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Gastrointestinal DiseasesNCT05804266

A Randomized Comparison of UnderwateR Versus Regular Coagulation in Endoscopic Submucosal DissectioN and Third Space Endoscopy

A study testing Coventional coagulation and Underwater coagulation in people with Gastrointestinal Diseases and Endoscopic Surgery, run by Istituto Clinico Humanitas at 1 site in Italy.

Completed

Finished. The study has ended and is not enrolling. Results may be posted on the official record.

Official record
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Trial summary

What the investigatorpropose in this protocol is a technique already used in clinical practice. It prevents the risk of bleeding and make third space endoscopy easier, quicker, safer and cheaper. Read more about this study

Who is it for?
Ages 18 years and older
Conditions the study is for
Gastrointestinal Diseases, Endoscopic Surgery
What is being tested?
Coventional coagulation and Underwater coagulation
Type of treatment
Surgery or procedure
Could I receive a placebo?
No, everyone receives an active treatment
How many people
73 participants
Where
1 siteItaly
Study dates
15 Apr 2024to 31 Mar 2025
Phase
Interventional
Are there results?
None posted in the registry

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

  • Ages 18 years and older
  • All sexes
  • No healthy volunteers
  • Adult, Older adult

Who may be able to join

  • All >18 years-old patients undergoing ESD for superificial GI neoplastic lesions or POEM for esophageal achalasia

Who cannot join

  • patients on antithrombotic/anticoagulant therapy patients suffering from bleeding disorders patients with esophageal and/or gastric varices patients previously treated for the same reason patients who were not able or refused to give informed written consent. vessels smaller than the knife inner diameter (1.2 mm)

Trial locations and contacts

1 site in 1 country.

Italy1 site
  • Humanitas Research Hospital

    Milan, Italy, 20089

Other trials in Italy

About this study

What the investigatorpropose in this protocol is a technique already used in clinical practice. It prevents the risk of bleeding and make third space endoscopy easier, quicker, safer and cheaper. Indeed, we noticed that preventive underwater coagulation of the candidate vessels during the submucosal dissection with the Hybrid Knife (HK), seal the wall of the vessel, resulting in a subsequent cut under CO2 without any bleeding. Such preventive coagulation is likely to be related with the conduction of the current underwater as it focalizes all the power on the interface between the vessel and the water, allowing a soft sealing of the vessel without cutting it. Despite widely used, there is no evidence up to know on the benefit and harm of such coagulation technique.

The hypothesis is that the use of this approach in clinical practice, especially when used to coagulate a vessel, may lead to an increase in safety, feasibility and cost-effectiveness, reducing the procedural time, the rate of complications and the need for coagulation forceps in comparison with the conventional preventive coagulation technique under CO2 insufflation. Therefore, this randomized study compares the underwater coagulation technique with the conventional coagulation technique in the CO2 setting during the submucosal dissection in third space endoscopy.

Read the detailed description

POEM will be performed under general anaesthesia in the supine position. The location of the esophagogastric junction (EGJ) will be identified and, then, after submucosal injection of saline mixed with methylene blue, a 2-cm mucosal incision carried out at 5-6 o'clock position about 10 cm above the EGJ. After, a dissection of the underlying submucosa will be performed to access the submucosal space. Then, the dissection of the submucosal layer will be continued to create the submucosal tunnel down to the narrower submucosal space at the EGJ and 2-3 cm into the cardia. During the submucosal tunnelling, coagulation of vessels will be performed with HK using SWIFT COAG E3, 89 W in the underwater setting in the treatment arm or with the standard technique in the CO2-setting in the conventional group. After, the myotomy of the circular muscular layer will be performed from 2-3 cm below the mucosal incision until 2-3 cm below the EGJ in both groups. In some cases, a full thickness myotomy, including the longitudinal muscular layer, will be carried out. Finally, complete closure of the mucosal entry site will be achieved with haemostatic clips. The procedure time, the number of instrument exchanges and bleeding episodes requiring the use of coagulation forceps during the procedure will be documented from start of submucosal tunnelling until final clip closure in both groups.

Fujifilm high-definition gastroscopes (Fujifilm Co., Tokyo, Japan) with a 2.8-mm operative channel and a transparent distal cap attachment will be used in both groups. A submucosal lift with saline mixed with methylene blue through a 23 G injection needle will be accomplished for the mucosal entry. POEM will be carried out using a HK (Erbe Elektromedizin GmbH, Tübingen) in both groups. This instrument has an outer diameter of 2.1 mm and an inner diameter of 1.2 mm with both electrosurgical and water-jet (WJ) surgery technologies in one device. The HK combines needle-less submucosal injection, cutting, dissection and coagulation in one instrument. The modular VIO generator (VIO 3, Erbe Elektromedizin GmbH, Tübingen, Germany) will be used as an electrosurgical system in combination with the ERBEJet 2 WJ surgery system in both groups. A slightly methylene blue-stained isotonic saline solution will be used for submucosal injection with the WJ technique in both groups. Mucosal incision and myotomy will be carried out using ENDO CUT Q 2-3-3 and ENDO CUT Q 2-3-3, respectively, in both groups.

Being tested
Coventional coagulation, Underwater coagulation
Keywords
POEM, TSE, G-POEM, Z-POEM, PREM
Medical subject headings
Gastrointestinal Diseases

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

  • Coventional coagulationProcedure or surgery

    In the conventional group, the haemostasis of vessels will be performed with the conventional coagulation technique under CO2 insufflation. First, submucosal fibres surrounding a blood vessel will be dissected and the vessel will be isolated. After, both sides of the isolated vessel will be coagulated using SWIFT COAG E3, 89 W for POEM and SWIFT COAG E4, 124 W for ESD until the blood vessel turns white and can be finally cut.

  • Underwater coagulationProcedure or surgery

    In the treatment group, the prophylactic haemostasis of vessels will be accomplished by the underwater coagulation technique. First, physiological solution will be instilled until there is no more air around the blood vessel. Then, the vessel will be coagulated using SWIFT COAG E3, 89 W for POEM and SWIFT COAG E4, 124 W for ESD until it turns white and, after the removal of all the physiological solution, can be finally cut.

Study groups in NCT05804266
Study groupRoleWhat they receive
Conventional coagulation of vesselsActive comparatorduring study procedure accomplished under CO2-insufflation with the HK using SWIFT COAG E3, 89 W for POEM and SWIFT COAG E4, 124 W for ESD
Receives: Procedure: Coventional coagulation
Underwater coagulation of vesselsExperimentalduring study procedure carried out in the underwater setting with the HK using SWIFT COAG E3, 89 W for POEM and SWIFT COAG E4, 124 W for ESD
Receives: Procedure: Underwater coagulation

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. Bleeding

    Rate of patients with at least on vessel bleeding and requiring an adjunctive hemostasis

    Measured: 12 months

Secondary outcomes (7)
  1. delayed bleeding

    Rate of delayed bleeding per patient defined as clinical evidence of bleeding (hematemesis, hematochezia or melena or a decrease of hemoglobin concentration > 2g/dL) which required transfusion or endoscopic reintervention with hemostasis within 30 days of hospital discharge the endoscopic resection.

    Measured: 12 months

  2. instrument exchanges

    Number of instrument exchanges per procedure

    Measured: 12 months

  3. complications rate

    Other intra- and post-procedural complications rate per patient

    Measured: 12 months

  4. Procedural time

    Mean procedural time

    Measured: 12 months

  5. Patient-reported outcomes

    in terms of tolerability and post-procedural pain

    Measured: 12 months

  6. variation of blood values

    Mean percentage variation of haematocrit, haemoglobin, C-reactive protein and white blood cells

    Measured: 12 months

  7. intra-procedural bleeding

    Rate of intra-procedural bleeding per each vessel requiring the use of coagulation forceps

    Measured: 12 months

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted7 Apr 2023
  2. Study start15 Apr 2024
  3. Primary completion4 Mar 2025
  4. Study completion31 Mar 2025

Resources

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design
Study type
Interventional
Phase
Phase N/A
Primary purpose
Treatment
Allocation
Randomised
Intervention model
Parallel groups
Model description
Considering a mean number of treated vessel of 4 per each patient, with standard technique we expect that 36% of patients need will have at least on vessel bleeding and requiring an adjunctive hemostasis, versus 6% of patients with underwater coagulation technique. With an alpha error of 5%, a power of 80% we need a total of 70 patients (35 in each arm), to detect this difference.
Masking
None (open label)
Enrolment
73 participants (actual)
IDs, dates and publications
ClinicalTrials.gov ID
NCT05804266
Sponsor's protocol ID
CURRENT ID 3303
Status last verified
Mar 2025
First submitted
8 Mar 2023
Last updated
3 Apr 2025
Results posted
No
Data monitoring committee
No
FDA-regulated drug
No
FDA-regulated device
No
Individual data sharing
No

Publications

  • Inoue H, Navarro MJH, Shimamura Y, Tanabe M, Toshimori A. The Journey from Endoscopic Submucosal Dissection to Third Space Endoscopy. Gastrointest Endosc Clin N Am. 2023 Jan;33(1):1-6. doi: 10.1016/j.giec.2022.09.004. Epub 2022 Oct 23.

    PubMed 36375876
  • Maydeo A, Dhir V. Third-space endoscopy: stretching the limits. Gastrointest Endosc. 2017 Apr;85(4):728-729. doi: 10.1016/j.gie.2016.12.002. No abstract available.

    PubMed 28317688
  • Karanfilian B, Kahaleh M. New Applications for Submucosal Tunneling in Third Space Endoscopy: A Comprehensive Review. J Clin Gastroenterol. 2022 Jul 1;56(6):465-477. doi: 10.1097/MCG.0000000000001694. Epub 2022 Apr 1.

    PubMed 35357336
  • Bapaye A, Korrapati SK, Dharamsi S, Dubale N. Third Space Endoscopy: Lessons Learnt From a Decade of Submucosal Endoscopy. J Clin Gastroenterol. 2020 Feb;54(2):114-129. doi: 10.1097/MCG.0000000000001296.

    PubMed 31851106
  • Baars JE, Stoklosa T, Kaffes AJ, Saxena P. Maintaining hemostasis during third-space endoscopy. VideoGIE. 2018 Aug 8;3(10):304-305. doi: 10.1016/j.vgie.2018.07.004. eCollection 2018 Oct. No abstract available.

    PubMed 30276349
  • Li AA, Zhou MJ, Hwang JH. Understanding the Principles of Electrosurgery for Endoscopic Surgery and Third Space Endoscopy. Gastrointest Endosc Clin N Am. 2023 Jan;33(1):29-40. doi: 10.1016/j.giec.2022.07.001.

    PubMed 36375884
  • Akintoye E, Kumar N, Obaitan I, Alayo QA, Thompson CC. Peroral endoscopic myotomy: a meta-analysis. Endoscopy. 2016 Dec;48(12):1059-1068. doi: 10.1055/s-0042-114426. Epub 2016 Sep 12.

    PubMed 27617421
  • Stavropoulos SN, Modayil RJ, Friedel D, Savides T. The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience. Surg Endosc. 2013 Sep;27(9):3322-38. doi: 10.1007/s00464-013-2913-8. Epub 2013 Apr 3.

    PubMed 23549760
  • Horikawa Y, Toyonaga T, Mizutamari H, Mimori N, Kato Y, Fushimi S, Okubo S. Feasibility of Knife-Coagulated Cut in Gastric Endoscopic Submucosal Dissection: A Case-Control Study. Digestion. 2016;94(4):192-198. doi: 10.1159/000450994. Epub 2016 Dec 9.

    PubMed 27931026

Questions about this trial

What is this clinical trial studying?

A study testing Coventional coagulation and Underwater coagulation in people with Gastrointestinal Diseases and Endoscopic Surgery, run by Istituto Clinico Humanitas at 1 site in Italy.

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 1 inclusion and 1 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: finished, as of the sponsor's last update on 3 Apr 2025. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 1 site in Italy. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

Are results available for this study?

The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.

How can a doctor refer a patient or contact the research team?

The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

Bleeding (time frame: 12 months). It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT05804266, which also lists 9 linked publications.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 3 Apr 2025.

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