Insulated-tip (IT) knife tunneling and C-shaped incision endoscopic submucosal dissection (ESD) of the esophagus is a safe and feasible alternative method for performing endoscopic resection of early esophageal neoplasms in the United States, according to the results of a study published in Techniques and Innovations in Gastrointestinal Endoscopy.

The advantages of this technique, which had been developed in Japan, are described by the authors: “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.” In the West, use of esophageal ESD is limited due to a lack of experience and fewer procedures being performed.

A team of investigators therefore conducted a prospective, single-center, observational study from April 2016 to December 2019 at the Cleveland Clinic to determine the safety and feasibility of IT-knife tunneling and C-shaped incision for ESD of the esophagus.

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A total of 42 patients included in the study underwent IT-knife tunneling: 35 had Barrett esophagus-related neoplasms, 3 had squamous cell cancers, 3 had granular cell tumors, and 1 had a submucosal cyst.

The investigators found a high rate of complete en bloc resection (97.6%) without major adverse events such as perforation (0%), stricture formation (0%), or significant bleeding (<5%). The mean procedure time was approximately 69 minutes.

A total of 36 patients underwent postprocedure surveillance. The mean follow-up time with no local or metastatic recurrence was 12.1 months.

This study was limited by its cross-sectional design with inherent biases and having a single ESD expert perform all procedures. Future prospective studies are warranted to assess IT-tunneling ESD vs other novel ESD techniques to determine the best method of ESD of the esophagus.

The study authors concluded that “IT-tunneling and C-shaped incision esophageal ESD is both feasible and safe.” They added, “This technique overcomes the difficulties of ESD in the esophagus such as the narrow lumen and thin walls. It provides a clear field of view and better traction in the submucosal layer with the C-shaped incision.”

Disclosure: One author declared affiliations with industry. Please refer to the original article for a full list of authors’ disclosures.


Mehta NA, Abe S, Vargo JJ, Saito Y, Bhatt A. Insulated-tip knife tunneling and C-shaped incision for esophageal endoscopic submucosal dissection: an initial Western experience. Techniques and Innovations in Gastrointestinal Endoscopy. Published online February 2, 2021.