A combination of pocket, double-clip countertraction, and isolated HybridKnife as a quick and safe strategy for colonic endoscopic submucosal dissection

Abstract

A combination of pocket, double-clip countertraction, and isolated HybridKnife as a quick and safe strategy for colonic endoscopic submucosal dissectionThe colon is considered to be one of the most technically challenging locations for endoscopic submucosal dissection (ESD) when superficial neoplastic lesions are being treated [1]. The difficulties include: the colonic loops, intestinal motility, the folded anatomy, problems caused by inconstant gravity, and constant modification of the operative fieldof-view attributable to insufflation. Good exposure of the submucosal layer is key for safe and efficient ESD; this can be particularly challenging in the colon where it is difficult to maintain a tangential position close to the muscle layer. Although individual physicians will prefer certain tips or tricks with which they are familiar, little information is available on combinations of these technical approaches. As case numbers are increasing worldwide, and as colorectal cancer screening programs are becoming more common and effective, further technical improvements are imperative. Here, we report on our treatment strategy for colonic ESD and seek to facilitate the resection of large superficial colonic lesions. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.First, we perform a careful diagnostic evaluation using a high-definition endoscope (HQ190, Olympus). We then begin ESD using a dedicated endoscope that allows retroflexion throughout the colon (Pentax Ultraflex; 580 RD, Fujinon). Each procedure commences using a DualKnife to create a mucosal incision at one side of the lesion (▶ Fig. 1 a); we then create a pocket under the lesion ( ▶ Fig. 1 b).Further development of a pocket-like tunnel facilitates a perfect view of the submucosal layer, avoiding leakage of submucosal fluid and stabilizing the endoscope beneath the lesion. After a large pocket has been created, we complete the mucosal incision around the lesion ( ▶ Fig. 1 c). The first clip, attached to a small ring of suture thread, is passed through the operative channel and fixed beneath the lesion (▶ Fig. 1 d). The suture thread is then grasped by another clip and attached to the opposite colonic wall. This double-clip technique (also termed ring-thread countertraction) allows the remnant submucosal fibers to be tensioned ( ▶ Fig. 1 e). Use of a HybridKnife type O (Erbe Medical, Tübingen, Germany), which has an isolated tip and the capacity to deliver high-pressure injections, allows rapid and safe completion of the procedure with a perfect view of the submucosal space (▶ Fig. 1 f; ▶ Video 1). We use this strategy to efficiently, rapidly, and safely treat most patients who require colonic ESD. We suggest that such a strategy could help to make the use of colonic ESD more widespread and avoid the need for surgery for large colonic superficial neoplasia. Endoscopy_UCTN_Code_TTT_1AQ_2ADCompeting interests

Pocket-creation method improves efficacy of colorectal endoscopic submucosal dissection: a system review and meta-analysis

“…PCM-ESD was first introduced by Yamamoto, et al [7][8][9]. In recent years, several studies reported the usefulness of PCM-ESD for colorectal neoplastic lesions with giant size, difficult location, different tumor types or postsurgery conditions [7,8,10,11,[18][19][20][21][22][23][24][25]. According to the experience of endoscopists, this new ESD strategy has several advantages over C-ESD.…”

The combination needle injection-incision technique using the two-in-one needle-snare device for knife-assisted resection

“…In order to perform advanced resections that require submucosal injection of substances such as endoscopic submucosal dissection (ESD) or hybrid endoscopic submucosal dissection/endoscopic mucosal resection (ESD-EMR), several instruments are required, including an injection needle, incision needle, and dissection knives and/or snaring devices 1 2 3 4 5 . The present report describes a novel and simple method that involves using a two-in-one device that combines a needle and a snare.…”

Colorectal Endoscopic Submucosal Dissection: Performance of a Novel Hybrid-Technology Knife in an Animal Trial

“…The Hy-bridKnife is also used for marking the targeted lesion, circumferential cutting, submucosal dissection, and coagulation, making it the only device available to perform the entire ESD procedure without exchanging multiple devices [25,[31][32][33]. Colorectal lesions are comparatively difficult to treat due to the very thin intestinal wall and other anatomic difficulties [34][35][36][37][38][39]. Despite its theoretical advantages, the HybridKnife is not extensively used in colorectal ESD.…”