COMPARISON OF ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) DONE WITH A DEFLECTABLE ENDOSCOPIC GRASPER AND DOUBLE CHANNEL ENDOSCOPE VERSUS CLASSIC ESD DONE WITH A SINGLE CHANNEL SCOPE IN AN EX VIVO BOVINE LARGE BOWEL MODEL.
Neil Mitra*1, Hansani N. Angammana1, Yanni Hedjar2, Timothy Pistell3, Diana Kantarovich1, Hmc Shantha Kumara1, Richard L. Whelan1
1Lenox Hill Hospital, New York, NY; 2Brookdale University Hospital and Medical Center, New York, NY; 3Rutgers New Jersey Medical School, Newark, NJ
Introduction: Limited retraction during ESD is obtained via gravity late in case if polyp is positioned "up" or with a dissection cap attached to the scope that extends beyond its tip. The cap edge is used to retract the cut surface to expose the submucosal fibers. The inability to actively retract and expose submucosal attachments increases the difficulty of ESD. If a double channel scope is used, retraction is possible with a straight grasper in 2nd channel (knife in 1st channel), however, upward retraction of the grasped edge shifts the scope's view upward and away from the submucosal target. A bendable grasper would allow retraction without altering the view of the dissection field A new endoscopic grasper that bends 90 degrees after being closed is now available (Trac Motion system, FujiFilm Corp.) for use with an upper GI Therapeutic Double Channel Endoscope (TDCE). The extent of angulation and the direction of the retraction can be controlled. This ex vivo bovine large bowel study was undertaken to compare Trac Motion grasper facilitated ESD (TM) to classic ESD (CESD). A T test was used for analysis.
Methods: Ex vivo bovine large bowel (+ anus) was used and 2-4 "polyps" branded onto the mucosal surface (20 and 25 cm from anus) via colotomy (suture closed). The colon was fixed to a PEG board and the proximal end closed. A TDCE was used for the TM cases and a pediatric colonoscope for the CESD cases. A sclerotherapy needle and needle knife with lift generating capabilities were used for all cases; lesions were resected with a margin. All cases were videoed and the following parameters tracked: case length, polyp pelt quality (en bloc, rent, holes, etc.?), and number of muscle injuries and perforations.
Results: A total of 18 ESD cases were done (9 TM and 9 CESD) using 5 bovine colons. En bloc removal was carried out in all cases and there were no perforations. The mean TM case length was shorter than the CESD cases (23.4 min. vs 30.2 min., p pending). The mean number of deep muscle injuries/case was 7.7 for the TM and 10.6 for the CESD group (p=pending). More pelt rents/tears/holes were noted in the TM group (TM 1.75/case, CESD, 1.88/case p=ns). Of note, before employing the TM grasper it was necessary to circumferentially incise the mucosa and to well undermine the distal edge via standard ESD. Once the TM was in place, the direction of dissection must be distal to proximal.
Conclusions: Mean TM case length was 6.8 minutes shorter vs CESD. No significant differences were noted as regards the other parameters although the TM group had fewer pelt rents/holes and fewer deep muscle injuries (p=ns). The ability to grasp and retract in a controlled and directed manner facilitates completion of ESD after initial scoring and undermining in this model. Further study and use are warranted.
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