 is a 41-year-old Han Chinese man who was hospitalized in the past 3 months due to chest discomfort. Endoscopic ultrasound revealed a hypoechoic cystic lesion arising from the muscularis propria. Submucosal tunneling endoscopic resection was performed using a dual knife, and a cystic mass was observed between the mucosa and the muscular layers of the esophagus. On locating the cyst, an incision was made on the oral side of the lesion for evacuation. The cyst wall was excised using endoscopic argon plasma coagulation. We successfully removed the esophageal bronchogenic cyst lesion in the intrinsic muscle layer using submucosal tunneling endoscopic resection.ConclusionEsophageal bronchogenic cysts are rare in clinical practice and lack specificity in clinical manifestations. Multiple methods can be used to determine the location and nature of the lesion and ultimately determine the treatment plan. Surgical resection and endoscopic treatment are two different treatment methods, and appropriate treatment plans need to be selected on the basis of the origin layer, size, and relationship with the esophagus of the lesion to reduce complications and improve prognosis.

Comparison of prognostic outcomes between endoscopic submucosal dissection and surgical treatment for early gastric cancer: a retrospective cohort study

Background and aimThe optimal management strategy for early gastric cancer (EGC) a topic of contention. This study aims to compare the prognostic outcomes of endoscopic submucosal dissection (ESD) and surgical treatment in patients diagnosed with EGC.MethodsIn thisretrospective cohort study, we analyzed data from539 patients diagnosed with EGC between January 2012 and December 2020 from two centers. We compared Clinicopathological features, procedure-related complications, recurrence rate, overall survival, and disease specific survival between the 262 patients who underwent ESD and the 277 patients who underwent surgical treatment. ESD procedures were conducted using a dual knife by experienced endoscopists, while surgical treatments included laparoscopic or open gastrectomy. Regular ollow-up examinations were conducted post-treatment.ResultsThe two groups exhibited comparable baseline characteristics. Multivariable Cox regression analysis identified vascular invasion as a risk factor for worse recurrence-free survival (RFS), and overall survival (OS) in patients with early gastric cancer. The ESD group experienced fewer overall postoperative complications compared to the surgical treatment group. Kaplan-Meier curves demonstrated no significant differences in recurrence rate or overall survival between the two groups.ConclusionsBoth ESD and surgical treatment emerged as safe and effective approaches for managing EGC. The choice of treatment should be tailored to individual patient factors. ESD can be considered an alternative treatment option for selected patients who are not suitable candidates for surgery. Further studies are warranted to determine the long-term outcomes of ESD and surgical treatment for EGC.

Paraganglioma with high-grade intraepithelial neoplasia in the oesophagus treated by endoscopic submucosal dissection.

A 37-year-old woman was hospitalised with a 4-month history of retrosternal pain. Gastroscopy revealed a protrusion lesion of approximately 0.6 cm in diameter in the left wall of the oesophagus, approximately 27 cm from the incisor (Fig. 1). Consequently, one biopsy specimen was taken from the oesophagus. Based on the pathology and immunohistochemistry findings, the patient was initially diagnosed with paraganglioma with high-grade squamous intraepithelial neoplasia. The patient underwent endoscopic submucosal dissection 12 days after the biopsy. The protrusion lesion was again observed under gastroscopy, with visible scarring on the surface (Fig. 2A). A hypoechoic and heterogeneous mass of about 7.1 mm × 2.0 mm in the muscularis mucosae layer was detected on endoscopic ultrasonography (Fig. 2B). The mass was excised after submucosal injection of adrenaline, melphalan, and glycerol fructose injection (Fig. 2C). The postoperative gross specimen was a mucosal tissue measuring 2 cm × 1.8 cm × 0.2 cm, with a bulging mass underneath (Fig. 2D). The results of immunohistochemical analysis were positive for CD56, Syn, CK8/18, LCK, and S-100 and negative for SSTR2 (Fig. 3D, E). Expression of wild-type P53, focal positivity of CgA, and weak positivity of NSE were noted. The Ki-67 labelling index was 1–2%. The diagnosis of paraganglioma with high-grade squamous intraepithelial neoplasia was confirmed based on the histopathology findings (Fig. 3A, B, C). The patient recovered well during the follow-up. Fig. 2(A) The protrusion lesion was found again under gastroscopy, with visible scarring on the surface. (B) Endoscopic ultrasonography detected a hypoechoic and heterogeneous mass of about 7.1 mm × 2.0 mm in the muscularis mucosae layer. (C) Adrenaline, melphalan and glycerol fructose injection was injected in the submucosa after the lesion was marked with a dual knife. (D) Gross specimen after endoscopic submucosal dissection. View Large Image Figure Viewer Download Hi-res image Fig. 3Microscopic examination. (A) Significant cytological atypia in squamous epithelium with continuous basement membrane, and arrangement of the cells in nests (“Zellballen”) in muscularis mucosae. (HE stain × 4) (B) The tumour was composed of chief cells and sustentacular cells. (HE stain × 10) (C) The chief cell is polygonal with a fine granular cytoplasm of acidophilia as well as basophilia. The nucleus is round to elliptical. The sustentacular cells of spindle-shape are distributed around the tumour cell nests or interdigitated amongst the sustentacular cells. (HE stain × 40) (D) positivity of S-100 protein (× 10). (E) positivity of Syn. (× 10). View Large Image Figure Viewer Download Hi-res image

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.

Outcomes of the Conventional versus Pocket-Creation Method for Endoscopic Submucosal Dissection of Gastric Body Tumors Using a Dual Knife: A Retrospective Study.

Various endoscopic submucosal dissection (ESD) methods for gastric tumors have been tried. However, no studies have yet compared results according to the ESD method for gastric body tumors using a dual knife. The objective of this study was to compare outcomes of two ESD methods for gastric body tumors: the pocket-creation method and conventional method. Patients who underwent ESD for a gastric body tumor were retrospectively reviewed. Patients were divided into two groups according to the ESD method: the conventional method (group I) and pocket-creation method (group II). Characteristics of patients and tumors, hospitalization period, incidence of complications, resection margin status, incidence of surgical operation, procedure time, and laboratory findings were investigated. Of the total of 100 patients, 52 belonged to group I and 48 to group II. All tumors were successfully resected en bloc. Resection margin involvement was found in six (11.5%) of group I and six (12.5%) of group II. Complications were observed in seven (13.5%; major complication five, minor two) of group I and eight (16.7%; major two, minor six) of group II. There were no significant differences in ESD outcomes such as hospitalization period, incidence of complications, resection margin status, incidence of surgical operation, procedure time, or inflammatory response after ESD between the two groups. Both methods are suitable for treating gastric body tumors with adequate treatment success rates and comparable complication rates.

Endoscopic septum division of tubular esophageal duplication in two children and systematic review

Tubular esophageal duplication is a rare congenital malformation The surgical treatment of this lesion can be challenging. We aimed to present our experience in two cases with tubular esophageal duplication. Both cases were endoscopically treated by a dual knife. The first patient underwent a single, while the second patient required three sessions of endoscopic septum division using an electrosurgical knife. Both showed satisfactory clinical, radiological and endoscopic response to treatment. Moreover, a systematic literature review has been performed. To identify all available studies, a detailed search on tubular esophageal duplication was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Tubular esophageal duplication was reported in 16 pediatric cases in 14 studies in the literature. Surgery was applied to 10 of these cases and endoscopic treatment was applied to two of them. In the follow-up, nine patients who underwent surgical treatment and two patients who underwent endoscopic treatment were uneventful. Tubular esophageal duplications can be successfully treated endoscopically. Endoscopic septum division is a minimally invasive procedure that allows full anatomical recovery and satisfactory therapeutic response.

How to Perform a High-Quality Endoscopic Submucosal Dissection

How to Perform a High-Quality Endoscopic Submucosal Dissection

Laparoendoscopic Management of Colonic Trichobezoar Causing Acute Large Bowel Obstruction in an Adolescent Girl

Laparoendoscopic Management of Colonic Trichobezoar Causing Acute Large Bowel Obstruction in an Adolescent Girl

Feasibility of ultrathin endoscope for esophageal endoscopic submucosal dissection.

Background and study aims Endoscopic submucosal dissection (ESD) is widely performed for superficial esophageal cancer, but stricture after extensive resection is a major clinical problem. Using an ultrathin endoscope would enable endoscopists to approach lesions beyond the stricture. We evaluated the feasibility of an ultrathin endoscope for esophageal ESD. Methods To perform ESD with an ultrathin endoscope, we developed a transparent hood and ESD knife. A total of 24 esophageal ESDs were performed by two endoscopists with excised and live porcine esophaguses. A GIF-Q260 J and Dual knife were used in the conventional group and the GIF-XP260NS and a newly developed knife were used in the ultrathin group. En bloc resection rates, perforation rates, and procedure times were compared. Results All 24 lesions were resected en bloc without perforation. The mean procedure time was longer in the ultrathin group, although not significantly so (274.3 ± 81.8 s vs 435.8 ± 313.9 s, respectively; P = 0.22). Conclusion Although the procedure time was longer in the ultrathin group, en bloc resection was performed without any perforation. The findings indicate that esophageal ESD with an ultrathin endoscope is feasible.

Snare Tip Is an Alternative Tool for Colorectal Endoscopic Submucosal Dissection.

Colorectal endoscopic submucosal dissection is typically performed by specialized knife, such as a dual knife. However, it is not covered by Taiwan's National Health Insurance. In the literature review, using a traditional snare tip for endoscopic submucosal dissection has been reported for stomach lesions only. The purpose of this study was to evaluate the outcomes of colorectal endoscopic submucosal dissection using a snare tip. We retrospectively reviewed the clinical using of a snare tip compared with a dual knife for colorectal endoscopic submucosal dissection. Postoperative short- and long-term outcomes were investigated after the procedure. This study was conducted at a single tertiary care institution. Patients who could not afford the expense of a specialized knife were included. Dissection time, dissection speed, and perioperative complications were used for short-term outcome measurement. Recurrence-free rate was used for long-term outcome measurement. Twenty-one lesions were in the snare tip group and 57 lesions in the dual knife group. The outcomes, including rate of en bloc resection, complication, local recurrence, and recurrence-free interval, between the 2 groups were similar. The mean resected specimen diameter in the dual knife group is larger than the snare tip group (p = 0.041). The dissection time of the snare tip group was shorter than the dual knife group (p = 0.025). However, the dissection speed was significantly slower in the snare tip group than in the dual knife group (p = 0.008). This study was a retrospective and single doctor chart review in nature with a limited patient number. The snare tip is an alternative tool for colorectal endoscopic submucosal dissection in a selected population without the support of specialized knives, such as the dual knife. Although the dissection speed is slower using a snare tip, it is still a recommended technique for developing country or low-income patients.

Preliminary experience of hybrid endoscopic submucosal dissection by duodenoscope for recurrent laterally spreading papillary lesions.

BACKGROUNDThe management strategies for recurrent ampullary adenoma after endoscopic papillectomy are still controversial. Patients with the recurrent papillary lesions need to receive repetitive endoscopic interventions due to the limitations of conventional endoscopic techniques.AIMTo assess the feasibility, efficacy, and safety of hybrid endoscopic submucosal dissection (ESD) by duodenoscope for recurrent, laterally spreading papillary lesions.METHODSWe enrolled two patients with recurrent, laterally spreading, duodenal papillary adenomas with no intraductal extension confirmed by follow-up between March 2017 and September 2018. After marking the resection borders of the lesion using a dual knife, a submucosal cushion was created by injecting a mixture of saline solution, methylene blue, and adrenaline. A total circumferential incision and submucosal excision was performed by dual knife combined with insulated-tip diathermic knife, and then the lesion was ligated and resected using an electric snare. Endoscopic hemostasis was applied during the endoscopic procedures. Moreover, the endoscopic retrograde cholangiopancreatography (ERCP) procedures, including selective cannulation and stent implantation of biliary and pancreatic ducts, were performed. Additionally, we performed endoclip closure for mucosal defect after ESD.RESULTSHybrid ESD using a duodenoscope and biliary and pancreatic stent placement were performed successfully in two patients. The endoscopic size of recurrent papillary lesions was no more than 2 cm. Generally, the average total procedure time was 95.5 min, and the procedure time of ESD and ERCP was 38.5 min and 15.5 min, respectively. No serious complications occurred during the intraoperative and postoperative periods. The histopathological examination revealed tubulovillous adenoma negative for neoplastic extension at the cut margin in both patients. The duodenoscopic follow-up and histopathology of biopsy specimens at 3 mo after ESD showed no residual or recurrent lesions in ampullary areas in both cases. Both cases have been followed up with no recurrence to June 2020.CONCLUSIONHybrid ESD by duodenoscope is technically challenging, and may be curative for recurrent, laterally spreading papillary adenomas < 2 cm. It should be performed cautiously in selected patients by experienced endoscopists.

S3595 "Cutting Edge Honjo Masamune Saving Lives" ESD Preferred and Popular for Early Gastric Cancer

INTRODUCTION: Gastric cancer (GC) is the second leading cause of cancer-related mortality worldwide and complete resection is the only curative treatment. Historically, total or subtotal gastrectomy was the only curative option. However, with the advances in therapeutic endoscopy, endoscopic submucosal dissection (ESD) has emerged as a minimally invasive treatment option for precancerous lesions and early stage gastric cancer. Here we present a case of large gastric mass that was able to be fully resected using ESD, which was found to be rare GC. CASE DESCRIPTION/METHODS: A 50-year-old female with multiple comorbidities who presented to our Gastrointestinal (GI) clinic for further evaluation of iron deficiency anemia. Her initial endoscopic gastroduodenoscopy (EGD) revealed a 5–6 cm large gastric mass in the greater curvature of the stomach. The mass was hyperechoic, heterogeneous, and extended to the deep mucosal layer on endoscopic ultrasound (EUS). No adjacent lymphadenopathy was noted. Endoscopic biopsies of the mass revealed atypical glandular proliferation with extensive acute inflammation. Resection of the lesion by ESD was planned. After the lesion and its borders were carefully evaluated, the entire circumference of the lesion was marked with the Dual Knife (Olympus, Tokyo, Japan). A submucosal cushion was created using ORISE gel (Boston Scientific) expanding the submucosa and lifting the lesion away from the muscularis propria layer. The Dual Knife was then used to perform incision at the oral aspect of the lesion. Following this, the submucosa was partially dissected using swift coagulation. The submucosa was then further injected with ORISE gel to expand the submucosal space. Further dissection was performed until the lesion was completely separated from the surrounding gastric mucosa. The lesion was removed en bloc from the patient via Roth net. The resected mass measured 5 × 8 cm. Final histopathology revealed Epstein-Barr virus (EBV)-associated gastric adenocarcinoma with lymphoid stroma with negative margins. Metastatic workup was negative, and the tumor was staged as stage 1. No complications were reported. The patient was referred to the Medical and Surgical Oncology clinic and underwent subtotal gastrectomy and lymphadenectomy despite negative margins and against GI recommendation. Notably, all of the surgically resected tissue was negative for malignancy. DISCUSSION: ESD is an effective minimally invasive treatment for premalignant and early stage gastric cancer.

Endoscopic treatment of Zenker's diverticulum by complete septotomy: initial experience in 19 patients.

Background and study aims Endoscopic treatment of Zenker’s Diverticulum (ZD) using a flexible endoscope and a diverticuloscope consists of myotomy of the cricopharyngeus muscle, sparing the lower part of the diverticular septum. However, recurrence occurs in up to 54 % of patients at 4 years. We assessed the feasibility and safety of a complete septotomy in endoscopic treatment of ZD. Patients and methods We conducted a retrospective analysis of a prospectively collected database at a single referral center. All consecutive patients treated by complete resection of the diverticular wall were included. The endoscopic technique used a distal attachment cap and division of the ZD septum using a Dual Knife or a Triangle Tip knife in endocut mode, until the esophageal muscularis propria was seen and no residual diverticulum remained. Symptoms were evaluated using the Augsburger questionnaire. Results Nineteen patients, 10 of whom were men with mean age 79 ± 12 years, were treated by complete septotomy for a symptomatic ZD with a median size of 2.5 cm (range 1–5 cm). The clinical success rate was 100 % and the complication rate was 10 % (one pneumonia and one atrial fibrillation). Median hospital stay was 2 days (range 1–3 days). On Day 1 esophagogram, no extraesophageal contrast leakage was seen, periesophageal CO 2 was still visible in two patients, and complete ZD regression was seen in 63 % of patients. The 6-month clinical success rate was 100 %, with two patients lost to follow-up, and a median symptom score of 0 (range 0–4). After a mean ± SD follow-up of 9 ± 5 months, the clinical success rate was 94 % (16/17). Conclusion Complete endoscopic septotomy is a feasible and safe therapeutic modality in patients with symptomatic ZD that does not require use of a diverticuloscope, and with good short-term efficacy. The complete regression of the diverticulum observed on Day 1 in 63 % of patients could be a marker of long-term clinical success.

Mo1689 DOUBLE SCOPE COLORECTAL ESD USING A GEL-BASED TAMIS ACCESS PLATFORM

Endoscopic submucosal dissection (ESD) is a promising endoscopic procedure that is increasingly being used for endoscopic resection of large colorectal lesions that may be difficult to remove en-bloc by snare polypectomy. The greatest challenge for ESD remains technical difficulty in achieving optimal traction. In the following study, we evaluate the use of Gel-based Transanal Access Platform, typically used for Transanal Minimally Invasive Surgery (TAMIS) to facilitate ESD of colorectal lesions by facilitating use of two separate endoscopes simultaneously. Patients undergoing colorectal ESD were consented for use of this device during their procedure. If difficulty with traction occurred during the submucosal dissection portion of the procedure, the device was employed as follows: A 4x4 cm Gel based-TAMIS access device was inserted into the anal canal. Two access holes were made in the gel cover 2cm apart with the pre-supplied trocars to allow for the passage of a 1T therapeutic gastroscope and an ultraslim gastroscope. After submucosal injection and circumferential incision, the pediatric forceps were passed through the working channel of the ultraslim scope, and the edge of the lesion was grasped and then manipulated to allow for dynamic traction of the lesion. Outcomes measured included procedure time, traction assessment, interference between two scopes and adverse events including anal discomfort and post procedure incontinence. Over the study period 5 subjects have required the TAMIS device to assist with traction. All cases have been performed by a single endoscopist. The average procedure time with use of the device over 5 cases was 19mins per 1cm of lesion. Traction was felt to be excellent in all cases. There was minimal to no interference with the second scope. All cases resulted in en-bloc and R0 resections. 1 case was a T2 cancer with R0 resection. 1 case was intramucosal cancer. 3 cases were tubulovillous adenoma with high grade dysplasia. There were no complications in all 5 cases. Zero patients complained of anorectal pain after the procedure or experienced incontinence. By using a commercially available Transanal Access Platform for the first time in an endoscopic procedure, there was greater ease performing ESD. This device allowed the insertion of an additional scope which provided more traction and assisted in resecting each lesion without any reported friction between the two scopes. The set-up of this device is simple and this device appears suitable not only for laparoscopic surgical procedures but also for endoscopic interventions. This is a lower cost option for ESD traction than other proprietary traction devices on the market. Further studies are underway to determine the technical success, easy of use, and safety of this dual scope with TAMIS platform technique for colorectal ESD.Second scope with Traction assisting with Dual Knife DissectionView Large Image Figure ViewerDownload Hi-res image Download (PPT)

1696 Is It Technically Feasible to Use Duodenoscopy in Endoscopic Submucosal Dissection for the Recurrent Laterally Spreading Ampullary Adenomas?

INTRODUCTION: The management strategies of recurrent ampullary adenomas after endoscopic papillectomy is still a controversial issue regarding the best modality for treatment. The aim of the study is to assess the feasibility, efficacy and safety of duodenoscopic submucosal dissection (DESD) for the recurrent laterally spreading ampullary duodenal lesion. CASE DESCRIPTION/METHODS: We prospectively enrolled two patients with recurrent laterally spreading ampullary duodenal adenomas after successful papillectomy. Following marking the resection borders of the lesion using a Dual knife, a submucosal cushion is created by injecting a mixture of saline solution, methylene blue and adrenaline. A circumferential incision followed by submucosal dissection was performed using Dual knife and IT knife, then the lesion was resected using an electric snare. Hemostasis was applied using coagulation grasper during the procedure. Following dissection ERCP with biliary and pancreatic stenting was performed. Finally closure of the resection site was achieved using Endo-clipping in order to prevent complications such as secondary hemorrhage and delayed perforation. DESD followed by biliary and pancreatic stenting was performed successfully for two patients with recurrent laterally spreading ampullary duodenal adenomas. Table 1 shows the procedure details for the initial papillectomy which showed En-bloc resection of both lesions. Table 2 shows detailed current characteristics and procedure details for the recurrent lesions. Figures 1 and 2 Show endoscopic procedures. The average total procedure time was 95.5 mins, and the procedure time of DESD and ERCP was 38.5 mins and 15.5 mins respectively with no serious intra-or post procedure complication. The histopathological examinations revealed tubulovillous adenoma with negative resection margins in case 1. Unfortunately specimen of case 2 was not retrieved successfully. Follow up at the third, sixth and twelfth month showed no residual or recurrent lesions in ampullary areas, biopsy of resection site showed inflammation with absence of adenomatous tissues in both cases. DISCUSSION: In conclusion, DESD is technically challenging, potentially effective and curative for laterally spreading duodenal ampullary adenomas within 2 cm in diameter. It should be performed cautiously in selected patients by experts with abundant experience in performing not only ESD but also ERCP. Watch the video: http://bit.ly/2Y4dE77.

A challenging case of gastric endoscopic submucosal dissection: removal of a sizable cancer through altering patient's position and multiple clip-line traction.

A challenging case of gastric endoscopic submucosal dissection: removal of a sizable cancer through altering patient's position and multiple clip-line traction.

Endoscopic submucosal dissection for colorectal laterally spreading tumors with the Dual knife only.

IntroductionThe knives for endoscopic submucosal dissection (ESD) have their strengths as well as shortcomings. They need to be used in combination in most cases. The Dual knife is a relatively novel type of ESD knife produced in 2009, which can be used for completing the whole procedure of ESD.AimColorectal laterally spreading tumors (LSTs) are a special subtype of colorectal neoplasms. We aimed to evaluate the clinical features and outcomes of ESD for colorectal LSTs only using the Dual knife from our experience.Material and methodsThis retrospective study included 162 patients (each patient had 1 lesion) with colorectal LSTs treated by ESD with the Dual knife by a single endoscopist at our hospital between June 2015 and January 2018. We analyzed the clinical features and outcomes after resection.ResultsWe obtained the en bloc ESD of the colorectal LSTs and the complete histological assessment in all patients. The mean age of the patients was 53.9 years. The mean diameter of lesions was 46 mm. The most common location of LSTs was the rectum. The most common histological type was tubular adenoma with 63 cases. The mean operating time was 56 min. Perforation and bleeding rates were 0.6% and 0.6%, respectively. No cases of local persistence or recurrence were observed at a follow-up endoscopy 6 to 31 months after the en bloc resection.ConclusionsThe ESD using the Dual knife only for colorectal LSTs has the advantages of safety, efficiency, and minimally invasiveness. It is worthy of widespread clinical application.

Flexible endoscopic treatment for Zenker's diverticulum - experience on 31 patients.

The aim of this study is to present the experience of our center over the last 8 years in a series of patients with Zenker's diverticulum (ZD), treated using an endoscopic, minimally invasive procedure. We retrospectively included 31 patients with a previously established diagnosis of ZD based on endoscopic and oral contrast examinations. Patients' age, comorbidities, size of the diverticulum or previous endoscopic treatment were not considered exclusion criteria. A soft, flexible diverticuloscope to expose the septum and a dual knife for "cutting" the diverticular septum were used. We analyzed the short term efficacy based on symptomatic relief and occurrence of side effects, and long term efficiency at 6 and 12 months by clinical assessment, upper gastrointestinal endoscopy and oral contrast media passage. Patients had a mean age of 67 years (range 42-86); 55% of them were male. All patients reported symptom relief after the procedure. A decrease of more than 70% from the initial size of the diverticulum was noted. There were 3 cases (9.67%) of intraprocedural hemorrhage, endoscopically managed. No serious post-procedural complications and no mortality were reported. The mean procedural time was 21.87 minutes (range 15-25 minutes). Average hospitalization was 2.5 days. Five patients developed recurrence and needed a second session of endoscopic treatment for achieving complete myotomy. Endoscopic management for ZD was efficient and safe in our series of patients. A short hospitalization period was required.

Endoscopic Submucosal Dissection Using a Novel Dissecting Distal Attachment: An Ex vivo Feasibility Study

There is need for device innovation to make endoscopic submucosal dissection (ESD) easier and safer to perform. The edge of the distal attachment, already used in ESD, is in the correct plane for submucosal dissection. Placing an electrosurgical blade on the inner surface of the distal attachment may have the following advantages 1. Easier submucosal dissection 2. Reduced risk of perforation as the distal attachment would be a protective barrier between the electrosurgical blade and the muscularis propria layer. 3. The accessory channel would be freed for other uses. To present and assess the feasibility of a dissecting distal attachment, we performed ESD procedure with our prototype device in a porcine model. A distal attachment was made from a heat resistant transparent glass. A custom electrosurgical blade, 6mm wide, was attached to the inner surface of the distal attachment. The electrosurgical blade connects to the electrosurgical generator by a cord that runs on the outside of the endoscope. The following equipment was available; ERBE VIO 300D (ERBE, Tuebingen, Germany) electrosurgical generator, Dual knife (Olympus KD-650U, Tokyo Japan). Procedure was performed on ex vivo porcine model harvested from 6-9 month old Sus scrofa domestic pig. Presented video is from an ESD performed on 3cm demarcated area in the stomach (Video 1). A dual knife was used for mucosal incision to access the submucosal layer. Time (median and interquartile range), en-bloc resection rate, and perforation rates were recorded. A total of 20 ESD procedures (10 esophageal, 10 gastric) were performed by one endoscopist (AB). The median time of procedure for esophageal and gastric ESD were 28 min (24 - 32) and 29 min (28 - 35), respectively. En-bloc resection without perforation was obtained in all procedures. Within a porcine model a dissecting distal attachment allows for easy, safe, and efficient esophageal and gastric ESD. Further development of this technology is warranted. Watch the video: https://goo.gl/bD4uVY

Prospective, Randomized Comparison of 3 Endoscopic Submucosal Dissection (ESD) Knives in an Acute Porcine Model

Introduction: Endoscopic submucosal dissection (ESD) is a well-established treatment for gastric cancer limited to the mucosa. ESD allows en bloc resection of lesions >10mm with increased complete resection rate and low recurrence rate compared to endoscopic mucosal resection. Few studies have compared the efficacy and safety of ESD knives. We present a prospective, randomized study comparing three mechanistically different ESD knives in the porcine model. Methods: In this prospective, randomized study, three different ESD knives were compared: Dual (KD-650L, Olympus), IT2 (KD-611L, Olympus) and Hybrid T-type (20150-060, ERBE). Twelve Yorkshire pigs weighing 33-50 kg underwent two esophageal and four gastric mucosal resections. A computergenerated randomization sheet was used to assign the type of knife for each resection site. The primary end point was total operative time (OT). Secondary outcomes were effects of lesion location and learning curve on OT, significant hemorrhage requiring the use of coag-grasper, macroscopic perforation, and injuries and depth of injuries as assessed histologically by a pathologist blind to the type of knife used. Results: HKT (average OT 27 minutes) was faster than Dual knife (average OT 27 minutes, 36 minutes, p < 0.05). HKT was faster than IT2 knife, but the difference was statistically insignificant. There were no statistically significant differences in hemorrhage, thermal injury to mucosa, injuries to muscularis propria, and mean size of resection specimen among the knives. No macroscopic perforations were present.Mean OT for gastric ESD was shorter than that for esophageal ESD (24 min, 41 min, p= < 0.01) and mean OT for proximal gastric lesions was shorter than that for distal ones(20 vs 29 min, p < 0.02). Conclusion: All three knives displayed equal efficacy in tissue removal as they all achieved complete resection of target mucosa. It appears that HKT is marginally faster than Dual and IT2 knives, which may be partially due to its ability to perform injections without change of accessories. Our study indicates that location of the lesion had a more significant effect on the OT than the type of knife used. For proximal gastric resection, the OT decreased significantly after the first seven ESDs. This was found to be true for all three knives. Our results confirm prior studies indicating that while there is a learning curve, the slope of the curve is not steep, possibly due to the operator's significant experience with the procedure.Table: Table. Mean Operating TimeFigure: Resection crater being assessed for perforations and bleeding.Figure: Learning effect demonstrated by decrease in operating time after first 7 ESDs.