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ITknife2

Model KD-611L

Dr. Hiroyuki Ono
Shizuoka Cancer Center

Interview With The Expert

What are the advantages of ITknife2?
There is a clear improvement in cutting performance in lateral cutting and fibroid areas.

It facilitates incision and dissection in total while maintaining the advantages of the conventional ITknife. The incision and dissection speeds have also been increased even more.

Are any procedures or precautions different from the conventional ITknife?
You can feel the difference in cutting performance by using the knife in the same way with ITknife.

However, you have to keep in mind that ITknife2 is quite a bit sharper. If you make the same kind of strokes you’re used to with ITknife, you may cut too deeply and increase the risk of perforation. You should be careful with the knife until you get used to it. It’s also a good idea to use the EndoCut mode. Or step on the high-frequency switch intermittently with a continuous wave mode, to prevent ITknife2 from slipping and causing a perforation. In addition, as with ITknife, laying the knife down too much increases the risk of perforation, so ITknife2’s sheath should be held slightly to upright direction than ITknife. Remember to be careful to avoid problems in the initial introductory phase. However, you won’t need to think about these points once you’ve gotten used to ITknife2 after several uses.

Are there any weak points of ITknife2?
Although the cutting performance is better than ITknife, a certain degree of skill is required when working on sites where the knife needs to approach perpendicularly.

In such a case, point the insulated tip straight toward the muscle layer and swing laterally by manipulating the endoscope or using the angulation function to cut the site little by little.

Under what conditions do you use other devices?
Since I started using ITknife2,

I have rarely needed to use a needle knife. However, a needle knife offers better cutting performance when an ulcer scar is very hard. In such a case, I use a needle knife until the mucosa is curled up in a certain amount and then I switch to ITknife2.

Applicability of ITknife2

Difficulty per region

○ : Easy. No mark: Ordinary. △ : Difficult.

Cardiac region    
 Fornix  △  
 Lesser curvature of upper body    
 Greater curvature of upper body  △  
 Anterior wall of upper body    
 Posterior wall of upper body    
 Lesser curvature of middle body    
Greater curvature of middle body    
 Anterior wall of middle body    
 Posterior wall of middle body    
 Lesser curvature of lower body    
 Greater curvature of lower body    
 Anterior wall of lower body    
 Posterior wall of lower body    
 Lesser curvature of anterior wall    
 Greater curvature of antrum  ○  
 Anterior wall of antrum  ○  
 Posterior wall of antrum  ○  
 Pyloric ring  △  

Note for beginners: It is recommended to start a trial procedure on a minor lesion in the anterior or posterior wall in the antrum or in the
greater curvature. If the endoscope cannot approach the lesion in the lesser curvature of the lower body, it is recommended that you use a
multi-bending endoscope.
*Multi-bending endoscope is not available in some areas.

Sedation
Intravenous anaesthesia Premedication General anaesthesia Monitoring
Opistan
(pethidine hydrochloride)*,
cercine (diazepam)*,
midazolam
Not used Not used SpO2, ECG,
blood pressure,
ETCO2, BIS

 

Electrosurgical unit VIO-300D
(Erbe)
ICC-200
(Erbe)
ESG-100
(Olympus Medical Systems)
Marking
Device Caution Setting
APC probe It causes little bleeding in marking and can leave clear marks. Forced APC
Flow1.8L/min
20W
APC
Flow1.8L/min
20W
 
Local injection
  Epinephrine Indigo carmine  
Glyceol
(concentrated
glycerin fructose)*
+
MucoUp
(sodium
hyaluronate)*
Used
(400X dilution)
Used
Appropriate
amount
Advantage: Long lifting time
Disadvantage: Bubbles during incision
Mix equal amount of Glyceol and MucoUp. Identification of the submucosal layer can be facilitated by submucosal dyeing using indigo carmine. Pale dyeing is applied.
Circumferential incision
  Device Caution Setting
Precutting Needle knife Since ITknife2 cuts very well, the cut duration can be 1 when cutting a thin wall in the EndoCut mode.
Circumferential incision is possible with the setting for precutting.
If bleeding is noticeable, set to SwiftCoag, Effect 5, 60 W.
DryCut
50W Effect4
AutoCut
60W Effect3
PulseCut
fast 60W
Circumferential
incision
ITknife2 EndoCut Q Effect2
Cut duration 2
Cut interval 2
EndoCut
80W Effect3
PulseCut
fast 60W
Submucosal dissection
Device Caution Countertraction Setting
ITknife2 Use the SwiftCoag mode mainly.If coagulation is too strong, the EndoCut mode can also be used. By twisting the endoscope or using a distal attachment. EndoCut Q Effect2
Cut duration 2
Cut interval 2
EndoCut
80W Effect3
PulseCut
fast 60W
SwiftCoag
60W Effect5
Forced 50W ForcedCoag2
50W
Haemostasis
Device Caution Setting
ITknife2 Begin haemostasis with ITknife2. SwiftCoag
60W Effect5
Forced 50W PulseCut
fast 60W
Hot biopsy
forceps
Switch to this device when haemostasis with ITknife2 is difficult. SoftCoag
80W Effect6
SoftCoag 80W SoftCoag 80W
Preventive haemostasis

Large vessels should be coagulated using hot biopsy forceps in advance.
When the vessels are plentiful and bleeding is expected, use the SoftCoag mode,
move ITknife2 slowly and bring both effects of cutting and coagulation simultaneously.

Perforation measure
Method Timing Tip
Applying a clip. Prevent blind operation by avoiding bleeding and securing the field of view. Immediately after perforation if possible.
Alternatively, when clips will not come in the way after dissection has been advanced.
With a small perforation, make the ulcer floors approximate. If large, patching with omentum is easier.

* May not be available in your area.

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