Endoscopic submucosal dissection by using clutch cutter and it knife 2 for early gastric cancer with sevre submucosal fibrosis: A case report

DISCUSSION EGC is a commonly encountered clinical problem in cases undergoing EGD. With the development of digestive endoscopic diagnosis and treatment technology, early digestive cancers can be detected in tiny lesions and treated by endoscopic resection. At present, the best method for endoscopic resection of EGC is ESD [6]. ESD has had high en bloc resection rate 93% and high rate of recurrence free could be seen after ESD ( at 5 years 100% but the bleeding complication rate of 1.6% and perforation rate of 2.5% [2]. The high risk of perforation rate and low rate of cn bloc resection caused by EGCs have severe submucosal fibrosis. The severe submucosal fibrosis makes unclear margin between submucosa and muscularis layers, the cndoscopitsts will dissect superficially towards to mucosa. This can cause an incomplete resection and high rate of local recurrence. The other harmful effect of severe submucosal fibrosis is high rate of perforation because the endoscopists can dissect deep into the muscularis layers. The current study showed perforation rates of ESD using a IT knife 2 and Clutch cutter was 1.6% and 3.6%, respectively [1]. In this case which was severe submucosal fibrosis, we used both of these devices as a modified technique to finish the ESD without perforation and successful cn-bloc resection (Fig. 8). The Clutch cutter was a grasping-type scissor knife and we used it to create the shallow holes. From these shallow holes, we dissected the severe submucosal fibrosis by using IT knife 2. These steps were performed carefully to avoid perforation.