Endoscopic Submucosal Dissection Knife Research Articles

Usefulness of an ultrathin endoscope in esophageal endoscopic submucosal dissection.

Background and study aims Endoscopic submucosal dissection (ESD) is sometimes challenging because of stenosis and scarring. We examined the use of an ultrathin endoscope for esophageal ESD, which is difficult using conventional endoscopes. Patients and methods A designated transparent hood and ESD knife for ultrathin endoscopes have been developed and clinically introduced. Esophageal ESD was performed on 303 lesions in 220 patients in our hospital from February 2021 to February 2023. Of them, an ultrathin endoscope was used on 26 lesions in 23 cases. The safety and utility of an ultrathin endoscope in esophageal ESD were retrospectively verified. Results All 26 lesions were resected en bloc, and serious complications such as perforation, massive bleeding, or pneumonia, were not observed. Lesions were found on the anal side of the stenosis and over the scarring in 38.6% (10/26) and 50% (13/26) of participants, respectively. Moreover, 46.2% of participants (12/26) had lesions on the cervical esophagus. The total procedure time was 64.1 ± 37.7 minutes, but the average time from oral incision to pocket creation was 121.2 ± 109.9 seconds. Conclusions Ultrathin endoscopes may be useful for difficult esophageal ESD.

A multicenter, retrospective study of a through-the-needle injection–capable electrosurgical knife for endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is a technically challenging resection technique for en bloc removal of dysplastic and early cancerous GI lesions. We conducted a single-arm retrospective study evaluating the safety and efficacy of a new through-the-needle injection-capable electrosurgical knife used in upper and lower ESD procedures performed at 6 U.S. academic centers. Data were retrospectively collected on consecutive cases in which the new ESD knife was used. The primary efficacy endpoint was successful ESD (en bloc resection with negative margins). Secondary efficacy endpoints included en bloc resection rate, curative resection rate, median ESD time, and median dissection speed. The safety endpoint was device- or procedure-related serious adverse events. ESD procedures of 581 lesions in 579 patients were reviewed, including 187 (32.2%) upper GI and 394 (67.8%) lower GI lesions. Prior treatment was reported in 283 (48.9%) patients. Successful ESD was achieved in 477 (82.1% of 581) lesions-lower for patients with versus without submucosal fibrosis (73.6% vs 87.0%, respectively; P< .001) but similar for those with versus without previous treatment (81.7% vs 82.3%, respectively; P= .848). A total of 443 (76.2% of 581) lesions met criteria for curative resection. Median ESD time was 1.0 (range, 0.1-4.5) hour. Median dissection speed was 17.1 (interquartile range, 5.3-29.8) cm2/h. Related serious adverse events were reported in 15 (2.6%) patients, including delayed hemorrhage (1.9%), perforation (0.5%), or postpolypectomy syndrome (0.2%). A newly developed through-the-needle injection-capable ESD knife showed a good success rate and excellent safety at U.S. (Clinical trial registration number: NCT04580940.).

Comparison of scissor-type knife to non-scissor-type knife for endoscopic submucosal dissection: a systematic review and meta-analysis.

Scissor-type endoscopic submucosal dissection (ST-ESD) knives can reduce the adverse events associated with ESDs. This study aimed to compare ST-ESD and non-scissor-type (NST)-ESD knives. We identified ten studies that compared the performance characteristics and safety profiles of ST-ESD and NST-ESD knives. Fixed- and random-effects models were used to calculate the pooled proportions. Heterogeneity was assessed using the I2 test. On comparing ST-ESD knives to NST-ESD knives, the weighted odds of en bloc resection was 1.61 (95% confidence interval [CI], 0.90-2.90; p=0.14), R0 resection was 1.10 (95% CI, 0.71-1.71; p=0.73), delayed bleeding was 0.40 (95% CI, 0.17-0.90; p=0.03), perforation was 0.35 (95% CI, 0.18-0.70; p<0.01) and ESD self-completion by non-experts was 1.89 (95% CI, 1.20-2.95; p<0.01). There was no heterogeneity, with an I2 score of 0% (95% CI, 0%-54.40%). The findings of reduced odds of perforation, a trend toward reduced delayed bleeding, and an improvement in the rates of en bloc and R0 resection with ST-ESD knives compared to NST-ESD knives support the use of ST-ESD knives when non-experts perform ESDs or as an adjunct tool for challenging ESD procedures.

Colorectal Endoscopic Submucosal Dissection: Performance of a Novel Hybrid-Technology Knife in an Animal Trial.

Endoscopic submucosal dissection (ESD) was developed for the removal of benign and early malignant lesions in the gastrointestinal tract. We aimed to evaluate the performance and safety of a novel high-pressure waterjet-assisted ESD knife in colorectal applications. Six female German Landrace pigs with an average weight of 62 kg (range 60-65 kg) were used in this prospective, randomized, and controlled study. Twenty-four ESDs were performed by three endoscopists: Twelve each with the new Erbe HYBRIDknife® flex T-Type (HK-T) and the Olympus DualKnife® J (DK-J), including six rectal and six colonic ESDs per instrument. The order of performance was randomized regarding anatomic position and instrument. As the primary endpoint, ESD knife performance characteristics were combined and rated on a 5-point Likert scale, with 5 Likert points (LP) representing the best response (5 = very good). The HK-T was rated significantly better than the DK-J (4.7 LP versus 4.4 LP, p = 0.0295), mainly because of HK-T injection ability (5 LP versus 3 LP, p < 0.0001) and hemostasis (5 LP versus 4 LP, p = 0.0452). There was no difference in procedure time (HK-T: 35 min versus DK-J: 34 min, p = 0.8005), resection diameter (3.1 cm versus 2.8 cm, p = 0.3492), injection volume (41 mL versus 46 mL, p = 0.5633), and complication rates. HK-T is as effective as DK-J in colorectal ESD in terms of dissection quality but has better injection and hemostatic properties. The impact of these technical advantages on the ESD treatment of patients with large superficial colorectal lesions remains to be clinically verified.

Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife

Video 1Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife. A 61-year-old man with a 3-decade history of recurrent cholecystitis presented to the community emergency department with severe right upper quadrant pain. A CT scan was performed and revealed gangrenous cholecystitis with likely cholecystoduodenal fistulous communication.After discussion with the patient and the HPB team, the plan was made to attempt endoscopic extraction of the obstructing stone. This would be performed in the operating room, such that if endoscopic extraction was not possible, surgical management would proceed.During the endoscopy, 1 L of liquid material was suctioned and the retained solids were cleared as best as possible. The large obstructing stone was then seen in the duodenal cap. In the cap, we could appreciate the obstructing stone and the fistulous tract.We then passed a guidewire distal to the stone and advanced a 15- to 20-mm extraction balloon over the guidewire. The balloon was passed distal to the stone and inflated to 20mm. We then applied firm, steady traction in an attempt to extract the stone.With the double-channel gastroscope, we passed a second wire and extraction balloon distal to the stone to increase the amount of traction that could be applied. Both balloons were inflated distal to the stone, and steady, firm traction was again applied. Unfortunately, this was not successful either.We then decided to use a regular ERCP needle knife to incise the stone. Because the knife was delicate, it was easily deformable, so we decided to switch to a triangle-tip knife.Using the "PreciseSECT" mode on the electrosurgical unit, the stone was repeatedly incised. Particular care was taken to avoid flinging the knife and damaging the duodenal wall.Saline was used as the irrigation solution to ensure electrosurgical conductivity when the current was applied.At this point, we could appreciate fragmentation of the stones after repeated incision.After about 3 hours of stone incision and fragmentation, the guidewire was passed beyond the stone; the extraction balloon was advanced over the wire; and the balloon was again inflated with steady traction applied. This time, the stone was successfully extracted from the stomach.The duodenum was then examined. There were no remaining large pieces of stone or any significant mucosal damage or perforation.Using a mechanical lithotripter, the remaining larger fragments of stone were fragmented and extracted. However, because the stone had a large diameter, lithotripsy at the center was not initially possible, and the smaller lateral aspects had to be performed until the stone was completely fragmented.This case demonstrates the incision and fragmentation of a massive gallstone with the use of an endoscopic submucosal dissection knife and electrosurgical unit.With cautious application of this technique, successful endoscopic management of a large gallstone causing Bouveret syndrome was achieved. This technique avoided open surgical management and allowed for elective cholecystectomy at a later date with less morbidity.

Tunneling-free peroral endoscopic septotomy for Zenker diverticulum.

Video 1Tunneling-free peroral endoscopic Zenker myotomy.

Efficacy of scissor-type knife for endoscopic submucosal dissection: a systematic review and meta-analysis.

Endoscopic submucosal dissection (ESD) is an effective resection technique for early cancers and large gastrointestinal luminal lesions. However, ESD is technically challenging, with the potential for severe adverse events. Scissor-type ESD (ST-ESD) knives with an inner cutting edge and an electrically insulated external coating could mitigate some of these risks. This study aimed to evaluate the performance of ST electrosurgical knives when used for ESDs. Electronic databases were queried for studies from January 2005 through December 2022 evaluating the performance of ST-ESD knives. Fixed- and random-effects models were used to calculate pooled proportions. Heterogeneity was assessed using the I2 test and by constructing funnel plots, while bias was calculated using Egger and Harbord bias indicators. Final analysis included data from 17 studies comprising 1652 ESD procedures. The pooled en bloc resection rate and R0 resection rate were 97.94% (95% confidence interval [CI] 97.20-98.57) and 94.32% (95%CI 93.11-95.43), respectively. The main adverse events were perforation and delayed post-procedural bleeding, with pooled rates of 1.07% (95%CI 0.63-1.62) and 1.86% (95%CI 1.26-2.56), respectively. There was no heterogeneity, as indicated by an I2 score of 0% (95%CI 0-44.50%). The mean procedure time was 67.45 min (95%CI 58.01-76.89). Our analysis shows that ST-ESD knives deliver consistently good performance across various locations in the gastrointestinal lumen and lesion sizes, with a good safety profile. This could be particularly appealing to newer adopters of ESD.

Efficacy and Safety of ClearCut™ Knife H-type in Endoscopic Submucosal Dissection for Gastric Neoplasms: A Multicenter, Randomized Trial.

Endoscopic submucosal dissection (ESD) is an effective treatment for early gastrointestinal neoplasms. However, this is a time-consuming procedure requiring various devices. This study aimed to evaluate the efficacy and safety of the ClearCut™ Knife H-type, which is an integrated needle-tipped and insulated-tipped (IT) knife. Between July 2020 and September 2021, 99 patients with gastric epithelial neoplasms scheduled for ESD at three tertiary care hospitals were randomly assigned to H-knife (ClearCut™ Knife H-type) or IT-knife (conventional IT knife) groups. Procedure times, therapeutic outcomes, and adverse events were analyzed. A total of 98 patients (50 in the H-knife group and 48 in the IT-knife group) were analyzed. The median total procedure time was 11.9 minutes (range, 4.4-47.2 minutes) in the H-knife group and 12.7 minutes (range, 5.2-137.7 minutes) in the IT-knife group (P=0.209). Unlike the IT-knife group, which required additional devices in all cases, no additional devices were used in the H-knife group (P<0.001). En-bloc resection was performed for all lesions in both groups. The incidence of adverse events was not significantly different between groups (4.0% in the H-knife group vs. 8.3% in the IT-knife group; P=0.431). The newly developed hybrid device, the ClearCut™ Knife H-type, had comparable efficacy to the conventional IT knife for gastric ESD. Clinical Research Information Service Identifier: KCT0005164.

Possibility of ultrathin endoscopy in radial incision and cutting for esophageal strictures.

Video 1The radial incision and cutting procedure using ultrathin endoscopy.

Efficacy and safety of one-step knife compared to conventional insulated-tip knife for endoscopic submucosal dissection: a preliminary study with prospective data collection and retrospective review.

Endoscopic submucosal dissection (ESD) is not as tiresome as gastrectomy, but it is a time-consuming procedure. One-step knife (OSK) is a novel knife that combines a knife for ESD and an injection needle into one sheath. In this study, we aimed to compare the insulated tip type of OSK and conventional knife (CK) in terms of procedure time and complication rate. Medical records of patients with ESD using CK between February and September 2020 were retrospectively reviewed. Subsequently, data from patients who underwent ESD using OSK by September 2021 were prospectively collected. Total procedure time, procedure time by location and complication rate in the OSK and CK group were compared. In the study period, a total of 203 patients (OSK, 102 patients; CK, 101 patients) were analyzed. On multivariate analysis, using CK, body location, resection size ≥ 40mm, and submucosal fibrosis were associated with longer procedure time. The total procedure time was statistically significantly reduced in the OSK group (median 11 vs. 17min, p < 0.01). The procedure time for each location was more reduced in the body (median 14 vs. 19min p < 0.01) than the antrum (median 10 vs. 14min, p = 0.01) in the OSK group. There was no significant difference in post-ESD bleeding and perforation in the two groups (3.9 vs. 3.9%, p = 0.99 and 1.0 vs. 2.0%, p = 0.56). OSK significantly reduced the total procedure time of ESD. OSK could be an effective and safe knife for gastric ESD, especially for body lesions.

Knives in Third Space

AbstractEndoscopic mucosal resection (EMR) has always been done with a snare. The maximum diameter of the snare is usually 2 cm and the largest lesion that can be removed in one piece is usually maximum of 2 cm. In EMR, after the elevation of the submucosa, snares are used for the resection of the mucosal lesion; however, for endoscopic submucosal dissection (ESD), special knives are required, which have various uses in different areas of the gastrointestinal tract. ESD knives have developed and evolved over the past 30 years allowing it to be performed safely. It allows very precise cutting of the mucosa as well as dissection of the submucosal tissue planes. This review discusses some of the more commonly used knives.

The Efficacy of a Novel Type of Integrated Knife for Endoscopic Submucosal Dissection in Early Gastric Cancer

Background/Aims: This study aimed to compare the efficacy of a recently developed clear-cut knife with that of widely used knives for endoscopic submucosal dissection (ESD) in early gastric cancer (EGC).Materials and Methods: Data were collected retrospectively from the National Health Insurance Service Ilsan Hospital between May 2017 and April 2019. The study included 105 patients (108 lesions) with EGC who underwent ESD. Fifty-six EGCs were dissected using an insulation-tipped diathermic knife in combination with a needle knife, while 52 EGCs were dissected using a clear-cut knife, a single device with an integrated needle and an insulated-tipped knife. Oncologic outcomes and technical success were compared between the two groups.Results: The distribution of the tumor locations, composition of the undifferentiated types of EGCs, and the size of EGCs (14.3±8.0 vs. 16.6±7.3 mm; P=0.130) were not significantly different between the groups. The complete (98.2% vs. 94.2%; P=0.273) and curative (87.5% vs. 88.5%; P=0.878) resection rates were not statistically different. Furthermore, no significant difference between the total procedure times (39±34.1 vs. 35.7±20.1 minutes; P=0.554), areas of the dissected specimen (858.6±406.5 vs. 980.3±393.8 mm2; P=0.119) and dissected areas per minute (32.4±17.9 vs. 35.5±16.2 mm2/min; P=0.345) were noted. Regarding complications, the overall perforation rates (3.6% vs. 4.0%) and bleeding rates (3.6% vs. 8.0%) were not statistically different.Conclusions: The newly developed clear-cut knife is as useful as the combination of classical knives for ESD in EGC.

A Novel Knife for Endoscopic Submucosal Dissection in Early Gastric Cancer

See the article "The Efficacy of a Novel Type of Integrated Knife for Endoscopic Submucosal Dissection in Early Gastric Cancer" on page 50.

SB Knife Jr: characteristics and tips on how to use

Widespread adoption of colorectal endoscopic submucosal dissection (ESD) in clinical practice is lagging despite the peer evidence that it permits en bloc resection of large lesions that can be curative and facilitate pathological staging, thereby improving management. Limited adoption of colorectal ESD is likely due to technical challenges and a steep learning curve. Most conventional ESD devices are used without fixing the target, making them difficult to maneuver and thus creating a potential risk of perforation. Comparatively, a scissor-type knife, such as the SB Knife Jr, enables grasping of the target tissue, facilitating controlled dissection of tissue being held between the blades. This potentially prevents unexpected muscular layer injury. Colorectal ESD with the SB Knife Jr does not require complex endoscopic maneuvering or advanced skills for safe ESD. Since the incision and dissection procedure using the SB Knife Jr is different from that of conventional ESD knives, familiarization with its features is vital. In this review, we focus on the use of the SB Knife Jr for colorectal ESD. The basic colorectal ESD procedure using the SB Knife Jr consists of grasping, pulling, and cutting. By repeating these steps, circumferential incision, submucosal dissection, and hemostasis can be performed with a single device. For incision and dissection, a circumferential mucosal incision is performed similar to “cutting paper”. Submucosal dissection is performed with the image of “connecting the dots at the appropriate dissection depth”. The SB Knife Jr is useful as a secondary device in challenging ESD procedures, and surgeons should master its use.

A Steep Early Learning Curve for Endoscopic Submucosal Dissection in the Live Porcine Model

Background: Endoscopic submucosal dissection (ESD) is a demanding procedure requiring high level of expertise. ESD training programs incorporate procedures with live animal models. This study aimed to assess the early learning curve for performing ESD on live porcine models by endoscopists without any or with limited previous ESD experience. Methods: In a live porcine model ESD workshop, number of resections, completeness of the resections, en bloc resections, adverse events, tutor intervention, type of knife, ESD time and size of resected specimens were recorded. ESD speed was calculated. Results: A total of 70 procedures were carried out by 17 trainees. The percentage of complete resections, en bloc resections and ESD speed increased from the first to the latest procedures (88.2%–100%, 76.5%–100%, 8.6–31.4 mm²/min, respectively). The number of procedures in which a trainee needed tutor intervention and the number of adverse events also decreased throughout the procedures (4 to 0 and 6 to 0, respectively). During the workshop, when participants changed to a different type of knife, ESD speed slightly decreased (18.5 mm²/min to 17.0 mm²/min) and adverse events increased again (0–2). Conclusions: Through successive procedures, complete resections, en bloc resections, and ESD speed improve whereas adverse events decrease, supporting the role of the live porcine model in the preclinical learning phase. Changing ESD knives has a momentarily negative impact on the learning curve.

How to Perform a High-Quality Endoscopic Submucosal Dissection

How to Perform a High-Quality Endoscopic Submucosal Dissection

Endoscopic submucosal dissection using scissors-type knife for a giant solitary duodenal polyp.

Video 1.

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.

Intraluminal gas escape from biopsy valves and endoscopic devices during endoscopy: caution advised during the COVID-19 era.

Background and study aims The risk of aerosolization of body fluids during endoscopic procedures should be evaluated during the COVID-19 era, as this may contribute to serious disease transmission. Here, we aimed to investigate if use of endoscopic tools during flexible endoscopy may permit gas leakage from the scope or tools. Material and methods Using a fresh 35-cm porcine rectal segment, a colonoscope tip, and manometer were placed intraluminally at opposite ends of the segment. The colonoscope handle, including the biopsy valve, was submerged in a water bath. Sequentially, various endoscopic devices (forceps, clips, snares, endoscopic submucosal dissection (ESD) knives) were inserted into the biopsy valve, simultaneously submerging the device handle in a water bath. The bowel was slowly inflated up to 74.7 mmHg (40 inH 2 O) and presence of gas leakage, leak pressure, and gas leakage volume were measured. Results Gas leakage was observed from the biopsy valve upon insertion and removal of all endoscopic device tips with jaws, even at 0 mmHg (60/60 trials). The insertion angle of the tool affected extent of gas leakage. In addition, gas leakage was observed from the device handles (8 of 10 devices) with continuous gas leakage at low pressures, especially two snares at 0 mmHg, and an injectable ESD knife at 0.7 ± 0.8 mmHg). Conclusions Gas leakage from the biopsy valve and device handles commonly occur during endoscopic procedures. We recommend protective measures be considered during use of any tools during endoscopy.

Novel temperature-responsive, biodegradable and injectable collagen sol for the endoscopic closure of colonic perforation holes: Animal study (with videos).

Endoscopic submucosal dissection (ESD) poses a risk of intraprocedural perforation. We have developed a biodegradable injectable collagen sol that undergoes a liquid-to-gel formation in response to body temperature. Here, we investigated the feasibility of this novel collagen sol for the endoscopic closure of iatrogenic perforation holes. In two experiments, 12 and 5 colonic perforation holes (3-5mm) were made using an ESD knife in four and three live pigs under general anesthesia, respectively. In Experiment 1, collagen sol was delivered to the perforation holes using an endoscopic catheter. When the colon was expanded by CO2 insufflation, endo-clips were applied to the perforation holes. For Experiment 2, Collagen sol adjusted based on the Experiment 1 results was delivered to the perforation holes in the same manner. A leak test was performed for every colon after the pigs were killed, and the histology of the perforation sites was evaluated. In both experiments, collagen sol was smoothly delivered to the target area and fixed as a gel on the perforation holes. Experiment 1, 83% (10/12) of the perforation holes were completely closed, and all endo-clips were placed with composure. Experiment 2, all perforation holes were completely closed with collagen gel. There was no leak from the perforation holes. Histology revealed a fixation of the collagen gel as an embolus agent in the perforation holes. This novel collagen sol may be used for the endoscopic closure of intraprocedural perforation. Further studies will determine this collagen sol's clinical feasibility and safety.