A novel device for endoscopic submucosal dissection that combines water-jet submucosal hydrodissection and elevation with electrocautery: initial experience in a porcine model

Background: Endoscopic submucosal dissection requires a high degree of endoscopic skill and specifically designed dissecting instruments. Objective: To describe the technique for endoscopic submucosal dissection when using the ERBE Hybrid Knife, which combines an ultrafine high-pressure water jet with an electrocautery needle. Design: Descriptive study (ex vivo and in vivo porcine esophagus, stomach, and colon). Interventions: The only instrument used for the dissection was the ERBE Hybrid Knife. The high-pressure water jet was used at a pressure between 45 and 60 bar for creating submucosal fluid elevation. After this, circumferential mucosal incisions and submucosal dissection were performed with the FORCED COAG and ENDOCUT D modes of the same device. The water jet was used intermittently during the dissection process. Main Outcome Measurements: At the end of the in vivo experiments, animals were killed and the organs removed for evaluation. Results: Multiple endoscopic submucosal dissection procedures were successfully performed. It was possible to create submucosal fluid cushions rapidly. Repeated fluid injections during dissection were easily facilitated with the same device. All ex vivo gastric endoscopic submucosal dissections of 50 x 40-mm lesions were completed within 10 minutes. In the in vivo studies, the mean size of the gastric and colonic specimens was 3.7 +/- 2.1 x 2.3 +/- 1 cm, and the dissections were completed within 8 minutes, No thermal injury was observed on the serosa, and no perforations were detected. Conclusions: Endoscopic submucosal dissection can be safely and effectively achieved in a porcine model with the ERBE Hybrid Knife and should be considered a suitable device for this procedure in humans.