Insulated-tip Knife Tunneling and C-shaped Incision for Esophageal Endoscopic Submucosal Dissection: An Initial Western Experience

Background & Aims Esophageal endoscopic submucosal dissection (ESD) can be challenging, and technique innovation is needed to make it easier to perform, especially in the West, where experience and procedure volumes are less. The loose esophageal submucosa allows easy entry of the entire ceramic tip of an insulated-tip (IT) knife, allowing the electrocautery blade to dissect the submucosa, while the tip protects the muscle layer. This technique is called IT-knife tunneling and has been described in Japan. We evaluated the safety and feasibility of IT-knife tunneling esophageal ESD in the West. Methods A prospective, single-center observational study evaluating the outcomes of IT-knife tunneling esophageal ESD from April 2016-December 2019. Lesions with expected fibrosis were excluded. All ESDs were performed by a single expert. Primary aim was to determine safety and feasibility of the technique. Results 42 patients underwent IT-knife tunneling esophageal ESD. 35 were Barrett's-related neoplasms, three squamous cell cancers, three granular cell tumors, and one submucosal cyst. Mean lesion size was 3.1cm, procedure time 69 min, and resection speed 9.7 mm2/min. No esophageal perforations. One case each with delayed bleeding and significant intraprocedural bleeding. En-bloc, R0, and curative resection rates were 97.6%, 88.1%, and 78.6%, respectively. 7/9 of the non-curative lesions were high-risk lesions in poor surgical candidates. 36 patients are under post-procedure surveillance. Mean follow-up time was 12.1 months with no local/metastatic recurrence. Conclusion IT-knife tunneling technique allowed for safe and feasible esophageal ESD of non-fibrotic lesions at our Western center. Further use of this technique in the West is warranted.