Keywords
endoscopic submucosal dissection - hybrid knife - hydrodissection - polyp
A 75-year-old patient who underwent colonoscopy that showed a cecal malignant polyp
was referred to our hospital for right colectomy ([Fig. 1]). Our multidisciplinary team decided to perform endoscopic submucosal dissection
(ESD).
Fig. 1 Cecal polyp of 3 cm size with a demarcated central, showing suspicious pattern of
submucosal invasion.
ESD was performed using ERBEJET 2 hydrodissection system and hybrid Knife (ERBE, Germany)
([
video 1
]). The lesion was elevated using selective-regulation high-pressure water-jet method.[1] Poor endoscopic operability due to paradoxical movements of the colonoscope resulted
in poor vision of the submucosa layer to safely perform dissection. In these situations,
the device is usually exchanged for another that facilitates the technique.[2] However, we continued ESD using a type T hybrid knife in “traction mode” ([Fig. 2]). With the use of this knife in an open position, it was possible to perform a T-tip
dissection that enabled traction and cutting of the submucosal tissue, similar to
HookKnife (Olympus, Japan). In this way, the colonoscope remained in a stable position
and slow and delicate movements were performed at a distance by pulling the tissue
toward the endoscope to perform the dissection. This technique enables clear vision
of the lesion, improving the dissecting process at the level of the deep submucosal
plane, including a perpendicular approach to the muscular layer, although it requires
maximizing operator’s vigilance.
Video 1
Endoscopic submucosal hydrodissection with paradoxical movement of the colonoscope
using hybrid knife in “traction mode” of a polyp with invasive submucosal carcinoma
in the cecum. Online content including video sequences viewable at: https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0041-1726155.
Fig. 2 Endoscopic submucosal hydrodissection using type T hybrid knife as “traction mode.”
The resection was completed en bloc within 135 minutes without adverse events ([Fig. 3a],[b]). Pathology examination revealed a well-differentiated adenocarcinoma confined to
the shallow submucosal layer with free resection margins ([Fig. 3c]). Oncological and endoscopic follow-up was relapse-free after 48 months from ESD.
Fig. 3 Post procedure. (a) Resection surface. (b) Resected specimen after endoscopic dissection submucosal (c) Histological examination show a tubular adenoma with an area of well-differentiated
adenocarcinoma confined to the shallow submucosal layer (<1,000 μm) without evidence
of lymphovascular or perineural invasion, absence of tumor budding, and free resection
margins.
The water-jet hydrodissection technique has been shown to be effective for colorectal
tumors.[3]
[4] This case report illustrates that type T hybrid knife is a useful device not only
for the elevation of the submucosal layer, cutting the mucosa, dissecting submucosal
fibers and small vessels, or stopping bleeding but also for cutting with traction.
