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©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Feb 27, 2021; 13(2): 116-126
Published online Feb 27, 2021. doi: 10.4240/wjgs.v13.i2.116
Assistant skill in gastric endoscopic submucosal dissection using a clutch cutter
Mitsuru Esaki, Toshiki Horii, Ryoji Ichijima, Masafumi Wada, Seiichiro Sakisaka, Shuichi Abe, Naru Tomoeda, Yusuke Kitagawa, Kei Nishioka, Yosuke Minoda, Shinichi Tsuruta, Sho Suzuki, Hirotada Akiho, Eikichi Ihara, Yoshihiro Ogawa, Takuji Gotoda
Mitsuru Esaki, Masafumi Wada, Kei Nishioka, Yosuke Minoda, Eikichi Ihara, Yoshihiro Ogawa, Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
Mitsuru Esaki, Toshiki Horii, Ryoji Ichijima, Sho Suzuki, Takuji Gotoda, Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo 101-8309, Japan
Seiichiro Sakisaka, Hirotada Akiho, Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu 802-0077, Fukuoka, Japan
Seiichiro Sakisaka, Yusuke Kitagawa, Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka 810-0001, Japan
Shuichi Abe, Department of Gastroenterology, Hara-Sanshin Hospital, Fukuoka 812-0033, Japan
Naru Tomoeda, Department of Gastroenterology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka 810-0065, Japan
Shinichi Tsuruta, Department of Anatomic Pathology, Kyushu University, Fukuoka 812-8582, Japan
Eikichi Ihara, Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
Author contributions: Esaki M, Horii T, and Ichijima R designed the research; Esaki M drafted and revised the article for important intellectual content; Wada M, Sakisaka S, Abe S, Tomoeda N, Kitagawa Y, Nishioka K, Minoda Y, and Tsuruta S analyzed and interpreted the data; Suzuki S, Akiho H, and Ihara E critically revised the manuscript for important intellectual content; Ogawa Y and Gotoda T supervised the whole process; All authors approved the final version of the article.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board at Kitakyushu Municipal Medical Center (ID: 20191076).
Conflict-of-interest statement: Seiichiro Sakisaka, Shuichi Abe, Masafumi Wada, Naru Tomoeda, Yusuke Kitagawa, Kei Nishioka, Yosuke Minoda, Shinichi Tsuruta, Hirotada Akiho, Toshiki Horii, Ryoji Ichijima, and Yoshihiro Ogawa have no conflicts of interest or financial ties to disclose. Mitsuru Esaki, Sho Suzuki, and Takuji Gotoda received lecture fees from Fujifilm Medical (Tokyo, Japan). Eikichi Ihara belongs to the endowed course supported by the companies mentioned, including Ono Pharmaceutical Co., Ltd., Miyarisan Pharmaceutical Co. Ltd., Sanwa Kagaku Kenkyusho Co., Ltd., Otsuka Pharmaceutical Factory, Inc., Fujifilm Medical Co., Ltd., Termo Corporation, Fancl Corporation, and Ohga Pharmacy. Eikichi Ihara received a lecture fee from Takeda Pharmaceutical Co. Ltd. Hands-on seminars were supported by Boston Scientific (Tokyo, Japan). Harvested porcine models, hyaluronic acid solution (MucoUp; Boston Scientific, Tokyo, Japan), and injection needles (SureLIFTERTM, Boston, Tokyo, Japan) were received from Boston Scientific. Clutch Cutter was received from Fujifilm Medical (Tokyo, Japan).
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
http://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Mitsuru Esaki, MD, Doctor, Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. esaki_saiseikai@yahoo.co.jp
Received: October 17, 2020
Peer-review started: October 17, 2020
First decision: December 1, 2020
Revised: December 13, 2020
Accepted: December 23, 2020
Article in press: December 23, 2020
Published online: February 27, 2021
BACKGROUND
A clutch cutter is a scissor-type knife used in endoscopic submucosal dissection (ESD) for gastrointestinal tract tumors. The assistant during the ESD using a clutch cutter (ESD-C) needs to rotate the device and grasp the target tissue appropriately; therefore, the assistant’s skill may affect the technical outcomes of ESD-C.
AIM
To determine how assistant skill level affected the technical outcomes of gastric ESD-C using an ex vivo porcine training model.
METHODS
In this pilot study, mock lesions of 15-30 mm in diameter were created in the middle or lower third of the porcine stomach. A total of 32 ESD-C procedures were performed by 16 trainees. Each trainee operator performed two ESD-C procedures; one ESD-C was assisted by an expert (ESD-C-E), and the other was assisted by a non-expert (ESD-C-NE). The total procedure time of the ESD was set as the primary outcome, and en bloc resection rate, complete procedure rate, perforation rate, and each procedure time/speed for mucosal incision or submucosal dissection were set as the secondary outcomes. In addition, we investigated factors associated with the difficulty of ESD including incompletion of ESD procedure, a long procedure time (≥ 20 min) or intraoperative perforation.
RESULTS
The median total procedure time of the ESD-C-E was significantly shorter than that of the ESD-C-NE (12.9 min vs 21.9 min, P = 0.001). The en bloc resection rate was 100% in both groups. Complete resection rates of the ESD-C-E and ESD-C-NE groups were 100% and 93.8%, respectively. No intraoperative perforation was observed in both groups. In the multivariate analysis, assistant skill was significantly associated with the difficulty of ESD, with the highest odds ratio of 16.5.
CONCLUSION
Assistance by an expert is an important factor when trainees perform ESD-C procedures.
Core Tip: The influence of assistant skill level on the technical outcomes of gastric endoscopic submucosal dissection with a scissor-type knife, clutch cutter (ESD-C) is unclear. We conducted an ex vivo porcine model study to compare the treatment outcomes of ESD-C assisted by an expert and those assisted by a non-expert. The median total procedure time of the ESD-C assisted by an expert was significantly shorter than that of the ESD-C assisted by a non-expert. Furthermore, assistant skill was significantly associated with the difficulty of ESD in multivariate analysis. Therefore, assistance by an expert is an important factor in ESD-C procedures.
