Advertisement
Original article| Volume 8, ISSUE 3, P96-99, March 2023

Download started.

Ok

Endoscopic submucosal dissection using an integrated needle-type knife and insulated-tip knife in a single device

Open AccessPublished:February 09, 2023DOI:https://doi.org/10.1016/j.vgie.2022.11.013

      Video

      (mp4, (114.06 MB)

      Endoscopic submucosal dissection using a multifunctional endoscopic submucosal dissection knife.

      Abbreviation:

      ESD (endoscopic submucosal dissection)

      Background

      Endoscopic submucosal dissection (ESD) allows for en bloc endoscopic resection of superficial lesions throughout the GI tract and is the first-line therapy for the endoscopic management of early gastric neoplasia.
      • Ono H.
      • Yao K.
      • Fujishiro M.
      • et al.
      Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition).
      ,
      • Choi I.J.
      • Lee J.H.
      • Kim Y.I.
      • et al.
      Long-term outcome comparison of endoscopic resection and surgery in early gastric cancer meeting the absolute indication for endoscopic resection.
      ESD requires familiarity with various specialized endoscopic knives that have been developed for mucosal incision and submucosal dissection.
      • Ge P.S.
      • Aihara H.
      Advanced endoscopic resection techniques: endoscopic submucosal dissection and endoscopic full-thickness resection.
      Currently, the most common knives used for ESD include the needle-type knife and the insulated-tip knife.
      • Gotoda T.
      • Kondo H.
      • Ono H.
      • et al.
      A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases.
      • Kakushima N.
      • Ono H.
      • Tanaka M.
      • et al.
      Endoscopic submucosal dissection using the insulated-tip knife.
      • Yamashita T.
      • Zeniya A.
      • Otani S.
      Endoscopic submucosal dissection (ESD) using the needle knife: its superiority to ESD using the insulation-tipped diathermic knife in physicians intending to master ESD.
      Recently, a novel multifunctional electrosurgical knife (ProdiGI Multi-Functional ESD Knife; Medtronic, Minneapolis, Minn, USA) was introduced (Fig. 1). This knife incorporates both a noninjectable needle-type knife (I-Knife) and an insulated-tip knife (O-Knife) into a single device designed to fit in a standard 2.8-mm endoscope working channel. There are 2 versions of the knife corresponding to the length of the I-Knife (1.5 mm and 2 mm). The O-Knife measures 4 mm in length in both versions. The endoscopist can promptly switch from one cutting technique to another by simply opening the handle of the device to use the I-Knife and advancing the sheath on the device while keeping the handle closed to use the O-Knife. Using this knife, the endoscopist can make the initial circumferential mucosal incision with the I-Knife, and then complete the submucosal dissection with either the I-Knife or the O-Knife depending on the orientation of the submucosal dissection plane. Here, we present 2 cases of gastric ESD using this device, demonstrating its advantages and potential limitations (Video 1, available online at www.giejournal.org).
      Figure thumbnail gr1
      Figure 1The novel multifunctional endoscopic submucosal dissection knife in its I-Knife (A) and O-Knife (B) configurations.

      Procedure

      In the first case, a 77-year-old man with esophageal lichen planus was found on surveillance to have a dysplastic lesion in the gastric antrum. ESD was proposed to obtain clear margins to reduce the burden of surveillance endoscopies because of the patient’s comorbidities. After the patient underwent general endotracheal anesthesia, a gastroscope (GIF-HQ190; Olympus America, Center Valley, Pa, USA) with transparent cap was advanced to the stomach. A 15-mm lesion (Paris IIa) was found along the lesser curve of the gastric antrum. Submucosal lifting was performed with a 6% hetastarch solution, and ESD was performed with the multifunctional knife. The initial circumferential mucosal incision was made using the I-Knife. Subsequently, submucosal dissection was performed using a combination of the I-Knife and the O-Knife. Visible vessels were coagulated without difficulty. With a reliable submucosal lift and no significant submucosal fibrosis, a 35- × 30-mm en bloc resection without perforation was attained in 12 minutes. Visible vessels within the resection defect were coagulated using hemostatic forceps, and a self-assembling peptide (PuraStat; 3-D Matrix Medical Technology, Tokyo, Japan) was applied for prophylaxis against postpolypectomy bleeding (Fig. 2). Final histopathology demonstrated tubular adenoma with low-grade dysplasia, with negative horizontal and vertical margins (Fig. 3). The patient was discharged home following the procedure with an uncomplicated recovery course.
      Figure thumbnail gr2
      Figure 2A, A patient was referred for resection of a dysplastic lesion at the gastric antrum. B, Initial mucosal incision was made using the I-Knife. Submucosal dissection was performed using a combination of the I-Knife (C) and O-Knife (D). Endoscopic appearance of resection defect (E) and specimen (F) after en bloc resection.
      Figure thumbnail gr3
      Figure 3Histopathology consistent with a tubular adenoma with low-grade dysplasia. Peripheral and deep margins of resections are free of dysplasia. A, H&E stain (orig. mag. ×20). B, H&E stain (orig. mag. ×200).
      In a second case, a 78-year-old woman with hereditary nonpolyposis colorectal cancer was found during routine surveillance to have early gastric cancer in the gastric body with biopsies indicating intramucosal adenocarcinoma. ESD was indicated for staging and possible definitive endoscopic management. A 10-mm lesion (Paris IIa+IIc) without ulceration or endoscopic features of deep submucosal invasion was found along the greater curvature of the mid-gastric body. The lesion was fibrotic, and submucosal lifting with hetastarch was noted to be suboptimal. The circumferential mucosal incision was made using the I-Knife. Submucosal dissection was attempted using both the I-Knife and the O-Knife functions. However, dense submucosal fibrosis was encountered, and multiple device exchanges were necessary with an injection needle to provide additional submucosal lifting. A suture-clip traction strategy was attempted; however, this also did not improve visualization of the submucosal dissection plane. Ultimately, because of extensive submucosal fibrosis, a hybrid ESD approach was used and the lesion was resected en bloc using an endoscopic snare. A 30- × 25-mm area was resected without perforation in 35 minutes, and the patient was discharged home with an uncomplicated recovery course (Fig. 4). Final histopathology showed a noncurative resection with moderately differentiated adenocarcinoma with submucosal invasion (pT1b) and lymphovascular invasion, with negative horizontal and vertical margins (Fig. 5). The patient was presented in a multidisciplinary tumor board with ultimate recommendation for systemic immunotherapy.
      Figure thumbnail gr4
      Figure 4A, A patient was referred for resection of early gastric cancer in the gastric body. B, Initial mucosal incision was made using the I-Knife. C, Submucosal dissection was attempted using the multifunctional knife, with significant fibrosis noted. D, The lesion was ultimately resected with hybrid endoscopic submucosal dissection. Endoscopic appearance of resection defect (E) and specimen (F) after en bloc resection.
      Figure thumbnail gr5
      Figure 5Histopathology consistent with invasive moderately differentiated adenocarcinoma with submucosal and lymphovascular invasion. A, H&E stain (orig. mag. ×40). B, H&E stain (orig. mag. ×200).

      Discussion

      The multifunctional knife combines the 2 most common electrosurgical knife configurations, allowing for the user to easily switch between the knives without device exchange and without consideration for additional procedural costs related to opening a second device. The first case in this video demonstrated the capabilities of this novel knife in facilitating an efficient en bloc resection with no device exchanges. A multifunctional knife allowed the endoscopist to easily switch resection strategies when the situation became unfavorable for the I-Knife, allowing the remainder of the resection to be safely completed with the O-Knife.
      However, there are also potential device-related limitations. As demonstrated in the second case, the lack of a water-injection capability resulted in multiple device exchanges for an injection needle in the setting of dense submucosal fibrosis, which led to conversion to an ultimately successful hybrid ESD approach. Significant fibrosis in this case was likely because of a combination of submucosal invasion and extensive preprocedure biopsies. In this setting, an injectable needle-type knife may have been more successful because of the ability to provide rapid submucosal lifting in unfavorable situations.
      • Huang R.
      • Yan H.
      • Ren G.
      • et al.
      Comparison of O-Type HybridKnife to conventional knife in endoscopic submucosal dissection for gastric mucosal lesions.
      ,
      • Coronel M.
      • Coronel E.
      • Romero L.
      • et al.
      Combination of a dynamic rigidizing overtube and a novel injectable needle-type knife to facilitate colorectal endoscopic submucosal dissection.
      Although the knife is novel in its concept, the true utility of multifunctional ESD knives in real life scenarios remains to be determined. This is particularly the case in the United States, where most third-space endoscopists routinely favor injectable needle-type ESD knives, with occasional use of insulated tip knives as a backup or a secondary knife in limited specific scenarios. The multifunctional ESD knife may therefore be most optimally suited for resection of small lesions that require a limited amount of submucosal injection but which have unusual cutting angles.
      In conclusion, we demonstrated our initial experience with a multifunctional ESD knife, highlighting potential advantages as well as limitations. Ongoing studies will seek to further define the role of this knife and its cost effectiveness in the ESD armamentarium.

      Disclosure

      Dr Ge is a consultant for Alira Health, Boston Scientific, and Ovesco America. All other authors disclosed no financial relationships.

      Supplementary data

      References

        • Ono H.
        • Yao K.
        • Fujishiro M.
        • et al.
        Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition).
        Dig Endosc. 2021; 33: 4-20
        • Choi I.J.
        • Lee J.H.
        • Kim Y.I.
        • et al.
        Long-term outcome comparison of endoscopic resection and surgery in early gastric cancer meeting the absolute indication for endoscopic resection.
        Gastrointest Endosc. 2015; 81: 333-341.e1
        • Ge P.S.
        • Aihara H.
        Advanced endoscopic resection techniques: endoscopic submucosal dissection and endoscopic full-thickness resection.
        Dig Dis Sci. 2022; 67: 1521-1538
        • Gotoda T.
        • Kondo H.
        • Ono H.
        • et al.
        A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases.
        Gastrointest Endosc. 1999; 50: 560-563
        • Kakushima N.
        • Ono H.
        • Tanaka M.
        • et al.
        Endoscopic submucosal dissection using the insulated-tip knife.
        Tech Gastrointest Endosc. 2011; 13: 63-69
        • Yamashita T.
        • Zeniya A.
        • Otani S.
        Endoscopic submucosal dissection (ESD) using the needle knife: its superiority to ESD using the insulation-tipped diathermic knife in physicians intending to master ESD.
        Surg Laparosc Endosc Percutan Tech. 2010; 20: 180-185
        • Huang R.
        • Yan H.
        • Ren G.
        • et al.
        Comparison of O-Type HybridKnife to conventional knife in endoscopic submucosal dissection for gastric mucosal lesions.
        Medicine (Baltimore). 2016; 95: e3148
        • Coronel M.
        • Coronel E.
        • Romero L.
        • et al.
        Combination of a dynamic rigidizing overtube and a novel injectable needle-type knife to facilitate colorectal endoscopic submucosal dissection.
        VideoGIE. 2021; 6: 297-300