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Mo1357 A Novel Polypectomy Evaluation Platform (PEP) for Objective Benchtop Evaluation of Submucosal Injectables to Improve Safetey and Efficacy of Polypectomy and Endoscopic Mucosal Resection
Abstracts
n⫽5) and standard laparoscopy (OTV-S7, A5002A, Olympus, Japan) group (LG). All procedures were performed under general anesthesia with endotracheal intubations. Trans-gastric NOTES approach was achieved by puncturing the gastric wall using a needle knife followed by a 8mm-balloon (CRETMESO/ PYL5839, Boston Scientific, USA) dilation for small sized endoscope and a 18mm-balloon (CRETMESO/PYL5841, Boston Scientific, USA) dilation for big sized endoscope. Carbon dioxide was used for laparoscopy and NOTES pneumoperitoneum. Following the peritoneoscopy, the endoscope was withdrawn into the stomach and gastric wall incision was closed with EndoClips. The animals were survived for 2 weeks and then sacrificed for post-mortem examination. Blood was drawn at 1h preoperatively and 1h, 12h, 2d, 7d postoperatively. WBC was tested and Inflammatory markers (TNF-a, IL-6) were analyzed by ELISA. Results: The peritoneoscopy was successfully finished by both NOTES route and laparoscopic route. There were no intra-operative and post-operative complications. No significant differences were found between SG, BG and LG in terms of TNF-a levels at 1h pre-operatively (P⫽0.414) and at 1h (P⫽0.9173), 12h(P⫽0.3352), 2d(p⫽0.6208), 7d(p⫽0.4109) post-operatively. There was no significant difference in IL-6 levels at the same time points as above among the 3 groups (p⬎0.05). There was no significant difference of WBC counts among the 3 groups at 2d (p⫽0.2879) and 7d (p⫽0.0690) post-operatively. Conclusions: Transgastric NOTES peritoneoscopy is not less invasive than laparoscopy and a small sized endoscope is not superior to a big sized one for NOTES procedure in terms of inflammatory response. Keywords: Natural Orifice Translumenal Endoscopic Surgery, Laparoscopy, Transgastric, Size of endoscope, Inflammatory response, Animal experiment.
allows consistent and completely objective side by side testing of a variety of injectants in their ability to provide a durable fluid cushion and their insulative abilities. 180 submucosal cushions were performed in ex vivo porcine colons with normal saline 0.9% (N ⫽60), hydroxypropyl methylcellulose (HPMC) (N⫽60), and 12.5gm albumin (25% solution) (N⫽60). Fluid cushion height was evaluated with the specimens attached to a custom platform (picture 1). Initial size before specimen injection was obtained, height and time post injection was then recorded at 5 and 10 minute intervals. The ability of the study solutions to prevent thermal injury was evaluated with a novel polypectomy evaluation platform (PEP) (picture 2). An aluminum base with a digital thermometer attached and a thermal probe placed just below the raised platform to measure the temperature on the serosal side of the fluid cushion was fashioned. A counter weighted lever arm was constructed with a sodering iron attached as a heat source. The specimen was placed on the raised platform, initial tissue temperature was obtained, then the injection of the study solution was performed. The time to reach 100 °F, 105 °F, and 110 °F were measured.This study showed HPMC was superior in dissipating heat when compared to normal saline and 25% albumin. This solution was also superior in maintaining fluid cushion height over a 10 minute period.With the advent of advanced endoscopic techniques, safer means to perform these procedures are needed. A majority of the data on the different injectants lack a standard means for comparison, making the superior solution elusive. With these benchtop devices an objective and reproducible means of evaluating injectable agents in their ability to lift and separate the colonic wall layers for an adequate period of time, as well as providing protection to the muscle wall from thermal injury, could be evaluated to help develop a standard means for future comparison of various injectants
Mo1356 Intraductal Ultrasound (IDUS) Substantiates the Diagnosis of Bile Duct Strictures of Unknown Etiology: Results of a Histopathologically Controlled Retrospective Study Including 402 Patients Tobias Meister, Hauke Heinzow, Carina Woestmeyer, Philipp Lenz, Wolfram F. Domschke, Dirk Domagk Department of Medicine B, University of Muenster, Muenster, Germany Background: The adequate diagnosis of bile duct strictures is still a challenging task. A variety of imaging modalities compete with each other for the best method. The examination of the bile duct by intraductal ultrasound (IDUS) is supposed to be the favored diagnostic tool. Methods: In the present study, 402 patients (189 males, 213 females, mean age 61 ⫾ 13 years) with bile duct strictures of unknown etiology were examined by IDUS. Histopathological correlation was available for 265 patients undergoing surgery. Sensitivity, specificity and accuracy of IDUS were compared with the definite diagnosis as proved by histopathology or long-term follow-up for those patients who had not undergone surgery. The mean follow-up for benign strictures was 39.7 months (range 12 - 100 months); no patient developed malignancy during follow-up. Statistical analysis was applied using SPSS 17.0. Results: Postoperative diagnosis revealed 26.1% pancreatic carcinomas, 26.1% bile duct cancers, 3.1% gallbladder cancers, 7.8% papillary carcinomas, 1.9% HCCs, and 33.1% benign bile duct strictures. In our tertiary center, ERCP supplemented by IDUS allowed for correct diagnosis in 90.7% of cases (359 of 396 patients) resulting in a sensitivity and specificity of 92.6% and 88.5%, respectively. Conclusions: With, to our knowledge, largest histopathologically controlled European patient cohort, IDUS shows excellent results for accurate diagnosis of bile duct strictures. Although ultrasonography does not provide histopathological diagnosis, IDUS yields specific tissue characterization and thus may direct the diagnostic process to the underlying disease.
Picture 1. Fluid cushion height platform
Mo1357 A Novel Polypectomy Evaluation Platform (PEP) for Objective Benchtop Evaluation of Submucosal Injectables to Improve Safetey and Efficacy of Polypectomy and Endoscopic Mucosal Resection Patrick J. McDevitt1, Travis Holtzman2, Matthew T. Moyer1 1 Department of Gastroenterology and Hepatology, The Penn State Milton S. Hershey Medical Center, Hershey, PA; 2Department of Engineering, Penn State University, Hershey, PA Thanks to the use of polypectomy and endoscopic mucosal resection (EMR), colorectal cancer is a largely preventable disease. One limitation of polypectomy and EMR is the risk of perforation, which approximately 90% are thought related to electrocautery damage to muscularis propria during the resection. With the use of submucosal injection, the muscularis propria can be protected from electrocautery injury during lesion removal and it stands to reason that injectables with thermoinsulative properties and those that give a lasting lift affect, offer an advantage in reducing the perforation risk. Most investigations evaluating different injectants are in case series and small clinical trials that are limited by confounding variables. We describe novel bench top devices which
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Picture 2. Polypectomy Evaluation Platform (PEP)
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB317
n⫽5) and standard laparoscopy (OTV-S7, A5002A, Olympus, Japan) group (LG). All procedures were performed under general anesthesia with endotracheal intubations. Trans-gastric NOTES approach was achieved by puncturing the gastric wall using a needle knife followed by a 8mm-balloon (CRETMESO/ PYL5839, Boston Scientific, USA) dilation for small sized endoscope and a 18mm-balloon (CRETMESO/PYL5841, Boston Scientific, USA) dilation for big sized endoscope. Carbon dioxide was used for laparoscopy and NOTES pneumoperitoneum. Following the peritoneoscopy, the endoscope was withdrawn into the stomach and gastric wall incision was closed with EndoClips. The animals were survived for 2 weeks and then sacrificed for post-mortem examination. Blood was drawn at 1h preoperatively and 1h, 12h, 2d, 7d postoperatively. WBC was tested and Inflammatory markers (TNF-a, IL-6) were analyzed by ELISA. Results: The peritoneoscopy was successfully finished by both NOTES route and laparoscopic route. There were no intra-operative and post-operative complications. No significant differences were found between SG, BG and LG in terms of TNF-a levels at 1h pre-operatively (P⫽0.414) and at 1h (P⫽0.9173), 12h(P⫽0.3352), 2d(p⫽0.6208), 7d(p⫽0.4109) post-operatively. There was no significant difference in IL-6 levels at the same time points as above among the 3 groups (p⬎0.05). There was no significant difference of WBC counts among the 3 groups at 2d (p⫽0.2879) and 7d (p⫽0.0690) post-operatively. Conclusions: Transgastric NOTES peritoneoscopy is not less invasive than laparoscopy and a small sized endoscope is not superior to a big sized one for NOTES procedure in terms of inflammatory response. Keywords: Natural Orifice Translumenal Endoscopic Surgery, Laparoscopy, Transgastric, Size of endoscope, Inflammatory response, Animal experiment.
allows consistent and completely objective side by side testing of a variety of injectants in their ability to provide a durable fluid cushion and their insulative abilities. 180 submucosal cushions were performed in ex vivo porcine colons with normal saline 0.9% (N ⫽60), hydroxypropyl methylcellulose (HPMC) (N⫽60), and 12.5gm albumin (25% solution) (N⫽60). Fluid cushion height was evaluated with the specimens attached to a custom platform (picture 1). Initial size before specimen injection was obtained, height and time post injection was then recorded at 5 and 10 minute intervals. The ability of the study solutions to prevent thermal injury was evaluated with a novel polypectomy evaluation platform (PEP) (picture 2). An aluminum base with a digital thermometer attached and a thermal probe placed just below the raised platform to measure the temperature on the serosal side of the fluid cushion was fashioned. A counter weighted lever arm was constructed with a sodering iron attached as a heat source. The specimen was placed on the raised platform, initial tissue temperature was obtained, then the injection of the study solution was performed. The time to reach 100 °F, 105 °F, and 110 °F were measured.This study showed HPMC was superior in dissipating heat when compared to normal saline and 25% albumin. This solution was also superior in maintaining fluid cushion height over a 10 minute period.With the advent of advanced endoscopic techniques, safer means to perform these procedures are needed. A majority of the data on the different injectants lack a standard means for comparison, making the superior solution elusive. With these benchtop devices an objective and reproducible means of evaluating injectable agents in their ability to lift and separate the colonic wall layers for an adequate period of time, as well as providing protection to the muscle wall from thermal injury, could be evaluated to help develop a standard means for future comparison of various injectants
Mo1356 Intraductal Ultrasound (IDUS) Substantiates the Diagnosis of Bile Duct Strictures of Unknown Etiology: Results of a Histopathologically Controlled Retrospective Study Including 402 Patients Tobias Meister, Hauke Heinzow, Carina Woestmeyer, Philipp Lenz, Wolfram F. Domschke, Dirk Domagk Department of Medicine B, University of Muenster, Muenster, Germany Background: The adequate diagnosis of bile duct strictures is still a challenging task. A variety of imaging modalities compete with each other for the best method. The examination of the bile duct by intraductal ultrasound (IDUS) is supposed to be the favored diagnostic tool. Methods: In the present study, 402 patients (189 males, 213 females, mean age 61 ⫾ 13 years) with bile duct strictures of unknown etiology were examined by IDUS. Histopathological correlation was available for 265 patients undergoing surgery. Sensitivity, specificity and accuracy of IDUS were compared with the definite diagnosis as proved by histopathology or long-term follow-up for those patients who had not undergone surgery. The mean follow-up for benign strictures was 39.7 months (range 12 - 100 months); no patient developed malignancy during follow-up. Statistical analysis was applied using SPSS 17.0. Results: Postoperative diagnosis revealed 26.1% pancreatic carcinomas, 26.1% bile duct cancers, 3.1% gallbladder cancers, 7.8% papillary carcinomas, 1.9% HCCs, and 33.1% benign bile duct strictures. In our tertiary center, ERCP supplemented by IDUS allowed for correct diagnosis in 90.7% of cases (359 of 396 patients) resulting in a sensitivity and specificity of 92.6% and 88.5%, respectively. Conclusions: With, to our knowledge, largest histopathologically controlled European patient cohort, IDUS shows excellent results for accurate diagnosis of bile duct strictures. Although ultrasonography does not provide histopathological diagnosis, IDUS yields specific tissue characterization and thus may direct the diagnostic process to the underlying disease.
Picture 1. Fluid cushion height platform
Mo1357 A Novel Polypectomy Evaluation Platform (PEP) for Objective Benchtop Evaluation of Submucosal Injectables to Improve Safetey and Efficacy of Polypectomy and Endoscopic Mucosal Resection Patrick J. McDevitt1, Travis Holtzman2, Matthew T. Moyer1 1 Department of Gastroenterology and Hepatology, The Penn State Milton S. Hershey Medical Center, Hershey, PA; 2Department of Engineering, Penn State University, Hershey, PA Thanks to the use of polypectomy and endoscopic mucosal resection (EMR), colorectal cancer is a largely preventable disease. One limitation of polypectomy and EMR is the risk of perforation, which approximately 90% are thought related to electrocautery damage to muscularis propria during the resection. With the use of submucosal injection, the muscularis propria can be protected from electrocautery injury during lesion removal and it stands to reason that injectables with thermoinsulative properties and those that give a lasting lift affect, offer an advantage in reducing the perforation risk. Most investigations evaluating different injectants are in case series and small clinical trials that are limited by confounding variables. We describe novel bench top devices which
www.giejournal.org
Picture 2. Polypectomy Evaluation Platform (PEP)
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB317