Endoscopic Submucosal Dissection (esd) Using Space Making Balloons and Magnetically Coupled Instruments- the Next Frontier

Rohan A Joseph, MD, Calvin L Lyons, MD, Barbara L Bass, MD, Brian J Dunkin, MD. Department of Surgery, The Methodist Hospital and Methodist Institute for Technology, Innovation and Education (MITIE)

Introduction: Endoscopic Submucosal Dissection (ESD) is one of the most challenging procedures to perform endoluminally. Currently used devices have ergonomic challenges that prolong procedure time and limit wide distribution of this technique. This video demonstrates how new ESD devices can greatly simplify the procedure with the potential for improved safety and more widespread adoption.

Methods: A surgical endoscopist performed ESD in porcine specimens using two novel device platforms. Both procedures began in the usual fashion with marking of the periphery of the lesion with electrocautery followed by submucosal injection to create a bleb. A needle knife was then used to create an incision in the mucosa. The first device (Apollo Medical, Austin TX) utilizes a novel cylindrically shaped tunneling balloon which is introduced into the mucosal incision. Inflation axially extends the balloon out of its shaft and longitudinally dissects the tissue off the underlying muscularis propria (MP). Serial expansion of a second radially expanding dissecting balloon creates an even larger submucosal space. Finally, a novel tissue resection device with an electrosurgical cutting wire is used to excise the margin of the lesion.
The second platform uses a magnetically coupled electrocautery device within the lumen of the stomach to perform ESD (magnetic anchoring and guidance system – MAGS. Ethicon Endo-surgery, Cincinnati, OH). The device consists of an oblong (7.8cm × 14mm) magnetic internal effector with a retractable monopolar cautery hook (6.3cm) coupled across the abdominal wall to an external hand-held magnet. By sliding the external magnet over the abdominal wall and applying external pressure, subtle motions of the hook cautery device within the lumen of the stomach can be achieved. The device was introduced via the esophagus and used to perform an ESD with the assistance of a single percutaneous needle grasper for retraction.

Results: Both procedures were accomplished successfully with no device malfunction in 30 and 40 minutes respectively. The sizes of the lesions resected were 6 and 5 cm respectively. Overall user satisfaction was good. At this time the design of the MAGS device allows it to be used for resections only on the posterior gastric wall.

Conclusions: Use of novel instrumentation greatly simplifies ESD with the potential to increase the safety of this procedure and foster more wide-spread performance.