Clin Endosc.  2014 Nov;47(6):544-554. 10.5946/ce.2014.47.6.544.

Endoscopic Submucosal Dissection Using a Novel Versatile Knife: An Animal Feasibility Study (with Video)

• Kwon CI
• Kim G
• Chung IK
• Kim WH
• Ko KH
• Hong SP
• Jeong S
• Lee DH

• KMID: 2134493
• DOI: http://doi.org/10.5946/ce.2014.47.6.544

Abstract

BACKGROUND/AIMS
In order to reduce the procedure time and the number of accessory changes during endoscopic submucosal dissection (ESD), we developed a novel versatile knife, which has the combined advantages of several conventional knives. The aim of this study was to compare the efficacy, safety, and histological quality of ESD performed using this novel versatile knife and a combination of several conventional knives.
METHODS
This was an in vivo animal study comparing two different modalities of ESD in mini-pigs. Completion time of each resection was documented, and the resected specimens were retrieved and evaluated for completeness. To assess the quality control of the procedures and adverse events, detailed histopathological examinations were performed.
RESULTS
A total of 18 specimens were dissected by ESD safely and easily (nine specimens using the new versatile knife; nine specimens by mixing conventional knives). All resections were completed as en bloc resections. There was no significant difference in procedure time between the 2 modalities (456 seconds vs. 355 seconds, p=0.258) and cutting speed (1.983 mm2/sec vs. 1.57 mm2/sec, p=1.000). The rate of adverse events and histological quality did not statistically differ between the modalities.
CONCLUSIONS
ESD with a versatile knife appeared to be an easy, safe, and technically efficient method.

Keyword

Equipment and supplies; Endoscopic submucosal dissection; Models, animal; Instrumentation

MeSH Terms

Animals
Equipment and Supplies
Feasibility Studies*
Models, Animal
Quality Control

Figure

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  Fig. 1 The novel versatile knife (Optimos knife; Taewoong Medical) used in this study. (A) The Optimos knife has a 1.9-mm-wide and 2.5-mm-long anchor-shaped tip, which can be smoothly and fully rotated by controlling the dial on the handle of the knife. (B) The outer sheath can perform the water injection function. (C) The handle of the knife.

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  Fig. 2 Endoscopic submucosal dissection (ESD) procedures in the animal model. (A) Markings were made with the tip of the Optimos knife (Taewoong Medical) in the soft coagulation mode. (B) The mixed solution was repeatedly injected into the submucosal layer. (C-E) The tip of the Optimos knife was used to make the incision along the markings, using the endocut mode. (F-J) Submucosal dissection was carried out using the forced coagulation mode. The vessel was coagulated by the hooking method using the soft coagulation mode and cut using the endocut mode. (K, L) The distal remnant mucosal area was cut with the hooking method. (M-O) The knife can coagulate the small vessels of a ramified vascular network in a forced coagulation mode. (P, Q) The water injection system was used to keep enough fluid in the submucosa for continuous submucosal dissection. (R, S) The Coagrasper forceps were used to control major bleeding from large vessels, using the soft coagulation mode. (T) The post-ESD ulcers were shown to prevent bleeding afterward. (U-X) Three conventional knives (the IT-2, the Hook Knife, and the Dual knife) were used for ESD in the combination knives group.

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  Fig. 3 Part of the stomach harvested from the second pig. Target lesions were centered on the greater curvature of the gastric body. The resected stomachs were incised along the lesser curvature to expose the interior, where no abnormality such as bleeding or perforation was found. The surrounding normal tissues were damaged and changed, but were not detected during endoscopic submucosal dissection. All numbers represent sequentially resected areas.

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  Fig. 4 Tissues from resected specimens pinned on a rubber board after formalin fixation. (Inset) Resected specimens just after the procedure.

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  Fig. 5 Representative histological findings of endoscopic mucosal dissection (ESD) specimens and residual muscularis propria tissue from the Optimos knife group (A-D) and combination knives group (E-H; H&E stain). (A, B) ESD showing minimal injury to the lamina propria and submucosa in the Optimos knife group. (C, D) Residual bed tissue showing minimal injury to the lamina propria and muscularis propria in the Optimos knife group. (E, F) ESD showing minimal injury to the lamina propria and submucosa in the combination knives group. (G, H) Residual bed tissue showing marked injury in the lamina propria and muscularis propria in the combination knives group. Arrows represent the extent of injury. Scale bars represent 50 µm in (B) and (F) and 500 µm in the others.

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  Fig. 6 Comparison of the levels of histological injury between the Optimos knife group and the combination knives group. (A) Extent of injury to the lamina propria in the dissected gastric specimens. (B) Extent of injury to the lamina propria in the remaining gastric bed tissue. (C) Depth of injury to the submucosa in the dissected gastric specimens. (D) Depth of injury to the MP in the remaining gastric bed tissue. LP, lamina propria; ESD, endoscopic mucosal dissection; SM, submucosa; MP, muscularis propria.

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