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AN ASSESSMENT OF 6 SUBMUCOSAL LIFTING SOLUTIONS FOR ESD IN AN EX VIVO BOVINE LARGE BOWEL MODEL
Carl Winkler*1, Jaspreet Sandhu2, Xiaohong Yan1, Erica Pettke1, Vesna Cekic1, Chandana Herath Mudiyanselage1, Nipa Gandhi1, Richard L. Whelan1
1Surgery, Mount Sinai West, New York, NY; 2Surgery, Brookdale University Hospital Medical Center, Brooklyn, NY
Introduction: Some surgical endoscopists believe it is possible to obtain the skillset/experience necessary to start a clinical ESD program by doing 40-50 cases in ex vivo models. Establishing and maintaining a submucosal lift is critical to ESD completion. It is not known and we cannot assume that the best clinical lift solution will prove to be equally effective in the ex vivo setting. The goal of this study was to identify the best lift solution for the ex vivo bovine large bowel ESD model.
Methods: The following 6 solutions were assessed: 1) normal saline, 2) dextrose (50%), 3) albumin (25%), 4) hyaluronate (0.4%), 5) Eleview®, and 6) Tissue-Tek® OCT Compound (a solution used in tissue banking that has shown promise). Bovine large bowel, including anus and 2-3 feet of colon, was used. A standardized volume of 1.3ml was injected into the submucosal space to create a lift. A plastic ring (diameter 2cm) was depressed into the mucosa around the point of injection, to confine the fluid to a fixed area, creating near-identical blebs. In Study A the height of each bleb (minus incision or dissection) at 0, 3, 5, 10, and 15 minutes for four of the solutions was determined (1,2,3,6). In Study B, immediately after injection, half the circumference of the bleb was incised with a hot needle knife, and the cut edge was then undermined (submucosal attachments divided); all 6 solutions were tested. The height of each bleb was measured at the same time points.
Results: A total of 5 bovine large bowels were utilized. Regarding Study A (untouched lift), the percent decrease in lift at 15 minutes was normal saline, 75%; dextrose, 80%; albumin, 46%; and OCT 46%. Regarding Study B (incised and undermined lifts) the average percent decrease in height at 15 minutes was as follows: normal saline, 55.8%; dextrose, 43.4%; albumin, 55.1%; hyaluronate, 63.7%; Eleview®, 51.6%; and OCT (Tissue-Tek®), 58.9%. The range of values between specimens for each solution was: normal saline, 14%; dextrose, 12%; albumin, 49%; hyaluronate, 59%; Eleview®, 44%; and OCT, 37%.
Conclusion: It is important to determine the best lift solution for ex vivo teaching models. In Study A albumin and OCT best preserved the lifts. In Study B, dextrose yielded the best results, however, there was a broad range of lift degradation seen for each solution and the differences between solutions were not striking. It was also recognized that the quality of ex vivo bovine tissue varied which impacted the lifts obtained. Based on these results, it is not possible to strongly recommend one solution. Because saline is cheapest, it is recommended for ex vivo tissue training. Regardless of the lift solution, frequent reinjections are advised during all ESD cases since they almost always provide some lift, and thus, decrease the chance of perforation during ESD.
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