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Innovative endoscopic devices have been developed and are now commercially available, which have contributed to the spread of the endoscopic submucosal dissection (ESD) technique for superficial neoplastic lesions.
In particular, needle-type diathermy knives with a waterjet function enable injection into the submucosal area from the tip of the knife immediately after the cutting maneuver.
An electrosurgical endoknife with a water-jet function (flushknife) proves its merits in colorectal endoscopic submucosal dissection especially for the cases which should be removed en bloc.
This may reduce the number of times the knife is moved through the working channel, leading to a shorter procedure time.
However, once massive bleeding occurs during ESD, hemostasis is often difficult because of the poor visibility that results from outflowing blood, even with the use of a waterjet function. To overcome this problem, hemostatic forceps are separately and repeatedly used. This leads to a high therapeutic cost and extended procedure time.
The Endosaber (Sumitomo Bakelite, Tokyo, Japan) is a newly developed, multifunctional, needle-type knife with 4 tiny channels at the tip of the sheath capable of both suctioning and injecting. The first-equipped feature distinct from conventional endoscopic devices is the suction function, which enables clear visibility of the arterial bleeding point. The tip of the sheath can come directly into contact with the bleeder and, with suction, clear the field at the same time.
Here, we describe several characteristics of the Endosaber in 2 case presentations of ESD (1 gastric and 1 colonic), along with a video (Video 1, available online at www.VideoGIE.org).
Patient 1 was an 88-year-old man with a 10-mm, 0-IIa type adenocarcinoma in the lesser curvature of the gastric angle. We performed gastric ESD using the Endosaber knife with an electrosurgical unit (VIO 300D; cut mode, Endocut I, effect 4, duration 3, interval 3; coagulation mode, Forced Coag, effect 2, 80 W; Erbe Elektromedizin GmbH, Tuebingen, Germany). Four tiny ports at the tip of the sheath can both suck and inject liquid; to use suction, the assistant manually applies negative pressure to the distal end of the sheath using a syringe. This function maintains visibility at the operation site while sucking up bloody fluid, enabling the endoscopist to recognize the bleeding point and perform precise hemostasis (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6). Furthermore, in comparison with conventional needle-type knives, the ball-shaped tip is slightly thicker in diameter, possibly leading to a higher hemostatic ability against submucosal blood vessels.
Figure 1Poor visibility due to spurting blood during performance of a circumferential incision.
Patient 2 was a 61-year-old woman with a 60-mm, 0-IIa type tumor (laterally spreading granular type) in the ascending colon. We performed colonic ESD using the Endosaber knife with an electrosurgical unit (VIO 300D; cut mode, Endocut I, effect 3, duration 3, interval 3; coagulation mode, Forced Coag, effect 2, 80 W; Erbe Elektromedizin GmbH). As with other commercially available knives with a jet function, it is also possible to inject liquid into the submucosal area through the 4 identical ports (Figs. 7 and 8).
Figure 7Submucosal injection of sodium hyaluronate with use of the waterjet function for a colorectal tumor.
Additionally, the assistant does not need to adjust the length of the tip because the tip is fixed to the end of the sheath and the length is unchangeable. Knives with 3 different tip lengths are currently available: 1.5 mm, 2.0 mm, and 2.5 mm.
In summary, the Endosaber is a novel needle-type knife with the unique characteristic of a suction function. This distinctive feature may enable us to keep clear visibility in the surgical area even while bleeding is occurring.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
An electrosurgical endoknife with a water-jet function (flushknife) proves its merits in colorectal endoscopic submucosal dissection especially for the cases which should be removed en bloc.
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