Insulation-tipped Diathermic Knife Research Articles

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.

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.

Pleural diseases.

Due to the increasing burden of pleural diseases worldwide, a personalized cost-effective management of these conditions is essential to optimize the healthcare sources. The current review is focused on latest evidence in diagnostic work-up and management of pleural diseases. Recent research highlights the increasing role of thoracic ultrasound in both diagnostic and therapeutic interventions and the potential suitability of cytological sampling from pleural effusions for molecular analysis, essential requirement for a satisfactory test in the era of personalized anticancer therapy. The thoracoscopic approach, by means of rigid or semirigid instruments, remains the gold standard, and attractive tools to increase diagnostic yield in semirigid pleuroscopy include insulated-tip diathermic knife and cryprobe. Talc pleurodesis and indwelling pleural catheters are the most effective interventions, and their combination, likely to result in additional benefits, is currently under investigation. Because of the huge variety of possible clinical settings, a proper management of pleural diseases should be tailored on a case-by-case basis and requires a multidisciplinary approach. Recent advances in technologies has conferred to interventional pulmonology an increasing relevant role in this context, leading to the development of a dedicated subspecialty, and training programs are urgently needed to standardize skills and care pathways.

Process of technical stabilization of gastric endoscopic submucosal dissection at the National Cancer Center in Japan

Endoscopic submucosal dissection (ESD) was originally developed in 1995 using an insulation-tipped diathermic knife (Olympus, Tokyo, Japan) to achieve en-bloc resection of early gastric cancer (EGC). It has been suggested that advances in endoscopic devices and medical equipment, such as the high-frequency generator (1999) and hemostatic forceps (2000), and procedural improvements including post-ESD preventive coagulation of visible vessels in the resection area (2003) led to further progress of ESD; therefore, we investigated the actual process of technical stabilization of gastric ESD. A total of 1,713 consecutive patients with solitary differentiated-type EGC at initial onset underwent ESD at our hospital from 1995 to 2006. We retrospectively assessed ESD outcomes for all patients by dividing them into three chronological periods: 1995-1998 (1st period; 57 patients), 1999-2002 (2nd period; 563 patients), and 2003-2006 (3rd period; 1,093 patients). The en-bloc resection, intraoperative bleeding, and delayed bleeding in the 1st/2nd/3rd period were 52.6%/94.7%/99.3% (1st vs. 2nd, p<0.01; 2nd vs. 3rd, p<0.01), 8.8%/7.1%/1.6% (1st vs. 2nd, no significant difference; 2nd vs. 3rd, p<0.01), and 15.8%/7.6%/3.3% (1st vs. 2nd, p<0.05; 2nd vs. 3rd, p<0.01), respectively. Gastric ESD has stabilized technically following advances in endoscopic devices and medical equipment together with procedural improvements.

A Second Assisting Endoscope for the Removal of an Accidentally Unreleased Detachable Snare during Colon Polypectomy

The incidence of postpolypectomy hemorrhage ranges from 0.3% to 6.1%, and is the most common complication of polypectomy.1 The risk of bleeding may be especially high after resecting pedunculated polyps because of the presence of a large artery in the stalk. Bleeding can occur in the immediate postpolypectomy period, or may be delayed up to 29 days.2 Several endoscopic techniques have been developed. In 1989, Hachisu3 developed a detachable snare device that completely stops blood flow in the stalk. While loading the detachable snare, it is important to verify that it is properly attached to the hook wire and smoothly pulled into and then pushed back from the coil sheath without getting stuck.4 A second endoscope-assisted endoscopic submucosal dissection for large colorectal tumors has been reported recently.5-7 Here, we report a case in which an accidently unreleased detachable snare used for colon polypectomy was successfully removed by a second assisting endoscope. A 40-year-old man underwent screening colonoscopy. A grossly 1.5 cm-sized pedunculated polyp with a 3 cm-long stalk was observed at the distal descending colon. A detachable snare (MAJ-254; Olympus, Tokyo, Japan) was placed around the lower one-third of the stalk. The detachable snare could not be released from the hook wire of the operating part, as the loop of nylon thread appeared to be tightly stuck between the coil sheath and hook wire. Hence, the snare loop and coil sheath were attached to the colon polyp, and the colonoscope could not be retrieved (Fig. 1). Fig. 1 The unreleased snare observed by the second assisting endoscope. A second assisting gastroscope was inserted. The stalk was cutoff with a conventional snare between the snare loop and the polyp head. Cutting of the unreleased detachable loop with hot biopsy forceps and an insulation-tipped diathermic knife was then attempted, but failed. A conventional snare was placed just above the rubber stopper of the detachable snare (Fig. 2), and the detachable snare, which tightly strangulated the stalk, was successfully released from the stalk by cutting at that position, and all the specimens were retrieved (Fig. 3). No complications such as bleeding or perforation were noted during the 2 weeks of follow-up. Fig. 2 Snare resection of the stalk just above the rubber stopper. Fig. 3 Gross specimen of the removed polyp. Clinical evidence supports the usefulness of the detachable snare in the management of postpolypectomy bleeding, bleeding from esophageal and gastric varices, and angiodysplasias.4 The detachable snare was developed for the prevention of hemorrhage after the removal of large pedunculated polyps.1 Hence, the most probable reason for the detachable snare not being released was that it got stuck between the coil sheath and hook wire in this case. Several complications related to the detachable snare have been reported. It became entangled with the polypectomy snare in one patient, and the proper transection of peduncle failed in another patient.8 A slip-off of an endoloop slip-off in five of 53 patients, and delayed bleeding occurred in three of 53 patients, especially those with semipedunculated polyps.8,9 A second gastroscope may easily be inserted up to the descending colon without increasing the patient's discomfort and may efficiently act as another hand by lifting the dissected lesion during the dissection procedure.5-7 In our case, a second endoscope, however, was required for the successful removal of the unreleased snare and colon polyp, as the first endoscope was unsuccessful.

CURRENT OPINIONS FOR ENDOSCOPIC SUBMUCOSAL DISSECTION FOR COLORECTAL TUMORS FROM OUR EXPERIENCES: INDICATIONS, TECHNICAL ASPECTS AND COMPLICATIONS

Endoscopic submucosal dissection (ESD) was first applied in the resection of large colorectal tumors 10 years ago. Frequent complications and technical difficulties were serious problems at first, but were gradually improved with experience. Here, we describe the indications, technical aspects and management of complications of ESD for colorectal tumors. In 2009, we introduce the use of small tip insulation-tipped diathermic (IT) knife. Features separating it from the IT knife and IT Knife2 are a smaller ceramic tip and small round disk at the root of the tip. During submucosal dissection, the small tip IT knife could dissect large pieces of tissue intact. This allows us to shorten the procedure time, particularly the submucosal dissection component. A total of 146 ESD for 140 patients were performed between January 2009 and July 2011. En bloc, and en bloc and R0 resection rates were 92.5% and 83.6%, respectively. Median procedural time was 48.5 min for 40.5 mm specimens. Perforation and delayed bleeding occurred in 2.1% and 1.4%, respectively. We successfully performed ESD for colorectal tumors with a shortened procedure time while preserving quality and safety.

Endoscopic submucosal dissection for early esophageal neoplasia: A single center experience in South Taiwan

Endoscopic submucosal dissection (ESD) is an advanced endoscopic procedure to resect early gastrointestinal neoplasm. It is technically more difficult and risky when used to treat early esophageal tumors. We report our experiences related to performing ESD for early esophageal neoplasia. The efficacy, complications, and outcome were also analyzed. From December 2007 to April 2010, 22 patients with documented early esophageal neoplasm underwent ESD. All patients completed a meticulous endoscopic examination using conventional endoscopy followed by narrow-band imaging. Lugol's staining was performed to identify the margin of the suspicious lesion. Insulation-tipped diathermic knife 2 was used for ESD. A total of 26 neoplastic lesions (including 13 tumors with high-grade dysplasia, 12 tumors with squamous cell carcinoma, and one tumor with adenocarcinoma) in 22 patients were enrolled. All patients were men. The mean age was 47.6 ± 8.6 years (range, 30-68 years). The mean size of tumors was 33.7 ± 21.7 mm (range, 8-80 mm). ESD was performed for 24 lesions in 20 patients. The mean size of resected specimens was 43.1 ± 19.2 mm (range, 15-90 mm). The mean operation time was 92.7 ± 69 minutes (range, 30-310 minutes). There were three ESD-related complications, including one with delayed bleeding, one with subcutaneous emphysema, and one with perforation. Two patients received additional operations after ESD due to deep submucosal invasion by cancer. Three lesions in two patients (12.5%) developed post-ESD esophageal stricture that needed repeated endoscopic bougination. There was no procedure-related mortality. No local recurrence was found during the follow-up period. ESD is a promising local curative treatment option for early esophageal neoplasia in Taiwan. However, this procedure may result in complications that are worth noting, especially post-ESD esophageal stricture. Education regarding this procedure and more hands-on training will facilitate endoscopists to improve the outcomes of patients undergoing this procedure.

PP23 ENDOSCOPIC TREATMENT OF ESOPHAGEAL TUBULAR DUPLICATION IN A BOY

Objective: Esophageal duplications are very rare congenital malformations that can be diagnosed at any age. Patients remain asymptomatic unless complications occur. Surgery is the standard treatment. The experience of endoscopic treatment is very limited. We report a case of a boy with esophageal tubular duplication successfully treated with endoscopic resection. Case Report: A 10-year-old boy with an uneventful medical history was urgently admitted in a peripheral hospital for acute dysphagia and severe retrosternal pain. During admission sialorrhea, cough, and fever appeared. Physical examination and chest X-rays were normal. Antibiotics were started with fever and cough resolution, but persistence of severe dysphagia with weight loss of 7 kg. Endoscopy demonstrated two ulcerations in proximal and distal esophagus, with mucus and pus. After a chest CT scan an esophageal duplication was suspected. The patient was then referred to our Institute. Because our initial suspect was a dissecting intramural hematoma, the child was maintained fasted in parenteral nutrition and antibiotics were continued. Barium esophagram revealed a double-barrelled esophagus with a longitudinal septum between two lumens, suggesting intramural esophageal dissection or esophageal duplication. Upper endoscopy showed two orifices in the mid-esophagus. Endoscope (5.9 mm ∅, GIF-XP160, Olympus) advanced through the main lumen and then through the 5-cm-long pseudo-lumen that presented normal esophageal mucosa with partial ulcerations and a distal wide communication to the main one. A thick bridge separated the two lumens. The diagnosis of a complete tubular duplication was confirmed. A nasogastric tube was inserted in the main lumen under direct vision and enteral feeding was started. Therapeutic endoscopy under general anesthesia was finally performed, with paediatric surgeons in attendance in case of failure or complications. After the insertion of a guide wire in the pseudo-lumen an insulated tip diathermic knife (ITDK, M.G. Lorenzatto, Turin, Italy) was connected through the endoscope channel to an electrosurgical intelligent workstation (ICC 200 E, ERBE, GA, USA), setting the ENDO-CUT® mode at 50/25 W. Starting from the upper opening a step by step mixed cutting and cautery of the septum was done, obtaining a lengthwise resection. The endoscopic procedure was completed uneventfully with success. The patient started to drink in the same day and oral food intake was introduced the next day without problems. He was discharged within 72 hours. Repeated endoscopy after 4 months showed normal esophagus with 2 longitudinal residual folds, without stenosis. At 8 months follow-up he is asymptomatic and in excellent general condition with full weight recovery. Conclusions: The diagnosis of esophageal tubular duplication is often occasionally and not easy, especially during complications. Repeated upper endoscopy is sometimes necessary to clarify the etiology of esophageal wall abnormalities. The definitive treatment is surgical excision, although the endoscopic treatment has been recently suggested. To our knowledge, only one complete endoscopic management of a tubular esophageal duplication has been reported so far. We describe another case of successfully endoscopic resection without complications. We used an ITDK, a device particularly useful to avoid potential injury of esophageal wall during the cutting of the interluminal septum. Our experience adds information about operative endoscopy for these rare esophageal congenital defects. Expert endoscopist should consider this less-invasive method as a valid alternative to surgery. PP24

Sp850 Endoscopic Submucosal Dissection of Early Gastric Cancer Adjacent to Gastric Varices

Endoscopic Submucosal Dissection (ESD) is an applicable technique for curable resection of early gastric cancer. Careful planning and designing of ESD should be done prior to the procedure if patient has any co-morbidity. The priority of treatment was given to fundal varix for the prevention of bleeding during ESD. ESD was performed. Endoscopic therapy with tissue adhesive was applied. After making several marking dots outside the lesion with dual knife, circumferential incision and direct dissection of the submucosal layer was made by using insulated-tip diathermic knife (IT-2). En block resection was accomplished and total procedure time was 90 minutes. Histology revealed moderately differentiated adenocarcinoma of 24 x 12 mm size with laterally free margin. The depth of submucosal invasion was measured by 150 μm without lymphovascular invasion. Follow-up endoscopy demonstrated an ulcer on healing without evidence of recurrence 2 months after ESD. Endoscopic submucosal dissection is appropriate treatment for early gastric cancer. If patients with combined cirrhosis and varices, treatment strategy is complicated that preventing bleeding tendency during procedure and post ESD ulcer bleeding should be considered. This case has another difficult situation that varices is adjacent to gastric varices. Prior to ESD, cyanoacrylate injection to gastric varices helps to prevent variceal bleeding and decreasing the size of varices. Endoscopic management of both gastric varices and early gastric cancer is performed without serious complication and successful resection of early gastric cancer is done.

Treatment of Gastric Epithelial Tumours by Endoscopic Submucosal Dissection Using an Insulated-Tip Diathermic Knife

Endoscopic submucosal dissection (ESD) is a promising technique for the treatment of large, pre- and early malignant gastrointestinal lesions. To assess the rates of en bloc resection, incidence of complications, procedure times and therapeutic outcomes of ESD using an insulated-tip diathermic knife; and to investigate predictors of these outcomes based on the final pathological features of biopsy specimens. One hundred twenty patients with endoscopically suspected gastric epithelial tumours who were treated with ESD from January 2006 to December 2009 were evaluated. The mean diameter of the gastric epithelial tumours in the present cohort was 1.88 cm. The mean diameter of the resected specimens was 3.33 cm. The en bloc resection rate was 90% (108 of 120). The median length of the operation was 64.6 min. The bleeding and perforation complication rates were 5.0% (six of 120) and 2.5% (three of 120), respectively. Of 10 gastric tumours initially diagnosed as adenocarcinoma on biopsy, four were found to be low-grade dysplasia and six were found to be high-grade dysplasia after resection and final pathological examination. A total of 112 (93.33%) patients underwent curative treatment, eight patients (6.67%) underwent noncurative treatment with ESD, and two patients (1.67%) experienced local recurrence and subsequently underwent surgery. ESD is a promising local curative treatment option for gastric epithelial tumours, but still carries the risks of bleeding and⁄or perforation. Differences in the interpretation of histological results among different pathologists and⁄or between biopsy specimens before ESD and the en bloc tissue specimens after ESD will result in discrepancies.

Endoscopic submucosal dissection of gastric lesions by using a Master and Slave Transluminal Endoscopic Robot (MASTER)

Performing endoscopic submucosal dissection (ESD) by using standard endoscopy platforms is technically challenging because of the equipment's lack of dexterity. To explore the feasibility of using the Master and Slave Transluminal Endoscopic Robot (MASTER), a novel robotics-enhanced endosurgical system, to perform ESD. ESD was performed on simulated gastric lesions in 5 Erlangen porcine stomach models (ex vivo) and 5 live pigs (in vivo). Performance of ESD by using the MASTER was compared with that using the insulation-tipped (IT) diathermic knife. SMART Laboratory, Advance Surgical Training Centre, National University Hospital, Singapore. Five Erlangen porcine stomach models and 5 pigs, 5 to 7 months old, each weighing about 35 kg. ESD. Lesion resection time, grasper and hook efficacy grade, completeness of resection, and presence of procedure-related perforation. In the Erlangen stomach models, 15 simulated lesions from the cardia, antrum, and body were removed en bloc (mean dimension, 37.4 x 26.5 mm) by electrocautery excision using the MASTER. The mean ESD time was 23.9 minutes (range 7-48 minutes). There was no difference in the dissection times of lesions at different locations (P = .449). In the live pigs, the MASTER took a mean of 16.2 minutes (range 3-29 minutes) to complete the ESD of 5 gastric lesions, whereas the IT diathermic knife took 18.6 minutes (range 9-34 minutes). There was no significant difference in the times taken (P = .708). All lesions were excised en bloc; the mean dimensions of lesions resected by the MASTER and the IT diathermic knife were 37.2 x 30.1 mm and 32.78 x 25.6 mm, respectively. The MASTER exhibited good grasping and cutting efficiency throughout. Surgical maneuvers were achieved with ease and precision. There was no incidence of excessive bleeding or stomach wall perforation. Exploratory study with limited sample size. Performing ESD by using the MASTER is feasible.

Transintestinal hepatectomy performed by hybrid NOTES using a customized X-TRACT Tissue Morcellator with an electrifiable round cutter

We tried to determine whether the customization of an X-TRACT Tissue Morcellator could avoid the laceration-induced distension of surgical incisions/openings when transintestinally removing resected liver tissue from the body, when the greatest dimension of the tissue exceeded the dimension of the opening. Pigs were used to examine changes in the caliber and shape of surgical incisions made with a conventional hook knife and insulation-tipped diathermic (IT) knife for electrodissection in endoscopy, and to examine changes in circular incision made with a customized X-TRACT Tissue Morcellator. The ENDO CATCH II device was used to remove tissue. Laceration occurred in the "roundness-lost portion" of the surgical incisions made with the hook knife, thus confirming the greatest dimension of the distended incisions and the occurrence of an irregular laceration. In the circular incision that were made with the customized X-TRACT Tissue Morcellator, by contrast, the removal of resected liver tissue whose greatest dimension was fivefold greater than that of the surgical openings did not increase the caliber of the openings. The shape of the openings remained round, and no laceration was observed. The use of the customized X-TRACT Tissue Morcellator with an electrifiable round cutter allowed the performance of transintestinal hepatectomy and the removal of a solid organ through surgical openings that had been made in the gastrointestinal wall.

Endoscopic Submucosal Dissection for Early Gastric Cancer and Gastric Adenoma: 3-Years Experience in a Single Center

Background/Aims: Endoscopic submucosal dissection (ESD) enables en-bloc complete resection of various gastrointestinal tumors compared with conventional endoscopic mucosal resection (EMR), and has been promising treatment option of early gastric cancer (EGC). This study aimed to evaluate clinical outcome of ESD for EGC and gastric adenoma using insulation-tipped diathermic knife. Methods: From April 2005 to June 2008, 884 patients (452 EGC and 432 gastric adenomas) were enrolled prospectively after ESD in Seoul National University Hospital. Follow-up endoscopies were performed in 3, 6, 12, 18 months, and then annually. Complete resection rate, complications, concordance of diagnosis in between the pre-treatment forcep-biopsy and pathologic mapping of ESD specimen and synchronous or metachronous lesions during follow-up were evaluated. Results: The median follow-up duration was 13.4 ± 9.7 months (range 3-39 months). The en bloc resection rate was 100%, complete resection rate was 91.1%(801/884) on the pathologic mapping and 96.4% (703/729) in 3-month follow-up endoscopy. Perforation occurred in 1.1% (10/884) and bleeding was noticed in 3.6% (32/884). There was no complication requiring operation or procedure related mortality. Gastric adenoma in the pre-treatment biopsy were finally proven as EGC with pathologic mapping in 22.5% (119/529) of cases. During the follow-up, 2% (9/432) of adenoma cases were retreated for the remnant lesion with argon-plasma coagulation (APC) or additional ESD. Additional surgical resection was performed in 5.1% (23/452) of EGC patients due to a residual lesion, tumor invasion more than deep submucosal layer, lymphatic invasion or undifferentiated carcinoma. Among the 23 surgically resected cases, there was residual carcinoma in 17.4%(4/23) and lymph node metastasis in 21.7% (5/23). One case revealed synchronous lesion at a different location from the initial ESD site (4.3%, 1/23). During follow-up period, 160 synchronous lesions (18.1%) within 1 year and 20 metachronous lesions (2.3%) were reported. No distant or lymph node metastasis was found during the follow-up. Conclusions: ESD shows high complete resection rate and more accurate pathologic diagnosis of EGC and gastric adenoma, and close follow-up is warranted for detection of synchronous or metachronous lesion.

Risk of perforation during endoscopic submucosal dissection using latest insulation-tipped diathermic knife (IT knife-2)

Endoscopic submucosal dissection (ESD) enables en bloc resection of lesions regardless of tumor size or location. The insulation-tipped (IT) diathermic knife (Olympus Medical Systems Corp., Tokyo, Japan) is a proven endoscopic device for ESD [1] [2]. ESD gastric perforations using the IT knife usually happen during submucosal dissection [3]. However, we present an ESD perforation case that occurred when an IT knife-2, an improved version of the IT knife [4], was being used for circumferential mucosal incision.

A new electrocautery pleural biopsy technique using an insulated-tip diathermic knife during semirigid pleuroscopy

The biopsy size obtained with standard flexible forceps (SFF) during semirigid pleuroscopy is often insufficient for pathological examination. An insulated-tip diathermic knife (IT knife) allows safe resection of a larger lesion during gastrointestinal endoscopy. We sought to validate an electrocautery pleural biopsy technique using the IT knife during semirigid pleuroscopy. We compared the diagnosis of specimens obtained using the IT knife and SFF in 20 subjects with unexplained pleural effusion, and reviewed pleuroscopic parameters such as complications, procedure time, and diameter of the specimens. After injecting saline with lidocaine and epinephrine below the affected pleura, the lesion was incised in a circular shape with full thickness by manipulating the IT knife. Diagnostic yields from specimens obtained with the IT knife and SFF were 85% (17 of 20 cases) and 60% (12 of 20 cases), respectively. The IT knife biopsy was superior to SFF in 8 of 20 patients (malignant pleural mesothelioma in three, nonspecific inflammation in two, metastatic breast cancer in one, and tuberculosis in one). These pleural lesions revealed thickened, smooth abnormal appearances. The overall diagnostic yield for both IT knife and SFF was 100%. Median time of the procedure, from first pleural injection to specimen removal, was 21 min (range 12-92 min), and median diameter of specimen was 13 mm (range 6-23 mm). There were no severe complications during the procedure. Electrocautery biopsy using the IT knife during semirigid pleuroscopy has great potential for diagnosing smooth abnormal pleura which are difficult to biopsy with SFF.

The Diagnostic Value of Full-thickness Pleural Biopsy Using an Insulated-tip Diathermic Knife During Semiflexible Thoracoscopy

The Diagnostic Value of Full-thickness Pleural Biopsy Using an Insulated-tip Diathermic Knife During Semiflexible Thoracoscopy

Pleural MALT lymphoma diagnosed on thoracoscopic resection under local anesthesia using an insulation‐tipped diathermic knife

A 79-year-old man presented with back pain. Chest CT scan showed elevated nodular lesions in the right parietal pleurae with pleural effusion. There were no intrapulmonary or mediastinal abnormalities. Under local anesthesia, right thoracoscopy and subsequent thoracoscopic pleural resection were performed using an insulation-tipped diathermic knife (IT-knife). The resected pleura, 2.2 cm in diameter, had a rough granular surface. Lymphoid cells histologically infiltrated diffusely into the pleura. They were composed of centrocyte-like and monocytoid cells. On immunohistochemistry they were found to be positive for Bcl2, CD20, CD45RB and CD79a, but negative for CD3, CD5, CD10 and cyclin D1. EBV-encoded small RNA-1 (EBER-1) in situ hybridization was negative. A diagnosis of extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) arising in the pleura was therefore made. To the authors' knowledge this is the first case in which IT-knife was used for diagnosis of a pleural lesion. This large, single-piece, only slightly crushed pleural specimen, enabled study of histopathological findings (listed here) that could not have been obtained on conventional biopsy: (i) lack of apparent evidence of plasmacytic differentiation; (ii) no recognition of lymphoid follicles; (iii) mesothelial cells not infiltrated by lymphoma cell clusters; (iv) thin layer of hyperplastic mesothelial cells continuously covering the surface; and (v) no proliferation of fibroblast-like submesothelial cells.

Usefulness of a novel electrosurgical knife, the insulation-tipped diathermic knife-2, for endoscopic submucosal dissection of early gastric cancer

Although endoscopic submucosal dissection (ESD) of early gastric cancer using an insulation-tipped diathermic (IT) knife enables the removal of large and ulcerative lesions en bloc, expert endoscopic skill is required. We developed an improved IT knife (IT-2) and compared its efficacy and safety with that of the original IT knife (IT-OM). We performed ESD of 602 gastric cancers. Of these, 314 previously untreated single lesions of initial onset were analyzed. Operating time, rate of en-bloc resection, and incidence of complications were compared in the IT-2 group (161 patients) and IT-OM group (153 patients). Lesions were further analyzed as to whether they met the Japanese Gastric Cancer Association indications for ESD or extended indications. Mean resection time was significantly shorter in the IT-2 than in the IT-OM group (48 vs 63 min). There were fewer surgeries lasting longer than 2 h in the IT-2 group than in the IT-OM group (3% vs 12%). En-bloc and margin-free resection rates in the IT-OM and IT-2 groups were 95% and 99%, respectively. Perforations occurred in 3.9% of patients in the IT-OM group and in 5% of patients in the IT-2 group (difference not significant [NS]). The incidence of postoperative hemorrhage was 7.8% in the IT-OM group and 8.7% in the IT-2 group (NS). In both groups, complications were treated endoscopically, and emergency surgery was unnecessary. Resectability and complication rates were similar in the two groups. However, operating time was shorter with IT-2, irrespective of the indications for the performance of ESD. This study suggests benefits of the IT-2 over the IT-OM.

Treatment of gastric remnant cancer post distal gastrectomy by endoscopic submucosal dissection using an insulation-tipped diathermic knife

To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife (IT-ESD) for the treatment of patients with gastric remnant cancer. Thirty-two patients with early gastric cancer in the remnant stomach, who underwent distal gastrectomy due to gastric carcinoma, were treated with endoscopic mucosal resection (EMR) or ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 10-year period from January 1998 to December 2007, including 17 patients treated with IT-ESD. Retrospectively, patient backgrounds, the one-piece resection rate, complete resection (CR) rate, operation time, bleeding rate, and perforation rate were compared between patients treated with conventional EMR and those treated with IT-ESD. The CR rate (40% in the EMR group vs 82% in the IT-ESD group) was significantly higher in the IT-ESD group than in the EMR group; however, the operation time was significantly longer for the IT-ESD group (57.6 +/- 31.9 min vs 21.1 +/- 12.2 min). No significant differences were found in the rate of underlying cardiopulmonary disease (IT-ESD group, 12% vs EMR group, 13%), one-piece resection rate (100% vs 73%), bleeding rate (18% vs 6.7%), and perforation rate (0% vs 0%) between the two groups. IT-ESD appears to be an effective treatment for gastric remnant cancer post distal gastrectomy because of its high CR rate. It is useful for histological confirmation of successful treatment. The long-term outcome needs to be evaluated in the future.

Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization

Endoscopic submucosal dissection (ESD) has been positively applied to and gradually standardized for early stomach cancer, particularly in Japan. However, because it is technically difficult to perform ESD of the colon, ESD is not a commonly used technique. The aim of this study was to evaluate the possibility of standardizing colorectal ESD. ESD was performed at the Department of Endoscopy, Hiroshima University Hospital. Time required for ESD, rate of complete en bloc resection, complication, and postoperative local persistence and recurrence were investigated retrospectively in 70 cases of colorectal neoplasia, wherein the lesion was more than 20 mm in diameter. All lesions were resected by ESD. The average (+/-SD) time required for ESD was 70.5+/-45.9 minutes (range, 15-180 minutes), and the histologic rate of complete en bloc resection was 80.0% (56/70). With regard to complication, 1.4% of cases of postoperative hemorrhage (1/70) and 10.0% of cases of perforation (7/70) were observed in total. The rate of perforation was investigated with respect to the type of knife used for ESD and the period after the induction of ESD. The rate of perforation markedly decreased with the practice of the technique. Moreover, the rate of perforation was high when an insulated-tip diathermic knife was used; practicing this technique was insufficient to reduce the rate of perforation. The average duration of follow-up was 614+/-289.5 days, and no case of local persistence and recurrence or metastasis was observed. The ESD technique depends on the level of each skill of each colonoscopist. With regard to ESD of the colon, complication, eg, perforation, could be decreased by sufficient practice and selection of an appropriate knife. It is suggested that, in the near future, ESD will be standardized for the colon.