Water-jet Hybrid Knife Research Articles

Bronchoscopic submucosal dissection with Hybrid Knife: a new technique treating tracheal leiomyoma.

Primary tracheal leiomyoma is exceedingly rare and recommended management has not been defined yet. Surgical management has been considered to be the standard treatment historically. Bronchoscopic intervention may be an ideal alternative for patients who refuse or are not fit for surgery. We report the first bronchoscopic submucosal dissection using an innovative water-jet Hybrid Knife performed on a patient with recurrent primary tracheal leiomyoma.

Transurethral en bloc resection of bladder tumors

Background. The high incidence of recurrent non-muscle-invasive bladder carcinoma (BC) necessitates searches for new surgical methods. Objective: to comparatively evaluate the efficiency and safety of en block resection of bladder tumors versus transurethral resection (TUR). Subjects and methods. In January 2010 to June 2013, a total of 292 patients with primary and recurrent bladder tumor stages, cTa-T2, underwent transurethral endoscopic treatment (as TUR) at the Unit of Minimally Invasive Urology, Moscow City Clinical Hospital Fifty-Seven. A major portion of these patients were included in the study of the efficiency and safety of en bloc TUR of bladder tumors. The criteria for study inclusion were primary or recurrent non-muscle-invasive bladder tumor measuring 1 to 3 cm, stage pTa-T1, signed informed consent to participate in the study and patients» readiness to undergo control examinations in inpatient setting for one year. The exclusion criteria were a confirmed or detected muscleinvasive tumor, multiple bladder involvement (> 3 tumors), as well as detected tumors spreading to the ureter, bladder neck, and prostatic urethra. The primary study endpoint was considered to be a recurrence of a tumor after TUR of the bladder (TURB). The secondary endpoint was the frequency of concealed bladder perforation, blood transfusions, recystoscopies for bladder tamponade, early recystoscopies to specify a BC stage, and the frequency of immediate intravesical injection of a chemical. For final analysis, the investigators selected 106 patients in a group where tumors were removed en bloc (a study group) and 133 patients in a group where tumors were retrieved using traditional TURB (a control group). In the study group, the tumor was removed en bloc by a monopolar J-shaped electrode (sand wedge electrode) in 45 patients, by a hook-like electrode in 14, by a hybrid procedure (hydropreparation and monopolar electrosurgery by a water-jet hybrid knife) in 10, and by holmium laser in the remaining 37 patients. Results. The recurrence rates in the study and control groups were 10.4 and 21.8 %, respectively (p ≤ 0.05). There were no significant differences in the time of surgery, the periods of bladder drainage, and the frequency of complications. In the study group, the immediate instillation of a chemical was possible in 54.7 % of the patients versus 24 % in the control group (р ≤ 0.05), indirectly suggesting that en bloc TUR of the bladder was less safe (the bladder resection area, concealed perforations, hemorrhagic complications, etc. were less.). Early recystoscopy and biopsy were required in 9.4 % of the patients in the study group versus 24 % of those in the control group (p ≤ 0.05), which is mainly attributable to more qualitative histological material obtained during en bloc TUR. According to the visual analogue scale, the quality of the histological materials obtained by retrieving the tumor en block was 93 versus 61 scores during standard TUR. Conclusion. En bloc TUR of the bladder is more effective and safer than standard TUR in the group of patients with non-muscle-invasive BC and 1–3-cm tumors. Histological material obtained by removing the tumor en bloc can provide a more qualitative morphological opinion.

Trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife: A pilot animal study

To investigate the feasibility and safety of Natural orifice trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife in a non-survival porcine model. Pure natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy was performed on three non-survival pigs, by transumbilical approach, using a water-jet hybrid-knife. Under general anesthesia, the following steps detailed the procedure: (1) incision of the umbilicus followed by the passage of a double-channel flexible endoscope through an overtube into the peritoneal cavity; (2) establishment of pneumoperitoneum; (3) abdominal exploration; (4) endoscopic cholecystectomy: dissection of the gallbladder performed using water jet equipment, ligation of the cystic artery and duct conducted using nylon loops; and (5) necropsy with macroscopic evaluation. Transumbilical endoscopic cholecystectomy was successfully completed in the first and third pig, with minor bleedings. The dissection times were 137 and 42 min, respectively. The total operation times were 167 and 69 min, respectively. And the lengths of resected specimen were 6.5 and 6.1 cm, respectively. Instillation of the fluid into the gallbladder bed produced edematous, distended tissue making separation safe and easy. Reliable ligation using double nylon loops insured the safety of cutting between the loops. There were no intraoperative complications or hemodynamic instability. Uncontrolled introperative bleeding occurred in the second case, leading to the operation failure. Pure NOTES trans-umbilical cholecystectomy with a water-jet hybrid-knife appears to be feasible and safe. Further investigation of this technique with long-term follow-up in animals is needed to confirm the preliminary observation.

879 A Prospective, Single Center Study of Endoscopic Submucosal Dissection of Rectal LST Lesions Larger Than 3 cm by Using an Innovative Concept of Injecting and Cutting: The Water-Jet Hybrid-Knife (ESD-H)

ESD has been recently developed to allow en bloc resection of early neoplasia of the GI tract. The endoscopic technique is not yet standardized and a number of different devices have been proposed to make easier the technique and allow a safe and effective resection of the lesions to be treated. This study aims to evaluate the efficacy and safety of the ESD treatment of large rectal polyps by using a new device which combines the function of injection and cutting.

Natural orifice transluminal endoscopic wedge hepatic resection with a water-jet hybrid knife in a non-survival porcine model

To explore the feasibility of a water-jet hybrid knife to facilitate wedge hepatic resection using a natural orifice transluminal endoscopic surgery (NOTES) approach in a non-survival porcine model. The Erbe Jet2 water-jet system allows a needleless, tissue-selective hydro-dissection with a pre-selected pressure. Using this system, wedge hepatic resection was performed through three natural routes (trans-anal, trans-vaginal and trans-umbilical) in three female pigs weighing 35 kg under general anesthesia. Entry into the peritoneal cavity was via a 15-mm incision using a hook knife. The targeted liver segment was marked by an APC probe, followed by wedge hepatic resection performed using a water-jet hybrid knife with the aid of a 4-mm transparent distance soft cap mounted onto the tip of the endoscope for holding up the desired plane. The exposed vascular and ductal structures were clipped with Endoclips. Hemostasis was applied to the bleeding cut edges of the liver parenchyma by electrocautery. After the procedure, the incision site was left open, and the animal was euthanized followed by necropsy. Using the Erbe Jet2 water-jet system, trans-anal and trans-vaginal wedge hepatic resection was successfully performed in two pigs without laparoscopic assistance. Trans-umbilical attempt failed due to an unstable operating platform. The incision for peritoneal entry took 1 min, and about 2 h was spent on excision of the liver tissue. The intra-operative blood loss ranged from 100 to 250 mL. Microscopically, the hydro-dissections were relatively precise and gentle, preserving most vessels. The Erbe Jet2 water-jet system can safely accomplish non-anatomic wedge hepatic resection in NOTES, which deserves further studies to shorten the dissection time.

511p: Endoscopic Submucosal Resection (ESD) of Early Barrett's Neoplasia (EBN) With a Water-Jet HybridKnife (ESDH): First Prospective Clinical Trial

EMR of EBN has frequently to be done in a piecemeal fashion. This approach can impair the histological evaluation of the resected specimen and may increase the risk of residual or recurrent neoplasia. ESDH has shown to be superior to EMR of esophageal lesions in an experimental trial (GIE 2009;70:112-20) but has not yet been studied in patients with EBN.

511n: Endoscopic Submucosal Resection of Early Gastric Neoplasia With a Water-Jet Hybridknife (ESDH): A Prospective Western Study in 31 Patients

511n: Endoscopic Submucosal Resection of Early Gastric Neoplasia With a Water-Jet Hybridknife (ESDH): A Prospective Western Study in 31 Patients

First Clinical Trial of Endoscopic Submucosal Resection (ESD) of Early Gastric Neoplasia with a Water-Jet Hybridknife (ESDH)

First Clinical Trial of Endoscopic Submucosal Resection (ESD) of Early Gastric Neoplasia with a Water-Jet Hybridknife (ESDH)

Randomized controlled study of EMR versus endoscopic submucosal dissection with a water-jet hybrid-knife of esophageal lesions in a porcine model

Endoscopic submucosal dissection (ESD) seems to be more effective than EMR for curative resection of GI mucosal neoplasia. However, ESD is technically difficult, hazardous, and time consuming. New technologies may overcome these drawbacks. Our purpose was to compare a new simplified ESD technique with conventional EMR. Prospective, randomized, and controlled trial in anesthetized pigs. A total of 25 esophageal areas with a diameter of 20 mm were marked with coagulation points in 6 pigs under general anesthesia. These lesions were then randomized to either EMR by use of the cap technique or ESD. Submucosal injection of saline solution was used for both methods. ESD was performed with a hybrid-knife (ESDH), which allows cutting and coagulation as well as a needleless, tissue-selective hydrodissection through an axial water-jet channel with a preselected pressure by using a high-pressure water-jet system (ErbeJet 2). Intraoperative bleedings were treated with hemostatic forceps. A comparison of the rates of complete resection of the lesions, the number and the size of resected specimens, the complication rate, and the procedural duration. Thirteen lesions were randomized to EMR and 12 to ESDH. ESDH achieved complete resection significantly more frequently than EMR (10/12 vs 6/13; P = .05). All ESDH resections were performed as a single piece, whereas a mean (SD) of 2.5 +/- 0.9 resections were needed for EMR (P < .05). The mean (SD) areas of the specimen were 3.63 +/- 1.20 cm(2) in the ESDH group and 1.83 +/- 0.78 cm(2) in the EMR group (P < .0001). ESDH was performed with a larger amount of fluid for injection and hydrodissection compared with EMR (78.1 +/- 32.8 mL vs 20.9 +/- 7.6 mL; P < .001). The procedural duration was longer for ESDH than for EMR (28.2 +/- 11.9 minutes vs 12.2 +/- 4.9 minutes; P < .001). ESDH and EMR caused bleedings in 6 of 12 and 5 of 13 of the cases (P = .09), respectively. Hemostasis could be achieved in all cases. There was no perforation in either group. Resection of artificial non-neoplastic lesions, small numbers, an animal trial. ESDH achieves complete resection of esophageal lesions significantly more frequently with a fewer number of specimens than EMR. ESDH is more time consuming, but the procedural duration seems to be shorter than conventional ESD because there is no need for exchange of devices for injection and cutting. The easy use of water-jet-assisted repeated injections of fluids may explain why ESDH was as safe as EMRC.

Randomized Controlled Study of Endoscopic Mucosal Resection (EMR) Versus Endoscopic Submucosal Dissection with a Waterjet Hybridknife (ESDH) of Esophageal Lesions in a Porcine Model

Introduction: Uncontrolled studies indicated that ESD is superior to EMR for en-bloc resection of gastrointestinal mucosal lesions. However, ESD is technically difficult and seems to be more time-consuming and hazardous than EMR. In addition experience with this method is limited in the esophagus although there may be more clinical applications for esophageal lesions than for gastric lesions in Western countries. The objective of our study is to compare a new simplified ESD technique with conventional EMR. Methods and aims: The study was performed in 6 pigs under general anesthesia. A total of 25 esophageal areas with a diameter of 20 mm were marked with coagulation spots. These lesions were then randomized to either EMR by use of the cap technique or ESD. Submucosal injection of saline solution was used for both methods. ESD was done with a hybrid knife which allows cutting / coagulation as well as injection / flushing through an axial water-jet channel with a preselected pressure of a high pressure waterjet system (Erbe Jet 2). Intraoperative bleedings were treated with hemostatic forceps. Primary objective: to achieve complete resection of the lesions including the coagulation markers with no mucosal bridges; secondary objectives: to minimize the number of specimen, to determine the complication rate and procedural duration. Results: 13 lesions were randomized to EMRC and 12 to ESDH. ESDH achieved complete resection significantly more frequently than EMRC (10/12 versus 6/13 p = 0.05). All ESDH resections were performed as a single piece whereas a mean ( ± SD) of 2.5 ± 0.9 resections were needed for EMRC (p < 0.05). Mean areas of the specimen were 4.7 ± 0.7 cm2 in the ESDH group and 3.7 ± 1.2 cm2 in the EMRC group (p < 0.04). ESDH was performed with a larger amount of fluid for injection/flushing compared to EMRC (78.1 ± 32.8 ml vs 20.9 ± 7.6 ml; p < 0.001). The procedural duration was longer for ESDH than for EMRC (28.2 ± 11.9 min vs 12.2 ± 4.9 min; p < 0.001). ESDH and EMRC caused bleedings in 6/12 and 5/13 (p = 0.09) of the cases, respectively. Hemostasis could be achieved in all cases. There was no perforation in both groups. Conclusions: This randomized controlled trial shows that ESDH significantly achieves complete resection of esophageal lesions more frequently with less number of specimen than EMRC. ESDH is more time-consuming but the procedural duration seems to be shorter than conventional ESD because there is no need for exchange of devices for injection and cutting. The easy use of water-jet assisted injection of large amount of fluids may explain that ESDH was as safe as EMRC in spite of the thin esophageal wall in a porcine model.