Basic Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 28, 2019; 25(28): 3764-3774
Published online Jul 28, 2019. doi: 10.3748/wjg.v25.i28.3764
Novel technique for endoscopic en bloc resection (EMR+) - Evaluation in a porcine model
Benjamin Meier, Andreas Wannhoff, Christoph Klinger, Karel Caca
Benjamin Meier, Andreas Wannhoff, Christoph Klinger, Karel Caca, Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg 71640, Germany
Author contributions: Meier B and Caca K have performed the ex vivo and in vivo experiments; Meier B has analyzed the data; Meier B, Andreas W and Christoph K have prepared the manuscript; and Caca K has approved the final version.
Institutional review board statement: Study was approved by local authority.
Institutional animal care and use committee statement: This study was approved by Regierungspräsidium Baden-Württemberg, Germany (approval number C1/15).
Conflict-of-interest statement: Karel Caca has received lecture fees for FTRD-training courses. Benjamin Meier, Andreas Wannhoff and Christoph Klinger have nothing to disclose.
Data sharing statement: No additional unpublished data are available.
ARRIVE guidelines statement: The ARRIVE guidelines have been adopted.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Benjamin Meier, MD, Adjunct Professor, Doctor, Klinikum Ludwigsburg, Department of Gastroenterology, Posilipostraße 4, Ludwigsburg 71640, Germany. dr.benjamin.meier@gmail.com
Telephone: +49-7141-9967201 Fax: +49-7141-9967219
Received: March 4, 2019
Peer-review started: March 4, 2019
First decision: April 8, 2019
Revised: May 24, 2019
Accepted: June 7, 2019
Article in press: June 8, 2019
Published online: July 28, 2019
Processing time: 147 Days and 0.5 Hours
Abstract
BACKGROUND

Endoscopic en bloc resection of larger polyps is relevant because risk of advanced neoplasia or malignancy correlates with tumor size. Recurrence rates after piecemeal endoscopic mucosal resection (EMR) are high and endoscopic submucosal dissection (ESD) is associated with higher complication rates in the western world.

AIM

To develop a modified endoscopic en bloc resection technique using an external additional working channel and novel agent for submucosal injection.

METHODS

EMR+ was considered as modified grasp and snare technique. For simultaneous use of a grasping and cutting device a novel additional working channel was used (AWC®, Ovesco Endoscopy, Tübingen, Germany). AWC® is installed on the outer surface of the endoscope, covered with a plastic sleeve and designed for single use. For submucosal injection a new agent consisting of poloxamers was used (LiftUp®, Ovesco Endoscopy, Tübingen, Germany). The agent is liquid at room temperature and forms a stable and permanent gel cushion after injection. Safety of LiftUp® has been shown in a pre-clinical study in domestic pigs. LiftUp® is commercially not yet available but approval is expected in early 2019. EMR+ was first developed ex vivo (explanted pig stomach) and subsequently evaluated in vivo (stomach, porcine model, 3 domestic pigs). Main outcome measurements were: Procedure time, macroscopic en bloc resection and adverse events.

RESULTS

Concept of EMR+ was first developed ex vivo (explanted pig stomach). Ex vivo, 22 resections were performed after technique was established. Median procedure time (measured from begin of injection to extraction of resection specimen) was 7 min (range 5-11, SD 1.68) and median size of resection specimens was 30 mm × 26 mm × 11 mm ex vivo. Subsequently 13 resections were performed in vivo (stomach, porcine model, 3 domestic pigs). In vivo, median procedure time (measured from begin of injection to extraction of resection specimen) was 5 min (range 3-12, SD 2.72) and median size of resection specimens was 35 mm × 35 mm × 11 mm. In vivo, resection was macroscopic complete in 92.3%, major adverse events were not observed. In one case (7.7%) minor periprocedural bleeding was observed and managed by coagulation.

CONCLUSION

EMR+ appeared to be effective and safe and was easy and fast to perform in the porcine model. EMR+ needs to be further evaluated clinically in comparative trials.

Keywords: Endoscopic resesection; En bloc; Additional working channel; Submucosal injection; LiftUp

Core tip: We report on a novel modified grasp and snare technique (EMR+) forendoscopic en bloc resection. The technique was developed ex vivo (explanted pig stomach) and evaluated in vivo in a porcine model (stomach, 3 domestic pigs). EMR+ includes a novel additional working channel (AWC®) and a new agent (consisting of poloxamers) for submucosal injection (LiftUp®, approval expected in early 2019). EMR+ appeared to be effective and safe in the stomach and allowed for en bloc resection for lesions up to 40 mm. EMR+ needs to be further evaluated clinically in comparative trials.