360 Development of Novel Endoscopic Delivery Devices for Cell Sheets Transplantation

Abstract

“Pop” the Pylorus! Per Oral Pyloro-Myotomya Novel Submucosal Endoscopy Technique Aman Ali*, Russell D. Yang Department of Medicine, Division of Gastroenterology, Southern Illinois University, Springfield, IL Introduction: Endoscopic submucosal dissection (ESD) and Per Oral Endoscopic Myotomy (POEM) procedures are elegant endoscopic techniques to explore the submucosal space and to offer minimally invasive approach to treat diseases that otherwise require invasive surgery. We envisioned using the submucosal space to access pylorus and to perform pyloro-myotomy. To our knowledge this has not been reported before. Potential applications of this technique could be in the endoscopic treatment of gastroparesis, pylorospasm, direct visualization injections to pylorus and other GI muscles and even in full thickness resection of gastric sub-epithelial neoplasms. Aim: To report feasibility of endoscopic per oral pyloro-myotomy in a live intubated porcine model. Methods. Study was approved by our animal lab facility. Two endoscopists with ESD experience performed the procedures. After adequate sedation, EGD (GIF 160, Olympus) was performed with a transparent cap attached. Pylorus was traversed a few times and ease of scope passage was rated on a scale of 1-5 (1 widely patenteasy passage; 5 spastic pylorus moderate resistance). After an adequate lift was obtained with a saline-methylene blue solution injection, a horizontal mucosal incision was made with Hybrid I knife (ERBE USA Inc., Marietta, GA), 10 cms proximal to the pylorus (Endocut Q, 30W,E2). Next the submucosal space was entered and tunneling was performed by submucosal dissection (dry cut -50W,E2), till pylorus was traversed and an open submucosal duodenal space was reached. Bleeding was controlled with soft coag (80W,E5). For myotomy, TT knife (Olympus Inc., Center Valley, PA) was used (spray coag 50W,E2) to hook & divide the inner transverse & oblique fibers, leaving intact the outer longitudinal fibers. Myotomy was started 5 cms proximal to pylorus and continued till pylorus was divided. Scope was withdrawn from submucosal tunnel and ease of scope passage was recorded again. Animals were euthanized and necropsy was performed. Procedure duration, mucosal injury, muscularis propria (MP) injury and perforation rates were recorded. Results: Between JulyNovember 2012, 5 POP procedures were performed. In the 1st two cases, athough ease of scope passage improved, necropsy revealed incomplete myotomy. Deeper incisions were performed in the remaining 3 procedures and necropsy confirmed the complete pyloro-myotomy. Mean duration of procedure was 63 minutes (range 53-75). No mucosal injury was seen. In one case intact serosa was seen but no perforations were noted. After POP the ease of scope passage improved from a mean score of 3.8 to 1.6. Non consequential MP injury was seen in 2/5 cases. Conclusion: Per Oral Pyloro-myotomy (POP) is a feasible procedure and we report first experience with this technique. Future animal lab data and survival models are required to further validate this technique.