A COMBINED ELECTROSURGICAL KNIFE AND LIFT INJECTION CATHETER FACILITATES ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) AND SHORTENS THE POLYPECTOMY TIME VS STANDARD NEEDLE KNIFE IN AN EX VIVO BOVINE LARGE BOWEL MODEL.
Neil Mitra*, Dhananjika S. Samarakoon, Yanni Hedjar, Xiaohong Yan, Vesna Cekic, Hmc Shantha Kumara, Richard L. Whelan
Northwell Health, New Hyde Park, NY
Introduction: Endoscopic Submucosal Dissection (ESD) permits en bloc resection of sessile colon polyps and is the gold standard. A critical requirement for ESD is a mucosal lift that expands the submucosal layer. Unfortunately, the lift decreases with time and as dissection proceeds it is necessary to re-inject the bowel wall multiple times to re-expand the submucosa. When using a standard needle knife it is necessary to remove the knife from the scope, insert the sclerotherapy catheter and then make the injection after which the tools are exchanged again. This process takes time including the maximum lift period immediately after reinjection. An electrosurgical knife (knife-J) with an injection catheter running in the knife's center is now available that allows mid-case re-lifts without instrument exchange. The lift injections are made directly into the submucosa through the cut edge with a syringe or standard endoscopy pump and immediate tissue cutting is possible (high pressure pump not required). This study assessed this knife's utility by performing ESD cases with the new and old knives and comparing the results.
Methods: Bovine colons (rectum/anal sphincter) were mechanically cleaned, prepared with preservation solution, and stored at -80°C. After thawing, 2 simulated mucosal lesions/colon were made 25-30cm from anus via colotomy that was subsequently closed. The colon was affixed to a peg board and the ends closed with zip ties. In each colon, 1 lesion was resected using the new knife (Knife-J) and 1 with the regular needle knife (Knife-R). All ESD cases were done by 1 endoscopist using a colonoscope. Case length, muscle injuries, volume of lift solution used (normal saline), and number of instrument exchanges per case noted. A Wilcoxon matched-pairs signed rank test was used to compare the 2 knives (p < 0.05 significant).
Results: Eighteen ESDs were carried out with each knife (36 lesions total, 18 colons). Resections were complete and equivalent. Knife-J cases were finished in less time (median[m]=35 minutes [min], range 25.5-50 min) compared with Knife-R cases (m=40.5 min, range 25.5-63 min, p=0.0176). Fewer instrument exchanges were required in Knife-J (m=2/case, range 1-5) than in Knife-R cases (m=10, range 4-18, p<0.0001). Slightly fewer muscle injuries occurred in Knife-J (m=4/case, range 0-12) vs. Knife-R cases (m=5, range 1-18/case, p=0.1722). Of note, more lifting solution was used with Knife-J cases (m=80 ml, range 43-163ml) than in Knife-R cases (m=59.5 min, range 36-151ml, p=0.0737).
Conclusions: In this model, the combined knife/catheter was associated with significantly shortened case times and the number of instrument exchanges needed for ESD; also fewer deep muscle injuries were noted with the Knife-J. The catheter/knife offers clear advantages over standard knifes and should be assessed in the clinical setting.
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