Post written by Toshio Kuwai, MD, PhD, from the Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Japan.

In this study, we describe 2 cases of duodenal endoscopic submucosal dissection (ESD)  using a scissors-type knife, Stag Beetle (SB) Knife Junior (Jr) (Sumitomo Bakelite Co., Tokyo, Japan). Our first case was a 72-year-old man with a flat elevated neoplasm (0–IIa) in the second part of the duodenum that was approximately 3.0 cm in diameter. The second case was an 83-year-old man with a flat elevated neoplasm (0–IIa) in the second part of the duodenum that was approximately 4.0 cm in diameter. The lesions were completely resected safely without any immediate or delayed adverse events, and no recurrence occurred in either case.

Duodenal ESD is considered challenging because of poor endoscopic operability. Furthermore, the muscle layer of the duodenum is thinner than that of any other site in the gastrointestinal tract, resulting in higher reported perforation rates of up to 30%. To prevent the risk of adverse events (especially perforations) associated with the use of a conventional knife in ESD for non-ampullary duodenal epithelial tumors (NADETs), we used the SB Knife Jr, which maintains an adequate dissection layer and a controlled cut that prevents unexpected muscular layer injuries. The SB Knife Jr has already been approved by the U.S. Food and Drug Administration, and it was released in the U.S. this May.

The SB Knife Jr allowed us to grasp the target tissue, facilitating controlled safe dissection even under poor endoscopic operability. ESD with the SB Knife Jr is technically feasible and safe for NADETs.

The SB Knife Jr is designed to grasp and cut tissue by using a focused electro-surgical current applied through insulated electrodes such that only the tissue grasped within the electrodes is cauterized. Furthermore, the small tapered and curved tip design with superior rotation allows accurate manipulation within the endoscope’s visual field to minimize unintentional muscular layer injury. While the SB Knife Jr has these potential advantages, it also has a few weak points.

First, during circumferential incision, it is difficult to cut the mucosal layer sharply because of the burning effect. Second, carburized tissue is attached to the blades, resulting in poor cutting and dissecting. A new model that will address these problems is expected.

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