Endoscopic submucosal dissection (ESD) enables resection of large or nonlifting gastrointestinal
epithelial neoplasms in an en bloc fashion. However, the high frequency of complications
and the complexity of the procedure need to be improved [1–4]. In collaboration with
the Pentax Corporation, Tokyo, Japan, we have therefore invented a novel electrosurgical
knife for ESD, called the splash needle (DN-2618A; Pentax Corp.), which has an ultra-thin
short needle with a water-jet function ([Fig. 1]. The advantages are: (i) the short needle is adjustable in length (maximum 2.5mm);
(ii) the thinness of the needle (0.3 mm diameter) makes it possible to resect using
only coagulation current from mucosal incision to submucosal dissection, to reduce
the risk of heavy bleeding, or to resect sharply with minimal tissue damage by using
cutting or Endocut current; (iii) the water-jet function from the knife itself allows
the endoscopic view field to be kept clean, bleeding vessels to be easily identified,
and additional submucosal injection to be done without changing the device. A disadvantage
could be that a sharper cutting ability could lead to perforation if the knife is
used incorrectly. A 64-year-old gentleman with a semicircular non-Lugol-staining area
diagnosed as squamous cell carcinoma in the lower esophagus was referred for ESD.
With a preoperative diagnosis of type 0-IIc intramucosal squamous cell carcinoma (m2),
3 cm in size, ESD was performed with a splash needle without complications in an operating
time of 65 minutes, in a similar way to that described previously, with some modification
[5] ([Fig. 2], [Video 1]). The main modifications were:
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A single channel upper GI endoscope with a water-jet system was used (GIF-Q260J; Olympus
Medical Systems Co., Ltd., Tokyo, Japan), which connected to a water-jet supplier
(OFP; Olympus Medical Systems) containing sterile water to wash out blood and mucus
from the target area, to keep the endoscopic view clean, and to identify bleeding
points precisely during the procedure. The knife was connected to another water-jet
supplier (SA-P2; Pentax) containing normal saline to make an immediate and sufficient
submucosal fluid cushion in the area intended to be cut without changing the device.
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The following electrocautery settings (VIO 300D; ERBE Elektromedizin, Tübingen, Germany)
were used: forced coagulation mode (effect 2, output 30 W) for marking and submucosal
dissection, and Endocut Q mode (effect 2, duration 1, interval 3) for circumferential
mucosal incision. This case shows that this novel knife unquestionably has several
functional advantages which enable a step forward in ESD techniques.
Endoscopy_UCTN_Code_TTT_1AO_2AG
Fig. 1 Splash needle. The tip of the knife consists of a small channel for water irrigation
and a thin needle.
Fig. 2 a – c Superficial esophageal cancer resected by endoscopic submucosal dissection with a
splash needle. a Type 0-IIc intramucosal squamous cell carcinoma (m2), 3 cm in size, is located in
the lower esophagus. b Mucosal defect after endoscopic submucosal dissection with a splash needle. c The lesion is completely resected in one piece with a tumor-free resected margin.
Video
1 Endoscopic submucosal dissection with a splash needle for superficial esophageal
cancer. Using the splash needle, the marking, mucosal incision, additional submucosal
fluid injection, and submucosal dissection are all possible without changing the device.
