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308093_1_En_26_MOESM1_ESM.mov
Submucosal injection. Around the gastric lesion (0-IIa) was marked with the tip of a knife before the submucosal fluid cushion was created. Important aspects of submucosal fluid injection are highlighted here. To ensure adequate submucosal fluid cushion, speed of injection of fluid should be fast (to create quick bulging) and the needle should be adjusted to see quick focal rise of mucosa, then withdraw the needle as it bulge to allow adequate expansion of submucosal space. It can be repeated along the markings where mucosal incision is planned. (If large lesion is targeted, it is advised not to plan circumferential submucosal injection since the fluid can dissipate half way of mucosal incision.) (MOV 19567 kb)
Hybrid Knife for sequential submucosal injection and mucosal incision. The Hybrid Knife (ERBE, Germany) is one of the few ESD knives available that is able to both inject and cut/coagulate. Sequential submucosal fluid injection and mucosal incision of mucosa is clearly demonstrated without device exchange (MOV 22,331 kb)
308093_1_En_26_MOESM3_ESM.mov
Hybrid Knife for submucosal dissection. The Hybrid Knife (ERBE, Germany) is used to complete the ESD. However, it is common to see less submucosal expansion toward the end of ESD. Here, careful dissection of submucosal tissue is performed under direct visualization of watery submucosal tissue and underlying thick rings of MP layer. Small amount of sm layer is dissected steadily. Visualization of layer is most important here prior to applying electrocautery (MOV 43,252 kb)
308093_1_En_26_MOESM4_ESM.mov
Preemptive coagulation. Smaller vessels can be coagulated with the ESD knife (Flex knife, Olympus USA) at encounter. However, when larger vessels (≥1mm) are encountered, it is important to switch to the hot forceps (Coagrasper, Olympus, USA) for effective coagulation with SOFT COAG. Then, subsequent cutting can be performed without bleeding (MOV 8,854 kb)
308093_1_En_26_MOESM5_ESM.mov
Coagulation for control of bleeding. Preemptive coagulation is always preferable; however, bleeding is a risk of ESD and does occur occasionally. The large vessel was overlooked or underestimated here with less than adequate coagulation being applied with IT2 knife. Then, further dissection caused significant arterial bleeding. It is important to first flush the affected area to pinpoint the bleeding site. Once the bleeding site is located, endoclips are deployed but failed to control bleeding (to avoid deep thermal injury at exposed muscular layer). However, if endoclips are not effective, coagulation should be employed to control bleed. Initial grasping ceases bleeding if the site is accurate, then cautery should be applied (SOFT COAG) (MOV 44,159 kb)
308093_1_En_26_MOESM6_ESM.mov
POEM procedure using Hybrid knife (I-type). POEM begins with a small mucosal incision to open the tunnel after submucosal injection. ENDO CUT is used to create entry site, then submucosal dissection is performed to create submucosal tunnel with SPRAY COAG. The circular muscles are incised longitudinally toward the distal esophagus to the gastric cardia. Some fibrosis was encountered due to past Botulinum toxin injection, and circular muscle is dissected to avoid mucosal injury. Here, circular muscle is incised leaving the longitudinal muscle layer intact. At the completion, visualization on myotomy is performed on withdrawal to ensure complete myotomy. Finally, the original mucosal incision is then closed with multiple endoclips. Post-procedural barium swallow revealed marked improvement on barium passage, and manometry confirmed significant reduction of simultaneous contractile and LES pressure (MOV 51,359 kb)
Video 1
Submucosal injection. Around the gastric lesion (0-IIa) was marked with the tip of a knife before the submucosal fluid cushion was created. Important aspects of submucosal fluid injection are highlighted here. To ensure adequate submucosal fluid cushion, speed of injection of fluid should be fast (to create quick bulging) and the needle should be adjusted to see quick focal rise of mucosa, then withdraw the needle as it bulge to allow adequate expansion of submucosal space. It can be repeated along the markings where mucosal incision is planned. (If large lesion is targeted, it is advised not to plan circumferential submucosal injection since the fluid can dissipate half way of mucosal incision.) (MOV 19567 kb)
Video 3
Hybrid Knife for submucosal dissection. The Hybrid Knife (ERBE, Germany) is used to complete the ESD. However, it is common to see less submucosal expansion toward the end of ESD. Here, careful dissection of submucosal tissue is performed under direct visualization of watery submucosal tissue and underlying thick rings of MP layer. Small amount of sm layer is dissected steadily. Visualization of layer is most important here prior to applying electrocautery (MOV 43,252 kb)
Video 4
Preemptive coagulation. Smaller vessels can be coagulated with the ESD knife (Flex knife, Olympus USA) at encounter. However, when larger vessels (≥1mm) are encountered, it is important to switch to the hot forceps (Coagrasper, Olympus, USA) for effective coagulation with SOFT COAG. Then, subsequent cutting can be performed without bleeding (MOV 8,854 kb)
Video 5
Coagulation for control of bleeding. Preemptive coagulation is always preferable; however, bleeding is a risk of ESD and does occur occasionally. The large vessel was overlooked or underestimated here with less than adequate coagulation being applied with IT2 knife. Then, further dissection caused significant arterial bleeding. It is important to first flush the affected area to pinpoint the bleeding site. Once the bleeding site is located, endoclips are deployed but failed to control bleeding (to avoid deep thermal injury at exposed muscular layer). However, if endoclips are not effective, coagulation should be employed to control bleed. Initial grasping ceases bleeding if the site is accurate, then cautery should be applied (SOFT COAG) (MOV 44,159 kb)
Video 6
POEM procedure using Hybrid knife (I-type). POEM begins with a small mucosal incision to open the tunnel after submucosal injection. ENDO CUT is used to create entry site, then submucosal dissection is performed to create submucosal tunnel with SPRAY COAG. The circular muscles are incised longitudinally toward the distal esophagus to the gastric cardia. Some fibrosis was encountered due to past Botulinum toxin injection, and circular muscle is dissected to avoid mucosal injury. Here, circular muscle is incised leaving the longitudinal muscle layer intact. At the completion, visualization on myotomy is performed on withdrawal to ensure complete myotomy. Finally, the original mucosal incision is then closed with multiple endoclips. Post-procedural barium swallow revealed marked improvement on barium passage, and manometry confirmed significant reduction of simultaneous contractile and LES pressure (MOV 51,359 kb)
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Fukami, N. (2015). Appendix: Commonly used ESD Knives. In: Fukami, N. (eds) Endoscopic Submucosal Dissection. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2041-9_26
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DOI: https://doi.org/10.1007/978-1-4939-2041-9_26
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