TECHNICAL TIPS AND TRICKS OF ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION USING THE IT KNIFE NANO

Abstract

Esophageal endoscopic submucosal dissection (ESD) is technically demanding because of the narrow esophageal lumen and thin esophageal wall. The IT knife nano has a shorter blade and smaller backside electrode on the ceramic tip compared with the standard IT2 knife, facilitating esophageal ESD. It allows us to perform safe and efficient mucosal incision and submucosal dissection. It also allows for easy application of the long blade to the submucosal space.

Esophageal ESD is performed with the patient in the left lateral position under deep sedation using propofol or general anesthesia. The use of deep sedation using propofol or general anesthesia is part of the protocol for ESD established at our hospital. First, after sufficient submucosal injection of sodium hyaluronate, semi-circumferential mucosal incision of the left side of the esophagus is performed using the IT knife nano and a dual knife. It is not necessary to press the ceramic tip of the IT knife nano against the submucosa as much as in gastric ESD. Next, submucosal dissection of the left side of the esophagus is performed. The tissue of the submucosa is hooked and lifted with the long blade of the IT knife nano, and the submucosal layer is dissected from inside to outside up to the left edge of the submucosal plane. This procedure is continued up to the distal left edge to shift the lesion against gravity, preventing muscle injury and perforation. After completion of submucosal dissection, the clip-and-line traction technique is routinely performed. This procedure provides sufficient tissue traction proximally and opens the submucosal space, allowing safe and efficient submucosal dissection. During esophageal ESD, it is very important to control carbon dioxide insufflation, which should be less than that during screening and diagnostic esophagogastroduodenoscopy, keeping the submucosa thick and soft.

The IT knife nano is a very helpful device for safely performing esophageal ESD. The IT knife nano can also be used to train less experienced endoscopists in performing esophageal ESD. However, expert hands are required for challenging cases such as an esophageal lesion with severe fibrosis.