Dualknife kd 650l

Third-space EFTR involved several endoscopic procedures (
Fig. 1). First, a circumferential mucosal incision was made around the lesion using the DualKnife (KD-650-L; Olympus Co. Ltd, Tokyo, Japan) after submucosal injection, and then the submucosa on the lateral side was undermined to enlarge the submucosal space. Second, a submucosal tunnel 3 to 4 cm in length was created on the proximal side of the lesion by removing the proximal mucosa with the ESD technique and suturing the lateral mucosa with the EHS technique in the shape of a tunnel or by simply using the per-oral endoscopic myotomy (POEM) technique
12 (link)
. Third, the mucosa surrounding the lesion was linearly sutured using the EHS technique, with the lesion extruded towards the outside. Fourth, submucosal dissection was performed around the lesion through the submucosal tunnel to broaden the “third space” around the lesion until the endoscope could smoothly approach the muscular layer around the lesion. Fifth, a seromuscular incision was made circumferentially to remove the lesion, and it was transorally retrieved through the submucosal tunnel. The procedure was completed with entry site closure using the EHS technique or clipping.

ESD was performed with either a single-channel or a 2-channel endoscope (GIF-Q260J, GIF-H290Z, and GIF-2TQ260M; Olympus, Tokyo, Japan), and with either a FlushKnife BT (DK2618JB; Fujifilm, Tokyo, Japan) or a DualKnife (KD-650L; Olympus, Tokyo, Japan) as the electrosurgical knife. ESD procedures were performed predominantly by four expert endoscopists who have performed more than 300 gastric ESDs. For the procedure, markings were made with the electrosurgical knife around the lesion. Sodium hyaluronate was injected into the submucosal layer, and a circumferential mucosal incision outside the markings was made with the electrosurgical knife. Subsequently, submucosal dissection of the lesion was performed, and pre-coagulation of visible vessels with hemostatic forceps (FD-230U or FD-410LR; Olympus, Tokyo, Japan) was performed during the submucosal dissection. After removal of the lesion, all visible vessels on the artificial ulcer bed were coagulated with hemostatic forceps. Neither endo-clip suturing and poly-glycolic acid sheet patching was done for post-ESD ulcer in this study.

The indications for ESD included intramucosal differentiated-type early gastric cancer (EGC) of any size without ulceration or signs of submucosal invasion, intramucosal differentiated-type EGC <30 mm in diameter with a scar but no lymph node involvement or distant metastases, and undifferentiated-type EGC <20 mm in diameter without a scar.
ESD was performed with a conventional singe-channel endoscope with a forward water-supply function (GIF-H260Z or Q260J; Olympus, Tokyo, Japan). The ESD process is shown in Fig. 2. The Dual Knife (KD-650L; Olympus) was the most commonly used endoscopic device. Hyaluronic acid solution was injected into the submucosal layer for the mucosal incision, while physiological salt solution was used for submucosal dissection. The ESD-induced ulcer was carefully examined, and any visible vessels were coagulated by homeostatic forceps (FD-410 L; Olympus). A VIO300D electrosurgical generator (ERBE, Tuebingen, Germany) was used, and the ESD procedure was performed by two endoscopists. ESD was performed with the withdrawal of anticoagulant or antiplatelet therapy. All subjects underwent a scheduled second-look endoscopy. Anticoagulant or antiplatelet therapy was resumed after the second-look endoscopy.

Enrolled patients (n = 300) underwent endoscopic examinations and ESD procedures performed by experts with much experience in ESD. ESD knives and electrocautery settings are DualKnife (KD-650L; Olympus, Tokyo, Japan), ITknife2 (KD-611L; Olympus), Coagrasper (FD-410LR; Olympus), and Gastroscope (GIF-Q260J; Olympus). The margin of resection was marked using electrocoagulation and included approximately 0.5 cm of normal mucosal tissue around the lesion. We injected normal saline into the submucosa to lift the lesion and separate the submucosa from the muscular layer. The mucosa and submucosa on the outer edge of the lesion were incised along the previously marked margin. Then, the submucosa was dissected until the mucosal lesion had been completely resected. Electrocoagulation was applied to exposed blood vessels in the post-ESD resection defects. The resected specimen was sent for pathologic examination. The measurements of the resected lesion and mucosal defects were recorded.

All ESD procedures were performed by either an experienced endoscopist or a resident under the supervision of an experienced endoscopist. The ESD procedure was carried out as previously described (10 (link)). The ESD procedure consisted of the following: Marking around a lesion, mucosal incision, submucosal dissection, and lesion removal. Just after the removal of the specimen, the created ulcer was carefully examined, and any visible vessels and adherent clots were coagulated. Clip closure or cover with a polyglycolic acid sheet was not performed in any of the cases. The time for the ESD procedure was measured from the start of marking until the completion of post-ESD coagulation. The ESD procedure was performed using an ITKnife2 (KD-611L; Olympus Medical Systems, Tokyo, Japan), a DualKnife (KD-650L; Olympus), an ITKnife (KD-610L; Olympus), or an ITknife nano (KD-612; Olympus). A Coagrasper (FD-411UR; Olympus) was mainly used as hemostatic forceps and a VIO 300D (ERBE Elektromedizin, Tübingen, Germany) was used as a high-frequency generator. Either a proton pump inhibitor or a vonoprazan was administered for 5 to 8 weeks after the ESD.