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Support Devices

Coagrasper Model FD-410LR
HotClaw Model FD-420LR
HotBite Model FD-430L

Dr. Toshihiko Doi
National Cancer Center Hospital East

Interview With The Expert

What are the advantages of the devices you invented?
You only need to have standard biopsy techniques to use the support devices.

They minimise bleeding and are all designed with full consideration for safety. HotClaw is suitable for connecting the incised parts or when approach with ITknife is difficult. HotBite and Coagrasper are support devices for ESD procedure and should be used when required during it.

Do you have any weak points for the devices you invented?
In principle, these devices can be used in any position in which biopsy is possible.

However, in positions where biopsy is difficult (where forceps should be positioned in the tangential direction), inevitably these devices are also difficult to use. In addition, cutting regions with strong fibrosis may be difficult. Due to the fact that, in present, coagulation results in strong degradation and electrosurgical systems have not yet been improved, these devices should be used as support devices. On the contrary, ITknife can cut those difficult positions mentioned above more easily and safely. For speedy cutting in the vertical position, ITknife will be the best. Please be noted, with any of these devices, grasping too much mucosa will lead to dropping the electrical resistance and adequate cauterisation may become difficult even if the current is supplied.

Under what circumstances do you also use other devices?
At present, I employ the two devices (HotBite and Coagrasper) in almost all ESD procedures. For vertical cutting,

ITknife is faster so I generally use it. I use other devices as support devices for now, but I believe ITknife has the lowest electrical risk. Using the appropriate device for a specific purpose is important, but there are affinities for each devices, just like there are surgeons who are good at using Cooper, surgeons who are good at using an electrosurgical knife, etc. Select the device you use not from “rumours” but from the viewpoint of radical curability and safety.

Applicability of the Support Devices

Difficulty per region

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

Cardiac region  △ To facilitate, use a hood after circumferential incision.
 Fornix  △ Distance from the endoscope is a problem
 Lesser curvature of upper body  △ Shallow circumferential incision is recommended
 Greater curvature of upper body  △ Ease the procedure by mainly using HotClaw.
 Anterior wall of upper body  △ Use 2CH endoscope to facilitate.
 Posterior wall of upper body  ◯ Facilitated by using 2CH endoscope.
Control bleeding.
 Lesser curvature of middle body  ◯  
Greater curvature of middle body  △ Mainly use HotClaw to facilitate. Strip biopsy can be applied after circumferential incision.
 Anterior wall of middle body  △  
 Posterior wall of middle body  ◯ Can also be slightly retroflexed in the antrum.
 Lesser curvature of lower body  ◯ Facilitated by using a 2CH endoscope.
Can also be slightly retroflexed in the antrum.
 Greater curvature of lower body  △ Mainly use HotClaw to facilitate. Strip biopsy can be applied after circumferential incision.
 Anterior wall of lower body  ◯  
 Posterior wall of lower body  ◯  
 Lesser curvature of anterior wall  ◯  
 Greater curvature of antrum  ◯  HotClaw can be used on the anal side.
 Anterior wall of antrum  ◯  
 Posterior wall of antrum  ◯  Facilitated by using 2CH endoscope.
 Pyloric ring  △  HotClaw can be used on the anal side.

Note for beginners: These devices are basically recommended for circumferential incision of a 30-mm (or less) differentiated carcinoma with preoperative diagnosis of m/ul (-). The operator must know another method besides ESD to complete the treatment in case continuing of ESD (haemostasis, dissection, and incision) becomes unmanageable. If the curability is expected to be lower than that of piecemeal resection, do not attempt to perform ESD. Use of HotBite to make holes and HotClaw to connect the holes, and the cutting the rest with ITknife are welcomed for beginners. Beginners should start with lesions that do not require dissection after circumferential incision. Keep in mind that ESD is an experimental medical procedure and patients’ curability as well as safety should be fully considered.

Sedation
Intravenous anaesthesia Premedication General anaesthesia Monitoring
Not used in principle
(Should always be
under supervision of
an anaesthesiologist.)
Buscopan (scopolamine butylbromide)*
or Dormicum (midazolam)*: As required.
Opistan (pethidine hydrochloride)*
+ Dormicum: As required.
Not used in principle
(Should always be
under supervision of
an anaesthesiologist.)
Used with all cases

 

Electrosurgical unit ICC-200
(Erbe)
PSD-60
(Olympus Medical Systems)
Marking
Device Caution Setting
HotBite
or
Needle knife
HotBite: Use the distal end in the same way as
coagulation probe. Low risk of perforation.
Forced 35W Forced 35W
Effect1
Local injection
  Epinephrine Indigo carmine  
Saline Used
(1 ampule
per 100 cc)
Used Merit: Approved by Japanese insurance system.
Demerit: Short duration.
Mannitol Used
(0.5 ampule
per 100 cc)
Used When lifting the submucosal layer is difficult.
Use of indigo: Recommended in principle.
Precutting
Device Caution Setting
HotBite   AutCut 120W Effect3 AutCut 120W Effect5~6
 Needle knife    AutCut 120W Effect3  AutCut 120W Effect4
Circumferential incision
Device Caution Setting
ITknife Pulling cut direction (2CH endoscope: An appropriate biopsy port should be used): Extremely quick, stable incision.
Bleeding can be reduced by maintaining the depth of HotBite.
EndoCut 120W
Effect3
AutoCut 120W
Effect3
EndoCut 120W
Effect3
AutoCut 120W
Effect5~8
 HotClaw  Same manipulation as biopsy. Cutting in the lateral direction with respect to the endoscope axis. Suitable for beginners.
Submucosal dissection
Device Caution Countertraction Setting
ITknife Coagulation performance is quite stable thanks to “ITknife’s line contact with tissue.”
*A HotBite may also be used with scarring, etc.
Use a 2CH
endoscope. Use a
distal attachment
and hood.
EndoCut 120W
Effect3
AutoCut 120W
Effect3
EndoCut 120W
Effect3
AutoCut 120W
Effect5~8
HotClaw  
Haemostasis
Device Caution Setting
ITknife Just supply Coag current during the incision or dissection. Forced 40W Forced 40W
Effect1
Coagrasper 2 to 3 sec. current supply. SoftCoag 50W
Forced 40W
SoftCoag 50W Effect4~5
Forced 40W Effect1
Preventive haemostasis

Haemostatic forceps: Spurting from vein―Current supply with distal end only (Forced 40W). Vein: SoftCoag 60 to 50W.
Artery: SoftCoag 40W. Arterial bleeding: SoftCoag 60 to 50W. If this cannot stop bleeding, add Forced 40W for a few seconds.
*The Forced mode enables instant haemostasis. Please be careful because the haemostatic ability becomes lower for the carbonised tissue. Supply SoftCoag current in several times, intermittently. If the patient has high blood pressure, control it to the normal range. If the water jet function is not available, use an irrigation tube on a 2CH endoscope. If bleeding cannot be stopped at all, use a clip and supply current.

Perforation measure
Method Timing Tip
Clipping
(Ligating snare can also be used together.)
Immediately after finding perforation. Discontinue the procedure if required and start over the next day.

* May not be available in your area.

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