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Mechanical needleless and punctureless high pressure endoscopic lift establishment method for ESD more reliably expands the submucosal layer vs. the standard sclerotherapy needle/catheter in an ex vivo bovine colon model.

Neil Mitra, MD1, Dasuni Niyagama Gamage, MD1, Sharabi Abdelsalam, MD1, Carl Winkler, MD1, Jaspreet Sandhu, MD2, Xiaohong Yan, PhD1, Vesna Cekic, RN1, HMC Shantha Kumara, PhD1, Richard Whelan, MD1. 1Mount Sinai West Hospital, 2Brookdale University Hospital Medical Center

Introduction: Generating a mucosal lift is critical for Endoscopic Submucosal Dissection (ESD).  The expanded submucosa (SM) provides a working space for polyp detachment.  The sclerotherapy catheter/needle (SN) is the most commonly used and economical lift generating method. Because a hard needle push is needed to penetrate the mucosa, the tip most often ends up in the muscularis propria (MP) or beyond.  While injecting, the needle is withdrawn until the SM expands (round and sharp elevation); then the needle is held still and the lift completed.  It has been shown that inadvertent stable deep wall lifts may develop (expansion of subserosal or MP layers) and that double lifts also occur.  ESD is not feasible with a deep lift. It can be difficult to distinguish superficial and deep wall lifts.  The alternative lift generation method is an electric machine pump driven high pressure needleless system that is usually housed in a needle knife but can also be independent.  The avoidance of a puncture should make deep lifts less likely.  This system seems ideal for creating superficial lift generation in a consistent manner.  This study assesses the lift generating capacity of a mechanical needleless/punctureless system that is driven by an electric machine pump (EMP) and compares it to the SN.

Methods: Harvested intact ex vivo bovine colon/rectum/anus was used for this study. Colons were cleaned, instilled with antibiotics and refrigerated until used.  Saline with dye was injected; lifts were generated via the EMP and SN methods (12-18 lifts/method/colon).  Videos and pictures of the pelts (post opening) were made. The lifts were visually inspected and the following parameters tracked: 1) lift shape (transverse oval/cigar shape [ie. deep lifts] vs round/sharp [SM]), 2) the initial and 3) final lift type impression. The lifts were also histologically assessed.

Results: Six bovine colons were used and 103 SN and 99 EMP lifts generated.  89% of the EMP lifts were round and sharp vs 38% with the SN (P value=<.01). The initial impression was superficial lift in 99% of EMP vs 42 % of SN lifts (P value=<.01).  The final impression was of a mixed lift (both muscle and submucosa) in 0% EMP and 24% SN (P value=<.01).  Despite the clinical impression, only about 20% of the lifts in both SM and EMP groups were histologically pure SM lifts (likely due to ex vivo colon’s poor tissue integrity). Mixed lifts were most often noted in both groups; however, it was judged (via dye distribution and penetrance pattern) that the SM layer expanded initially in 94 % of MP vs 53% of SN lifts (P value=<.01). 

Conclusion: Based on shape and lift qualities the EMP method was more likely to generate a superficial lift (vs SN).  The histological results show that with dead tissue it is difficult to make pure SM lifts, likely, because of poor tissue integrity. However, the data suggests the EMP method is more likely to initially expand the SM space. The EMP method may be preferable to SN for lift generation. Further study is needed.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 98834

Program Number: ET002

Presentation Session: Emerging Technology Session

Presentation Type: Podium

120

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