Radu Pescarus, MD, Eran Shlomovitz, MD, Ahmed Sharata, MD, Maria Cassera, BS, Kevin M Reavis, MD, Christy M Dunst, MD, Lee L Swanstrom, MD. Providence Portland Medical Center and Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Portland, Oregon.
Introduction and objectives: Recent enthusiasm for endoscopic full thickness resection (EFTR) has resulted in various efforts to perfect this technique. The current clinical EFTR attempts are hindered by the challenges of obtaining a secure closure post resection as well as avoiding peritoneal seeding in the setting of a malignant lesion. The use of a stapling device has the potential to alleviate some of these ongoing challenges. Unfortunately, currently available commercial laparoscopic staplers have not been suitable for these procedures due to their size and bulk. These staplers have a minimal diameter of 12 mm and are difficult and impractical to manipulate in the gastric or colonic lumens.
Description of the technology: A new small diameter 5mm stapler with a 34cm shaft (MicroCutter XCHANGETM, Cardica Inc, Redwood City, CA, US) has recently achieved FDA approval for use in minimally invasive surgery. It offers a 30 mm length, double row stapling on either side using a D-shape staple configuration. It’s 5 mm diameter, full 360-degree rotation as well as up to 80 degrees of articulation to either side makes this technology a viable option for performing endoluminal stapled full thickness resection. This new instrument can be incorporated easily to the existing laparoscopic or endoscopic equipment to facilitate these procedures.
Preliminary results: Using a porcine animal model, an endoscopic assisted, transgastric resection of a pseudolesion in the gastric wall was performed with the assistance of a 5 mm trans-gastric port. Retraction was obtained either with a suture placed with a laparoscopic needle driver inserted through the same 5 mm port or with a snare inserted through the endoscope.
In a second porcine model a rectal EFTR was performed with the MicroCutter XCHANGETM. Under colonoscopic and laparoscopic guidance a full thickness resection was performed in the upper rectum with the stapler inserted in a transanal fashion.
In both animal models the staple lines performed using a medium tissue thickness (blue) cartridge appeared adequate, intact, hemostatic and with a precise tissue sampling.
Conclusion: This novel articulating 5 mm stapling device appears better suited than other available technologies for stapled, endoscopic assisted gastric resections as well as trans-anal EFTR. Its main advantages are a slim profile, precise closure with avoidance of peritoneal seeding or contamination and 80-degree angulation allowing for precise tissue sampling. We hope that in the future, a flexible endoscopic stapling platform will allow a purely endoscopic stapled EFTR.