Colon - Endoscopic Submucosal Dissection Using a Ball-tip Bipolar Needle Knife for Large Colorectal Tumors
Comments: Background: We previously reported on the safety and usefulness of the bipolar current needle knife (B-Knife) for colorectal endoscopic submucosal dissection (ESD) Therefore remains a slight risk of perforation, however, so we developed a B-knife with a ball shape tip at the end of the needle which further reduces the risk of perforation.
Objective: The aim of this study was to evaluate the safety and efficacy of ESD using the newly developed ball-tip B-knife compared with using a conventional B-knife.
Design and setting:
Case series conducted at the National Cancer Center Hospital (NCCH), Tokyo, Japan
Patients: Patients with 300 Colorectal LST's were included in this study between January 2003 and November 2007. Through December 2006, 229 Colorectal tumors were treated by ESD using a conventional B-knife while 71 colorectal tumors were treated by ESD using ball-tip B-knife beginning in January 2007.
Interventions: ESD procedures were performed using a needle knife and insulation-tip knife (IT knife). After injection of glycerol and sodium hyaluronate acid into the submucosal (sm) layer, a circumferential incision was made and sm dissection was performed. All lesions were determined to be intramucosal or sm superficial by magnified colonoscopy before treatment. Main outcome measurements: We recorded tumor size, operation time, en-bloc resection rate and complications.
Case 1
A 35mm LST-granular type was located on the appendices orifice. This patient had a history of appendectomy, so fibrosis and non-lifting sign were expected. In fact non-lifting sign was observed after submucosal injection. A conventional EMR would have resulted in piecemeal resection because of severe fibrosis, so ESD was performed on this lesion.
Video
After injection of glycerol and sodium hyaluronate acid into the sm layer a marginal incision was made using a conventional b-knife. An attachment is necessary for colorectal ESD in order to visualize the cutting .line directly using counter-traction on the resected specimen. After a circumferential incision was made, sm injection of hyaluronate acid was added.
This is the newly-developed ball-tip b-knife which is safer due to the small tip at the end of the needle. This ball tip is not insulated but the risk of perforation is lower because of its round shape which enables it to hook the tissue like a Hook-knife.
The length of the needle is adjustable from 0mm to 3mm. We shorten the needle length when the knife approaches the lesion vertically and use the whole length when the knife approaches the submucosal layer horizontally depending on the situation.
ESD in the cecum bottom is more difficult because the cecum wall is thinner compared to other colon sites and the B-knife should approach the lesion vertically rather than horizontally. This is the fibrosis area after appendectomy and the ball-tip B-knife was very useful for the dissection of this fibrotic tissue.
An en-bloc resection was achieved without complication within 60 minutes.
After the en-bloc resection and the resected specimen.
Histological diagnosis was a well differentiated adenocarcinoma and the depth of invasion was intramucosal. A curative resection was achieved.
Case 2
A slightly reddened 0-IIb lesion was identified in the Recto-sigmoid colon. Since only redness and disappearance of the micro-vascular pattern were the findings for this lesion, detection was very difficult even using NBI.
After injection of glycerol and sodium hyaluronate acid into the sm layer, a marginal incision was made using a conventional B-knife. An attachment is necessary for colorectal ESD in order to visualize the cutting line directly using counter-traction for the resected specimen. After a circumferential incision was made. Sm injection of hyaluronate acid was added.
This is the newly-developed ball-tip B-knife which is safer due to the small tip ar the end of the needle. This ball tip is not insulated but the risk of perforation is lower because of its round shape which also enables it to hook tissue like a Hook-knife.
The length of the needle is adjustable from 0mm to 3mm. We shorten the needle length when the knife approaches the lesion vertically and use the whole length when the knife approaches the submucosal layer horizontally depending on the situation. An IT-knife makes the ESD procedure faster due to its longer blade. En-bloc resection was achieved without complication.
This is the ulcer bed after en-bloc ESD. The resected specimen revealed a well differentiated adenocarcinoma and the depth of this lesion was intramucosal. A curative resection was achieved.
Results: A total of 300 colorectal ESD's were performed. Mean tumor size was larger in the second group using the ball-tip B-knife with a average resectec specimen size of 45mm (range, 20-120mm) compared to the first group using a conventional B-knife with an average resected specimen size of 37mm (range, 20-150mm). There were no significant differences in operation times and en-bloc resection rates between the two groups. Most importantly, there were no perforation in the second group using the ball-tip B-knife.
Limitations: The number of ESD's using the ball—tip B-knife in our series was limited and there was a possible learning curve in the first group when using a conventional B-knife.
Conclusion: ESD using the newly developed ball-tip B-knife is a safe effective technique for large colorectal tumors.
| Contributed by: |
Yutaka Saito, MD, PhD Physician National Cancer Center Hospital, Japan |
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Citation: Saito, Y. (May 19 2008). Colon - Endoscopic Submucosal Dissection Using a Ball-tip Bipolar Needle Knife for Large Colorectal Tumors. The DAVE Project. Retrieved Sep, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=761 Times viewed since Feb 2006: 4690 |
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