Hook Knife Research Articles

Tenoscopic‐assisted subcutaneous approach to a plantar annular ligament desmotomy in a horse with severe constriction of the fetlock canal

SummaryThe desmotomy of the palmar/plantar annular ligament (PAL) is recommended when it hinders the sliding motion of the flexor tendons in the sesamoidean canal, leading to persistent lameness that often does not improve with conservative treatment. Tenoscopic‐assisted PAL desmotomy can be accomplished with various instruments via an intrathecal approach. However, severe constriction or adhesions within the fetlock canal can restrict manoeuvrability and access of instruments within the sheath, preventing safe and effective transection of the ligament. This case report describes the successful use of a hook knife via a subcutaneous approach to safely transect the PAL under tenoscopic visualisation in a horse where severe constriction of the fetlock canal prohibited the standard intrathecal approach. In similar chronic tenosynovitis cases, a subcutaneous approach to PAL transection at the start of the tenoscopic examination of the digital flexor tendon sheath may minimise iatrogenic injury to intrathecal structures.

Sonographically controlled minimally-invasive A1 pulley release using a new guide instrument – a case series of 106 procedures in 64 patients

BackgroundWith percutaneous and minimally-invasive pulley release becoming more popular, safety and reliability of such minimally-invasive procedures remain a concern. Visualization of the technical steps by ultrasound suggests increased safety but shows the potential for harm to tendons, nerves and vessels without proper instrumentation. We present the results of implementing a sonographically guided minimally-invasive procedure in 106 trigger digits of 64 patients between 2018–2021.MethodsA guide instrument for use with a commercially available hook knife was developed and tested in 16 cadaver hands. Due to complication early in our clinical series this guide was modified in due course. A revised design of the guide has been in use since November 2019 with improved performance and safety.ResultsOne hundred six procedures in 64 patients were performed. After guide revision, we report a success rate of 97.3%. Complications after instrument revision include two cases of incomplete pulley release and one case of inadvertent skin laceration. The majority of patients report returning to all strenuous activities within two weeks at most apart from four individuals with prolonged postoperative discomfort.ConclusionWe present the results of the development and implementation of a novel guide instrument for use with a hook knife to treat trigger finger. Despite several limitations of this study, we show that sonographically controlled, minimally-invasive A1 pulley release can be performed safely and effectively with appropriate surgical instruments and practice.

Minimally Invasive Carpal Tunnel Release Using a Hook Knife through a Small Transverse Carpal Incision: Technique and Outcome.

Compared to the classic open technique, limited exposure techniques have the advantages of less scar pain, more grip and pinch strength, and earlier return to daily life. We evaluated the effectiveness and safety of our novel method of minimally invasive carpal tunnel release using a hook knife through a small transverse carpal incision. This study included 111 carpal tunnel decompressions in 78 patients who underwent carpal tunnel release from January 2017 to December 2018. We performed carpal tunnel release using a hook knife through a small transverse incision just proximal to the wrist crease under local infiltration of lidocaine with tourniquet inflation in the upper arm. All patients were tolerable during the procedure and discharged following the procedure on the same day. At an average of 29.4 months of follow-up (range, 12-51 months), all but one patient (99%) revealed complete or near complete symptomatic recovery. The average of the symptom severity score on the Boston questionnaire was 1.31 ± 0.30 and the average of the functional status score was 1.19 ± 0.26. The final mean Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) score was 8.66 (range, 2-39). There was no superficial palmar arch injury or nerve injury of the palmar cutaneous branch, recurrent motor branch, or median nerve itself as a complication of the procedure. No patient showed any wound infection or wound dehiscence. Our carpal tunnel release using a hook knife through a small transverse carpal incision performed by an experienced surgeon is a safe and reliable method that is expected to have the benefits of simplicity and minimal invasiveness.

Conventional versus hybrid knife endoscopic submucosal dissection in large colorectal laterally spreading tumors: A propensity score analysis.

Colorectal endoscopic submucosal dissection (CR-ESD) has become a promising treatment for laterally spreading tumors (LSTs), but is accompanied by great challenges. This study aimed to evaluate the efficacy and safety of CR-ESD with a hybrid knife, versus the conventional technique for LSTs ≥30 mm in diameter, and analyze the risk factors for piecemeal resection and perforation. Patients eligible for CR-ESD were divided into two groups according to the use of the hybrid knife (HK group) or the use of the conventional technique, with an interchange of injection and hook knife (C-group). We performed propensity score matching (PSM) to compare the HK group and the C-group. Risk predictors for perforation and piecemeal resection were identified. PSM identified 61 (132 patients) and 61 (129 patients) patients in the C-group and the HK group, respectively. Resection speed was significantly faster in the HK group than in the C-group (18.86 vs. 13.33 mm2/min, P < 0.001). The rate of knife exchange was significantly lower in the HK group than in the C-group (1.6% vs. 49.2%, P < 0.001). Multivariate analysis revealed that unfavorable locations, including the splenic flexure, hepatic flexure, or cecum, were predictive of piecemeal resection. The presence of severe fibrosis and a semilunar fold were independent risk factors for perforation. : The use of a hybrid knife appears to increase CR-ESD resection speed. The indicators for piecemeal resection or perforation in CR-ESD identified herein might help to assess the technical difficulties of CR-ESD.

Sensitivity and specificity of 3 Tesla magnetic resonance imaging and multidetector computed tomographic tenography to identify artificially induced soft tissue lesions in the equine cadaveric digital flexor tendon sheath

SummaryBackgroundA common cause of lameness in horses is tenovaginitis of the digital flexor tendon sheath (DFTS). Ultrasound and contrast tenography have become frequently used diagnostic tools for abnormalities in the DFTS, but are considered insufficiently accurate in describing specific lesions.ObjectivesTo determine the sensitivity and specificity of computed tomographic tenography (CTT) and 3 Tesla magnetic resonance imaging (MRI) to detect artificial lesions within the DFTS.Study designBlinded laboratory study.MethodsUsing an arthroscopic hook knife, lesions (10–20 mm long and 3–5 mm deep; n = 52) were created tenoscopically in the superficial digital flexor tendon (SDFT), deep digital flexor tendon (DDFT), manica flexoria (MF) and proximal scutum in 19 distal limb specimens. MRI and CTT were performed and images were reviewed. Sensitivity and specificity were calculated for each modality and compared.ResultsComputed tomographic tenography and MRI identification of SDFT and MF lesions showed similar sensitivity (75% vs. 85%, respectively; p = 1) and specificity for MF lesions (96% for both). SDFT lesions specificity was similar for CTT versus MRI (85% vs. 77%, respectively; p = 0.88). For DDFT lesions, MRI sensitivity (62%) was higher compared to CTT (38%), although not statistically significant (p = 0.58). MRI specificity (92%) was lower than CTT (96%, p = 1). Lesions in the proximal scutum were more frequently identified by MRI compared to CTT (sensitivity: 93% vs. 57%, p = 0.17; specificity: 96% vs. 100%, p = 1).Main limitationsArtificial, small lesions were assessed. An incomplete arthroscopic portal seal resulted in pressure loss and contrast leakage.ConclusionsThe sensitivity and specificity of both modalities are good to excellent for the diagnosis of most artificially created lesions. CTT performed similarly to MRI in detecting SDFT and MF lesions. MRI showed a higher sensitivity for the diagnosis of DDFT and proximal scutum lesions. The results indicate a future application of CTT for the diagnosis of DFTS pathologies, whenever suspecting MF tears.

Ultra-minimally Invasive Sonographically-guided Trigger Digit Release: An External Pilot Study.

ObjectivesThe most common surgical option for releasing the first annular pulley in trigger digit (TD) is classic open surgery followed by blind percutaneous release. However, they have been related to major complications and incomplete releases, respectively. Intrasheath sonographically-guided first annular pulley release has recently been shown to be safe and effective in every digit. The objectives of this pilot study were to preliminary compare clinically an intrasheath sonographically-guided first annular pulley release versus a classic open technique and to evaluate the feasibility of a future clinical trial in patients with TDs.MethodsThirty patients were randomized 1:1 in an external pilot study comparing the two surgical techniques: a percutaneous sonographically-guided release performed through a 1 mm incision using a hook knife versus a classic open surgery with a 1 cm incision. Inclusion criteria were primary TD grade III (Froimson). We defined success if primary (safety and efficacy) and secondary (recruitment rates, compliance, completion, treatment blinding, personnel resources, and sample size calculation for the clinical trial) objectives could be matched. We registered the grip strength, the QuickDASH score and a set of postoperative clinical variables at one, three, and six weeks and at three months. We calculated the sample size for the clinical trial using the QuickDASH at the end of the follow-up. Outcomes assessors were blinded.ResultsAll patients in both groups showed resolution of their symptoms with no associated complications or relapses. Secondary feasibility objectives were matched: 76.9% of eligible patients were included in the study, 3.3% refused randomization, 20 patients per month were recruited, 100% received blinded treatment, 98.5% showed compliance, and 100% completed the study. The sample size for a future clinical trial was 84 patients. There were no differences in grip strength. The intrasheath sonographically-guided first annular pulley release showed significantly better QuickDASH scores, until the sixth postoperative week.ConclusionsThe intrasheath sonographically-guided first annular pulley release is safe and efficacious, and shows a trend toward clinical superiority versus the classic open procedure, which should be confirmed with a clinical trial. Our study shows that a randomized clinical trial is feasible.

Clinical observation of arthroscopic single channel treatment of carpal tunnel syndrome with self-made instruments

To investigate the efficacy of self-made arthroscopic single channel in the treatment of carpal tunnel syndrome. Sixty patients with primary carpal tunnel syndrome treated from January 2014 to December 2019 were divided into arthroscopic group and traditional open operation group. There were 30 cases in arthroscopic group, including 12 males and 18 females, aged (47.5±4.5) years and the course of disease was (6.6±4.2) months. There were 30 cases in the traditional operation group, including 10 males and 20 females, aged (48.5±3.5) years, and the course of disease was (5.6±4.4) months. Both groups were unilateral. According to the anatomy of wrist joint and the characteristics of transverse carpal ligament and arthroscopy, the instruments including cannula, inner heart and hook knife were designed. The patients in two groups were treated with decompression of transverse carpal ligament using arthroscopy combined with self-made instruments and traditional open sergery. The incision length, operation time, intraoperative bleeding, hospitalization cost, hospitalization time and recovery time of the two groups were observed and compared. Boston Carpal Tunnel Questionnaire (BCTQ) score was used to evaluate the clinical efficacy of arthroscopy combined with self made instruments in the treatment of carpal tunnel syndrome. Compared with the traditional group, the arthroscopic group had significant advantages in incision length, operation time, intraoperative bleeding and hospital stay, but the total cost of hospitalization was increased. The Boston score was significantly higher in the arthroscopic group than that in the traditional group at 1 month after operation, but not at 3 and 6 months after operation. Arthroscopy combined with self-made instruments in the treatment of carpal tunnel syndrome is more reliable, minimally invasive and simplified than open surgery, but the patients should be clearly diagnosed and appropriately selected before operation to achieve satisfactory clinical effect.

The radiological approach to the carpal tunnel release – An anatomical pilot study

Different techniques are available for carpal tunnel release such as classical surgical operations or minimally invasive procedures. A minimally invasive approach and the relevant regional anatomy are reported in this pilot study which was conducted with bodies from a body donation program. The method described here uses a hook knife to cut through the transverse carpal ligament or flexor retinaculum under ultrasound guidance. The results are documented by means of magnetic resonance and ultrasound imaging as well as by anatomical dissection.

How to Perform a High-Quality Endoscopic Submucosal Dissection

How to Perform a High-Quality Endoscopic Submucosal Dissection

Endoscopic removal of entirely embedded esophagus-penetrating foreign bodies (with video).

Traditionally, surgery is the only choice for esophageal foreign bodies (FBs) penetrating into the mediastinum or cervical para-esophageal space. Recent progress in endoscopic techniques and devices has made it possible to perform endoscopic procedures in the mediastinum. Here, we describe a novel method to remove the entirely embedded esophagus-penetrating FBs through an endoscopic approach. Patients who underwent endoscopic removal of entirely embedded esophagus-penetrating FBs were prospectively enrolled between December 2018 and June 2020. All procedures were performed by using five major steps: localization of the FB; mucosal incision; wound debridement, myotomy, and FB exposure; FB extraction; and closure of the esophageal wound. A total of five cases of entirely embedded esophagus-penetrating FBs were evaluated, two in children and three in adults. All FBs were successfully removed and extracted using a therapeutic endoscope and a hook knife or a hybrid knife and a grasping forceps as accessories. The average procedure time was 19.0±12.4min (range 10-40min). The major surgical procedure was avoided in all patients. The average length of hospital stay was 3.8±2.5days (range 2-8days). There were no severe short-term adverse events after all procedures. During the 1month and 3months follow-up, no patient developed long-term adverse events including stenosis of the esophagus and fistula formation. Endoscopic approach was a safe and effective way to remove entirely embedded esophagus-penetrating FBs.

Practice patterns, techniques, and outcomes of flexible endoscopic myotomy for Zenker's diverticulum: a retrospective multicenter study.

Flexible endoscopic myotomy has been increasingly performed for Zenker's diverticulum using various endoscopic techniques and devices. The main aims of this study were to assess practice patterns and compare outcomes of endoscopic myotomy for Zenker's diverticulum. Procedures performed at 12 tertiary endoscopy centers from 1/2012 to 12/2018 were reviewed. Patients (≥ 18 years) with Zenker's diverticulum who had dysphagia and/or regurgitation and underwent endoscopic myotomy were included. Outcomes assessed included technical success, clinical success, and adverse events. 161 patients were included. Traditional endoscopic septotomy was performed most frequently (137/161, 85.1 %) followed by submucosal dissection of the septum and myotomy (24/161, 14.9 %). The hook knife (43/161, 26.7 %) and needle-knife (33/161, 20.5 %) were used most frequently. Overall, technical and clinical success rates were 98.1 % (158/161) and 78.1 % (96/123), respectively. Adverse events were noted in 13 patients (8.1 %). There was no significant difference in technical and clinical success between traditional septotomy and submucosal dissection groups (97.1 % vs. 95.8 %, P = 0.56 and 75.2 % vs. 90.9 %, P = 0.16, respectively). Clinical success was higher with the hook knife (96.7 %) compared with the needle-knife (76.6 %) and insulated tip knife (47.1 %). Outcomes were similar between centers performing > 20, 11 - 20, and ≤ 10 procedures. Flexible endoscopic myotomy is an effective therapy for Zenker's diverticulum, with a low rate of adverse events. There was no significant difference in outcomes between traditional septotomy and a submucosal dissection approach, or with centers with higher volume, though clinical success was higher with the hook knife.

Comprehensive Analysis of Adverse Events Associated with Gastric Peroral Endoscopic Myotomy: An International Multicenter Study.

Gastric peroral endoscopic myotomy (G-POEM) has emerged as an effective management approach for patients with refractory gastroparesis. This study aims to comprehensively study the safety of G-POEM and describe the predictive factors of adverse events (AEs) occurrence. This study is a retrospective study involving 13 tertiary care centers (7 USA, 1 South America, 4 Europe, and 1 Asia). Patients who underwent G-POEM for refractory gastroparesis were included. Cases were identified by the occurrence of AEs. For each case, two controls were randomly selected and matched for age (± 10years), gender, and etiology of gastroparesis. A total of 216 patients underwent G-POEM for gastroparesis. Overall, 31 (14%) AEs were encountered [mild 24 (77%), moderate 5 (16%), and severe 2 (6%)] during the duration of the study. The most common AE was abdominal pain (n = 16), followed by mucosotomy (n = 5) and capnoperitoneum (n = 4), and AEs were most commonly identified within the first 48-h post-procedure 18 (58%). The risk of adverse event occurrence was significantly higher for endoscopists with experience of < 20 G-POEM procedures (OR 3.03 [1.03-8.94], p < 0.05). G-POEM seems to be a safe intervention for refractory gastroparesis. AEs are most commonly mild and managed conservatively. Longitudinal mucosal incision, use of hook knife, use of clips for mucosal closure and endoscopist's experience with > 20 G-POEM procedures is significantly associated with decreased incidence of AEs.

A snare-assisted pure NOTES retrograde cholecystectomy using a single channel flexible endoscope: a pilot experiment in a porcine model.

Natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy is an emerging technology. Interest is ongoing and developments have been rapid but NOTES cholecystectomy has failed to gain traction. Here, we share our experience of snare-assisted pure NOTES retrograde cholecystectomy using porcine models. Under general anesthesia, an incision was created on the posterior vagina wall and an endoscope with a snare attached to the transparent cap was introduced into the pelvic cavity and then upward into peritoneal cavity. After locating the liver and gallbladder, the fundic wall of gallbladder was grasped using a biopsy forceps and the snare was released to ligate the fundus. The gallbladder was then carefully dissected from the gallbladder bed using hook/IT knives with the assistance of the snare. The cystic duct and cystic artery were identified, clipped twice and isolated from the gallbladder using the hook knife to cut between the clips. The specimen was then removed through the vagina using the snare. This procedure was successfully performed in 8 consecutive pigs. The average procedure time was 53min (range 40-60min). No severe bleeding or other complication was observed either during or after the procedure. Normal diets were given on the same day of the procedure. All animals recovered uneventfully. We successfully performed snare-assisted pure NOTES retrograde cholecystectomy in pigs using standard endoscopic instruments. In our experience, pure NOTES cholecystectomy using the retrograde approach performed with a single channel flexible endoscope proved safe and feasible with a short procedure time and quick recovery. The translation of this technique to human subjects seems straight forward and provides a new fitting path to pure NOTES.

Ex vivo evaluation of an alternative technique for resection of the proximal manica flexoria in horses.

To describe and evaluate an alternative technique for tenoscopic resection of the manica flexoria (MF). Descriptive study. Equine cadaver forelimbs and hind limbs (n = 36). Three surgeons varying in experience resected the MF in 12 limbs. The procedure was divided into six steps, including resection of the lateral/medial borders of the MF with a hook knife and resection of the proximal border with a micro scalpel. Outcomes compared between surgeons included completeness of resection, appearance of the margins of resection, appearance of the resected MF, collateral damage, and time required for resection. The MF was successfully resected in all specimens, with a median time of 14 minutes 54 seconds (range, 6 minutes 42 seconds to 43 minutes 33 seconds). Nineteen of 36 MF were categorized as symmetric, 11 of 36 MF were categorized as mildly asymmetrical, and six of 36 MF had unequal borders. No differences were detected between surgeons regarding the appearance of the MF and number of iatrogenic lesions. Five lesions were considered potentially clinically relevant; three were caused by the arthroscope in the scutum (1) and the deep digital flexor tendon (DDFT; 2), and two consisted of DDFT damage caused by the microscalpel. The MF was successfully and symmetrically resected with minimal damage to adjacent structures by surgeons with varying levels of experience. The results of this study provide evidence to justify further evaluation of the technique described here in live horses with rupture of the MF.

Clinical significance of microsurgical excision of the posterior longitudinal ligament using a high-frequency electrosurgical excision procedure in anterior cervical discectomy and fusion.

IntroductionAnterior cervical decompression and fusion surgery using traditional methods to remove the posterior longitudinal ligament often causes massive bleeding, increasing the risk of surgery. However, the use of a high-frequency electrotome under the microscope can significantly reduce bleeding and reduce the risk of surgery.AimTo explore the clinical significance of electrosurgical excision of the posterior longitudinal ligament in the cervical anterior approach under the microscope.Material and methodsFrom December 2015 to December 2017, patients who underwent anterior cervical discectomy and fusion at our hospital were followed up. We enrolled 73 men and 50 women who were 30 to 74 years old (mean, 49.96 years). Among 67 patients in group A treated with a high-frequency electrosurgical knife under the microscope, 58 were followed up; among 73 patients in group B treated with a traditional cervical hook knife under the microscope, 65 were followed up. Clinical data, operative time, intraoperative bleeding volume, VAS score, and Japanese Orthopaedic Association (JOA) improvement rate were retrospectively analyzed.ResultsThere were significant differences in the mean operative time and intraoperative bleeding volume between the two groups (p < 0.05); however, no significant differences were found in the incidence of cerebrospinal fluid leakage, JOA improvement rate at 3 months postoperatively, and VAS score at 3 months postoperatively between the two groups (p > 0.05).ConclusionsElectrosurgical resection of the posterior longitudinal ligament of the cervical vertebrae under the microscope can significantly reduce intraoperative bleeding and shorten the operative time and has obvious advantages compared with traditional methods.

Ultrasound-Guided Incisionless Carpal Tunnel Release Using a Hook Knife: A Cadaveric Study.

Carpal tunnel syndrome (CTS) is the most common entrapment mononeuropathy of the median nerve. In comparison to open surgical and endoscopic carpal tunnel release, a new ultrasound-guided hook knife carpal tunnel release (CTR) procedure was reported to have superior results in terms of reduced morbidity and early return to work. To evaluate the reproducibility of the hook knife CTR procedure when performed by musculoskeletal ultrasound trained physicians without prior experience in this technique. Cadaveric study. Tertiary-level academic institute. Sixteen lightly embalmed forearm and hand specimens. The ultrasound-guided CTR was done using a 1-mm proximal wrist puncture, creation of a tunnel, followed by the retrograde percutaneous release of the transverse carpal ligament (TCL) using a 3-mm hook knife. Assessment of the completeness of TCL release, the integrity of the surrounding neurovascular structures, and the technical and subjective procedural difficulty encountered during the procedure. In 14 of 16 specimens, complete release of the TCL was achieved. In two specimens with an incomplete release, the TCL resection was 52% and 55%, respectively. The integrity of the surrounding neurovascular structures and superficial anatomy volar to the dissection path was maintained in all specimens. The mean level of procedural difficulty was 2.6 (range 2-4) on a Likert 5-point rating scale. In cadavers, the ultrasound-guided hook knife CTR procedure was found to be reproducible when performed by ultrasound-trained physicians with no experience in this technique. Further in vivo investigations are required.

It is possible to release the plantaris tendon under ultrasound guidance: a technical description of ultrasound guided plantaris tendon release (UPTR) in the treatment of non-insertional Achilles tendinopathy

Open plantaris tendon excision and ventral paratendinous stripping is a recognised treatment option in selected patients with non-insertional Achilles tendinopathy. The aim of this study was to develop a minimally invasive outpatient technique of ultrasound guided plantaris tendon release (UPTR). A 19 gauge needle, 15 gauge scalpel blade, hook knife (Smith and Nephew, Boston, MA, USA) and a beaver blade (Arthrex, Naples, FL, USA), were used under ultrasound guidance to identify and divide the plantaris tendon in 12 cadaveric legs. Specimens were dissected to identify whether division of the plantaris tendon had been successful. UPTR was subsequently performed on patients. The 15 gauge scalpel blade, hook knife (Smith and Nephew, Boston, MA, USA) and beaver blade (Arthrex, Naples, FL, USA) were all able to cut the plantaris tendon. However, on dissection the hook knife (Smith and Nephew, Boston MA) caused less damage to surrounding structures. Subsequently, the plantaris tendon was successfully divided in three patients using UPTR technique without complication. UPTR is a viable technique for treating plantaris related non-insertional Achilles tendinopathy.

Sonographically Guided Plantaris Tendon Release: A Cadaveric Validation Study.

The plantaris tendon (PT) has been implicated in the pathogenesis of symptoms in a subset of patients with Achilles region pain syndromes and traditionally has been managed via open surgical resection. Although the PT can be visualized on ultrasound, a minimally invasive technique for sonographically guided PT release has not been formally described. To validate a technique to perform sonographically guided PT release in an unembalmed cadaveric model. Prospective, cadaveric laboratory investigation. Procedural skills laboratory in a tertiary medical center. Twenty unembalmed cadaveric knee-ankle-foot specimens (10 right, 10 left) obtained from 16 donors (6 male, 10 female) ages 55-96 years (mean 82.6 years) with body mass indexes of 14.1-33.2 kg/m2 (mean 23.3 kg/m2 ). After simulated local anesthesia and sonographically guided hydrodissection of the plantaris tendon-Achilles tendon interval, a single experienced operator performed sonographically guided PT release on each specimen using an in-plane, lateral-to-medial approach, a commercially available, disposable 3.0-mm hook knife, and either a 17-5 MHz or 15-7 MHz linear array transducer. Each specimen was subsequently dissected to assess for PT release and iatrogenic injury. Status of the PT, Achilles tendon, and regional neurovascular structures as determined by dissection. All 20 PT releases were completed in a single attempt through a 3- to 5-mm incision. Dissection confirmed complete PT release in all specimens without damage to the adjacent Achilles tendon or regional neurovascular structures. Sonographically guided PT release is technically feasible and can be performed while avoiding injury to the Achilles tendon and regional neurovascular structures. Additional research is warranted to further define the role of sonographically guided PT release in patients with suspected PT-mediated Achilles region pain syndromes. IV.

Sa1919 CLUTCH CUTTER KNIFE IMPROVES THE SAFETY OF ENDOSCOPIC SUBMUCOSAL DISSECTION AMONG NOVICES

Endoscopic submucosal dissection (ESD) is a method of resecting gastrointestinal lesions that allows for curative en bloc resection of large, flat lesions. However, ESD is technically challenging and difficult to learn. The risk of perforation remains a significant barrier to its widespread usage. Unlike conventional ESD knives, the Clutch Cutter knife allows for tissue grasping prior to electrosurgical incision, helping improve cut precision. We aimed to determine whether use of the Clutch Cutter improved safety among novice performers of ESD. We prospectively studied gastroenterology trainees and staff without experience in ESD. Participants performed ESD on an ex-vivo porcine stomach model. We compared the differences in ESD performance using the Clutch Cutter and a conventional knife (Hook knife). Participants were provided a brief theoretical introduction to ESD. A short hands-on session to practice using the knives in the animal model followed. Participants then performed circumferential incision and submucosal dissection of two, 2 cm (diameter) marked and submucosally lifted lesions. One excision was performed with the Clutch Cutter and the other with the conventional knife. Participants were individually randomized to use a certain knife first. We recorded adverse events (including full-thickness perforation, target sign, and unintentional incision), procedure time, and successful en bloc resection for each dissection. Continuous variables were compared using paired t-test; categorical variables were compared using Chi-squared analysis. P-values <0.05 were considered statistically significant. Seven endoscopists (5 trainees and 2 staff) participated in this study. Prior endoscopic experience ranged from 430-5000 (median 726) endoscopies, but all participants were novice to performing ESD. Compared to the conventional knife, use of the Clutch Cutter was associated with a significantly lower rate of perforation or target sign (14.3% vs. 71.4%, P=0.031), and unintentional incision (0% vs. 85.7%, P=0.001) (Table 1). All perforations and target signs in both groups were incurred during submucosal dissection. When compared to the conventional knife, use of the Clutch Cutter was associated with a trend towards longer time to completion of circumferential incision (median 18 min vs. 8 min, P=0.112), but shorter time to completion of submucosal dissection (median 3 min vs. 15 min, P=0.094). The total procedure time was not significantly different between use of the Clutch Cutter and conventional knife (median 23 min vs. 20 min, P=0.738). Among novices performing ESD on an animal model, use of the Clutch Cutter knife was associated with a significantly lower rate of adverse events without prolonging procedure time. Based on limited data, the Clutch Cutter appears to improve ESD safety, at least among learners.Tabled 1Outcomes of endoscopic submucosal dissection using the Clutch Cutter and a conventional knife.Clutch Cutter (n=7)Conventional knife (n=7)P-valueAdverse eventsPerforation14.3% (1/7)28.6% (2/7)0.094Target sign14.3% (1/7)57.1% (4/7)0.031Perforation or target sign14.3% (1/7)71.4% (5/7)0.031Unintentional incision0% (0/7)85.7% (6/7)0.001Median no. unintentional incision per resection02 (IQR 1-3)0.036Time to initial incision (sec)150 (IQR 36, 220)22 (IQR 15, 65)0.071Circumferential incision time (min)18 (IQR 11, 20)8 (IQR 2, 9)0.112Submucosal dissection time (min)3 (IQR 2, 14)15 (IQR 7, 18)0.094Total procedure time (min)23 (IQR 17, 38)20 (IQR 14, 24)0.738En bloc resection100% (7/7)71.4% (5/7)0.127IQR, interquartile range Open table in a new tab

Cricopharyngeal myotomy with flexible endoscope for Zenker's diverticulum using hook knife and endoclips (with video describing an objective measurement of the cutting length).

Cricopharyngeal myotomy with flexible endoscope is a well-known and safe treatment for Zenker's diverticulum. We describe hereafter how we perform this flexible endotherapy. From January 2011 to January 2017, we treated 28 patients with this endotherapy. Our technique is described step-by-step in the paper: the main principle is to perform an endoscopic cut of the diverticular septum and cricopharyngeal muscle's fibers (see the video). We describe an objective measurement of the cutting length and depth of the myotomy. Technical success was achieved in all the patients. As to clinical success, 76.2% of patients showed a significant improvement and relevant disappearance of preoperative dysphagia. The present follow-up ranges from 6months to 5years. This flexible endoscopic technique can overcome some limitations of rigid endoscopic technique (i.e., upper teeth protrusion, inadequate jaw opening, or limited neck mobility). The main indication was based on clinical presentation and referred to the diverticular dimensions between 2 and 5cm. Tips for the technique are described in the paper. This variant of cricopharyngeal myotomy with flexible endoscopy is feasible and effective for the treatment of Zenker's diverticulum in selected patients.