Endoscopic Submucosal Dissection Using a Novel Dissecting Distal Attachment: An Ex vivo Feasibility Study

Abstract

There is need for device innovation to make endoscopic submucosal dissection (ESD) easier and safer to perform. The edge of the distal attachment, already used in ESD, is in the correct plane for submucosal dissection. Placing an electrosurgical blade on the inner surface of the distal attachment may have the following advantages 1. Easier submucosal dissection 2. Reduced risk of perforation as the distal attachment would be a protective barrier between the electrosurgical blade and the muscularis propria layer. 3. The accessory channel would be freed for other uses. To present and assess the feasibility of a dissecting distal attachment, we performed ESD procedure with our prototype device in a porcine model. A distal attachment was made from a heat resistant transparent glass. A custom electrosurgical blade, 6mm wide, was attached to the inner surface of the distal attachment. The electrosurgical blade connects to the electrosurgical generator by a cord that runs on the outside of the endoscope. The following equipment was available; ERBE VIO 300D (ERBE, Tuebingen, Germany) electrosurgical generator, Dual knife (Olympus KD-650U, Tokyo Japan). Procedure was performed on ex vivo porcine model harvested from 6-9 month old Sus scrofa domestic pig. Presented video is from an ESD performed on 3cm demarcated area in the stomach (Video 1). A dual knife was used for mucosal incision to access the submucosal layer. Time (median and interquartile range), en-bloc resection rate, and perforation rates were recorded. A total of 20 ESD procedures (10 esophageal, 10 gastric) were performed by one endoscopist (AB). The median time of procedure for esophageal and gastric ESD were 28 min (24 - 32) and 29 min (28 - 35), respectively. En-bloc resection without perforation was obtained in all procedures. Within a porcine model a dissecting distal attachment allows for easy, safe, and efficient esophageal and gastric ESD. Further development of this technology is warranted. Watch the video: https://goo.gl/bD4uVY