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Tu1399 Is Porcine Stomach Suitable As an Animal Training Model for Gastric Endoscopic Submucosal Dissection (ESD)?
Abstracts
Tu1398 Endoscopic Submucosal Dissection With Hydrodissection Technique: Results and Learning Curve in an Animal Model Joaquin De La Peña*1, Jose Miguel Esteban2, Oscar Nogales Rincon11, Sarbelio RodríGuez-MuñOz3, Angel Calderon4, Aitor Orive-Calzada5, Leopoldo Lopez-Roses6, David Martinez-Ares7, Eloy Sanchez-Hernandez8, Juan J. Vila9, Gloria Fernandez-Esparrach10 1 Experimental surgery, HVirtual Valdecilla, Santander, Spain; 2 Endoscopia, H clinico San Carlos, Madrid, Spain; 3Endoscopia, h 12 Octubre, Madrid, Spain; 4Digestivo, h Basurto, Bilbao, Spain; 5Digestivo, h Galdakao-usansolo, Galdakao, Spain; 6Digestivo, CHU Lugo, Lugo, Spain; 7Digestivo, CHU Vigo, Vigo, Spain; 8Digestivo, CHU Ourense, Ourense, Spain; 9Digestivo, CH Navarra, Pamplona, Spain; 10Endoscopy unit Institut de Malalties Digestives i Metabòliques, H Clinic, Barcelona, Spain; 11Digestivo, H Gregorio Marañon, Madrid, Spain Background: ESD in an effective but time-consuming treatment for early neoplasia that requires a high level of expertise. The combination of high-pressure water jet with electrocautery needle in the same device could facilitate the procedure, especially among beginners. Aim: To assess the efficacy and learning curve of gastric ESD with ERBE hybrid knife in a set of endoscopists with preliminary experience with ESD in experimental models. Methods: Hybrid and classic gastric ESD were alternatively performed in live pigs. For Hybrid technique we used a water-jet hybrid knife (ERBE). For classic ESD we used needle Knife (DND2718A,PENTAX) and Mucosectome isolated (DP-D2518, PENTAX). Dissection with electrocautery was alternate with submucosal fluid injection as many times as needed. All the endoscopists had previously completed their training in animal models. Variables analyzed were: number of ESD completed, number of ESD with all marks included (R0), size of specimens, time and speed of dissection and complications. Results: 10 endoscopists performed a total of 50 gastric ESD (30 hybrid and 20 classic). 46 (92%) ESD were completed and 25 (50%) were R0 (hybrid: n⫽ 12, 40%; classic: n⫽ 13, 65%; p⫽0.004). The size of the specimens was not different in both groups (hybrid: 40.3⫹13.2 mm; classic: 35.5⫹10.9 mm; p⫽0.826). Hybrid ESD was faster than classic (time: 44.6⫹21.4 minutes vs 68.7⫹33.5 minutes; p⫽0.009 and velocity: 20.8⫹9.2 mm2/seg vs 14.3⫹9.3 mm2/seg; p⫽0.033). Complications were no different with an incidence of perforation of 4 (13%) and 2 (10%), respectively (p⫽0.722). It was a trend to improve the velocity with both techniques (hybrid: from 20.33 to 28.18 mm2/seg; p⫽0.615 and classic: from 6.4 to 19.48 mm2/seg; p⫽0.607). the learning curve showed an improvement in R0 rate in the hybrid group (from 30% to 100%). Conclusions: ESD with hydrodissection technique is faster than classic ESD but is associated with a decrease in R0. The learning curve with the hydrodissection technique is short and shows a rapid improvement. ESD is a very effective technique when performed properly and the introduction of new tools to facilitate the implementation of ESD should be done with caution to avoid a negative impact on the results.
stomach, however there was no statistically difference between two part (p⫽0.06). The survey revealed similarity of maneuverability between human and porcine stomach in L/Ant and L/Post and U/Ant and U/Post during the dissection step (p⫽0.03). In contrast, discrepancies of maneuverability were shown in L/Gre and U/Gre (p⫽0.03) during the step of injection and incision. Study2; Histology revealed the ratio of the thickness of mucosal layer to full layer was obviously high in the L/Gre (1. 56.3%; 2. 36.6%; 3. 28.6%; 4. 17.0%; 5. 17.6%; 6. 18.3%; median 23.5%). In contrast, the ratio of muscle layer to full layer of L/Gre was thinner than other parts of porcine stomach (1. 25.7%; 2. 42.4%; 3. 47.5%; 4. 63.2%; 5. 41.5%; 6. 47.8%; median 45.0%). In human stomach, the ratios of the thickness of mucosal layer to full layer were almost similar in all 6 parts (median30.9%, range24.8-39.2). Conclusions: The maneuverability during dissection, an important step in the ESD procedure in the porcine stomach was similar to that of stomach in L/Ant, L/Post, U/Ant and U/Post. In addition, histological characteristics of porcine stomach considered to be similar to human stomach excepting L/Gre. These results suggest the porcine stomach may be suitable for animal training model for gastric ESD in such sites. 1. Imagawa A, et al. Endoscopy 2006;38:987-90.
Tu1400 Simulating Bleeding for Gastric Endoscopic Submucosal Dissection in Ex Vivo Porcine Models Jongchan Lee*1, Kayoko Saito1, Changdon Kang1, Mark a. Gromski1, RAM Chuttani1, Kai Matthes1,2 1 Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 2Anesthesiology, Children’s Hospital Boston, Harvard Medical School, Boston, MA Background: Training using animal ex vivo simulators improves endoscopic skills in gastric endoscopic submucosal dissection (ESD). However, there is no established training model that simulates hemorrhage encountered during gastric ESD. The aim of this study is to develop an ex vivo simulator that realizes bleeding during gastric ESD. Method: For the simulation of bleeding during ESD, bleeding sites were prepared in the stomach body. Short segments (2-4 cm) of porcine splenic or renal arteries were sutured into the submucosal layer of the stomach. The distal end of the vessel was connected to an artificial blood perfusion system. The target lesions, measuring 3 ⫻ 3 cm, were demarcated on the stomachs by coagulation markings with a needle knife. Results: A total of ten cases of gastric ESD were performed. Mean procedure time was 33.8 ⫾ 9.1 minutes. Simulation of bleeding was successful in nine among ten cases. Hemostasis was performed successfully in eight cases. Bipolar hemostatic forceps were used in five cases and hemoclips were used in three cases. In one case, the blood vessel was too large to control bleeding with endoscopic devices. Conclusions: The advantage of this model is to simulate realistic bleeding like those encountered in clinical practice. Trainees can practice how to use bipolar hemostatic forceps or hemoclips for bleeding control during gastric ESD.
Tu1399 Is Porcine Stomach Suitable As an Animal Training Model for Gastric Endoscopic Submucosal Dissection (ESD)? Joichiro Horii*1, Toshio Uraoka1, Masayuki Shimoda2, Hiroyuki Ishii1, Osamu Goto1, Kaoru Takabayashi3, Toshifumi Hibi3, Yasunori Okada2, Naohisa Yahagi1 1 Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; 2 Department of pathology, Keio University School of Medicine, Tokyo, Japan; 3Division of Gastroenterology and Hepatology, Department of Internal medicine, Keio University School of Medicine, Tokyo, Japan Background: Training with animal model is generally recommended before starting endoscopic submucosal dissection (ESD) in human because of the high level of technically difficulty. Clinically, endoscopists should start performing ESDs on the lower third (L) of stomach because of the lower risk of perforation and less difficulty1. However, there are few reports of differences between porcine and human stomach considering of ESD training model. Aim: To clarify the suitability of porcine stomach as animal training model for ESD. Methods: Study1; Five endoscopists who engaged in clinical gastric ESD routinely performed ESD for 6 hypothetical lesions located in 6 parts of an isolated porcine stomach (1. L/greater curvature (Gre); 2. L/anterior wall (Ant); 3. L/posterior wall (Post); 4. Upper third (U)/Gre; 5. U/Ant; 6. U/Post). Each lesion was 2cm in diameter. Procedure times per unit (sec./cm2) were compared between each part. Each participant was asked for a rating of maneuverability of endoscope in three steps of ESD (injection, incision and dissection) at the end of the procedure. The questionnaire was a score evaluation form that assumed 5 points were most similar to the L of human stomach. Study2; Histological characteristics were investigated in isolated porcine stomach and resected human gastric specimen. Thicknesses of mucosal layer were histologically evaluated at above-mentioned 6 parts both in porcine and human stomach. Results: Study1; Procedure times per unit tended to be longer in L/Gre and U/Gre of porcine
Arterial spurting in ex vivo porcine model
AB526 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
Tu1398 Endoscopic Submucosal Dissection With Hydrodissection Technique: Results and Learning Curve in an Animal Model Joaquin De La Peña*1, Jose Miguel Esteban2, Oscar Nogales Rincon11, Sarbelio RodríGuez-MuñOz3, Angel Calderon4, Aitor Orive-Calzada5, Leopoldo Lopez-Roses6, David Martinez-Ares7, Eloy Sanchez-Hernandez8, Juan J. Vila9, Gloria Fernandez-Esparrach10 1 Experimental surgery, HVirtual Valdecilla, Santander, Spain; 2 Endoscopia, H clinico San Carlos, Madrid, Spain; 3Endoscopia, h 12 Octubre, Madrid, Spain; 4Digestivo, h Basurto, Bilbao, Spain; 5Digestivo, h Galdakao-usansolo, Galdakao, Spain; 6Digestivo, CHU Lugo, Lugo, Spain; 7Digestivo, CHU Vigo, Vigo, Spain; 8Digestivo, CHU Ourense, Ourense, Spain; 9Digestivo, CH Navarra, Pamplona, Spain; 10Endoscopy unit Institut de Malalties Digestives i Metabòliques, H Clinic, Barcelona, Spain; 11Digestivo, H Gregorio Marañon, Madrid, Spain Background: ESD in an effective but time-consuming treatment for early neoplasia that requires a high level of expertise. The combination of high-pressure water jet with electrocautery needle in the same device could facilitate the procedure, especially among beginners. Aim: To assess the efficacy and learning curve of gastric ESD with ERBE hybrid knife in a set of endoscopists with preliminary experience with ESD in experimental models. Methods: Hybrid and classic gastric ESD were alternatively performed in live pigs. For Hybrid technique we used a water-jet hybrid knife (ERBE). For classic ESD we used needle Knife (DND2718A,PENTAX) and Mucosectome isolated (DP-D2518, PENTAX). Dissection with electrocautery was alternate with submucosal fluid injection as many times as needed. All the endoscopists had previously completed their training in animal models. Variables analyzed were: number of ESD completed, number of ESD with all marks included (R0), size of specimens, time and speed of dissection and complications. Results: 10 endoscopists performed a total of 50 gastric ESD (30 hybrid and 20 classic). 46 (92%) ESD were completed and 25 (50%) were R0 (hybrid: n⫽ 12, 40%; classic: n⫽ 13, 65%; p⫽0.004). The size of the specimens was not different in both groups (hybrid: 40.3⫹13.2 mm; classic: 35.5⫹10.9 mm; p⫽0.826). Hybrid ESD was faster than classic (time: 44.6⫹21.4 minutes vs 68.7⫹33.5 minutes; p⫽0.009 and velocity: 20.8⫹9.2 mm2/seg vs 14.3⫹9.3 mm2/seg; p⫽0.033). Complications were no different with an incidence of perforation of 4 (13%) and 2 (10%), respectively (p⫽0.722). It was a trend to improve the velocity with both techniques (hybrid: from 20.33 to 28.18 mm2/seg; p⫽0.615 and classic: from 6.4 to 19.48 mm2/seg; p⫽0.607). the learning curve showed an improvement in R0 rate in the hybrid group (from 30% to 100%). Conclusions: ESD with hydrodissection technique is faster than classic ESD but is associated with a decrease in R0. The learning curve with the hydrodissection technique is short and shows a rapid improvement. ESD is a very effective technique when performed properly and the introduction of new tools to facilitate the implementation of ESD should be done with caution to avoid a negative impact on the results.
stomach, however there was no statistically difference between two part (p⫽0.06). The survey revealed similarity of maneuverability between human and porcine stomach in L/Ant and L/Post and U/Ant and U/Post during the dissection step (p⫽0.03). In contrast, discrepancies of maneuverability were shown in L/Gre and U/Gre (p⫽0.03) during the step of injection and incision. Study2; Histology revealed the ratio of the thickness of mucosal layer to full layer was obviously high in the L/Gre (1. 56.3%; 2. 36.6%; 3. 28.6%; 4. 17.0%; 5. 17.6%; 6. 18.3%; median 23.5%). In contrast, the ratio of muscle layer to full layer of L/Gre was thinner than other parts of porcine stomach (1. 25.7%; 2. 42.4%; 3. 47.5%; 4. 63.2%; 5. 41.5%; 6. 47.8%; median 45.0%). In human stomach, the ratios of the thickness of mucosal layer to full layer were almost similar in all 6 parts (median30.9%, range24.8-39.2). Conclusions: The maneuverability during dissection, an important step in the ESD procedure in the porcine stomach was similar to that of stomach in L/Ant, L/Post, U/Ant and U/Post. In addition, histological characteristics of porcine stomach considered to be similar to human stomach excepting L/Gre. These results suggest the porcine stomach may be suitable for animal training model for gastric ESD in such sites. 1. Imagawa A, et al. Endoscopy 2006;38:987-90.
Tu1400 Simulating Bleeding for Gastric Endoscopic Submucosal Dissection in Ex Vivo Porcine Models Jongchan Lee*1, Kayoko Saito1, Changdon Kang1, Mark a. Gromski1, RAM Chuttani1, Kai Matthes1,2 1 Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 2Anesthesiology, Children’s Hospital Boston, Harvard Medical School, Boston, MA Background: Training using animal ex vivo simulators improves endoscopic skills in gastric endoscopic submucosal dissection (ESD). However, there is no established training model that simulates hemorrhage encountered during gastric ESD. The aim of this study is to develop an ex vivo simulator that realizes bleeding during gastric ESD. Method: For the simulation of bleeding during ESD, bleeding sites were prepared in the stomach body. Short segments (2-4 cm) of porcine splenic or renal arteries were sutured into the submucosal layer of the stomach. The distal end of the vessel was connected to an artificial blood perfusion system. The target lesions, measuring 3 ⫻ 3 cm, were demarcated on the stomachs by coagulation markings with a needle knife. Results: A total of ten cases of gastric ESD were performed. Mean procedure time was 33.8 ⫾ 9.1 minutes. Simulation of bleeding was successful in nine among ten cases. Hemostasis was performed successfully in eight cases. Bipolar hemostatic forceps were used in five cases and hemoclips were used in three cases. In one case, the blood vessel was too large to control bleeding with endoscopic devices. Conclusions: The advantage of this model is to simulate realistic bleeding like those encountered in clinical practice. Trainees can practice how to use bipolar hemostatic forceps or hemoclips for bleeding control during gastric ESD.
Tu1399 Is Porcine Stomach Suitable As an Animal Training Model for Gastric Endoscopic Submucosal Dissection (ESD)? Joichiro Horii*1, Toshio Uraoka1, Masayuki Shimoda2, Hiroyuki Ishii1, Osamu Goto1, Kaoru Takabayashi3, Toshifumi Hibi3, Yasunori Okada2, Naohisa Yahagi1 1 Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; 2 Department of pathology, Keio University School of Medicine, Tokyo, Japan; 3Division of Gastroenterology and Hepatology, Department of Internal medicine, Keio University School of Medicine, Tokyo, Japan Background: Training with animal model is generally recommended before starting endoscopic submucosal dissection (ESD) in human because of the high level of technically difficulty. Clinically, endoscopists should start performing ESDs on the lower third (L) of stomach because of the lower risk of perforation and less difficulty1. However, there are few reports of differences between porcine and human stomach considering of ESD training model. Aim: To clarify the suitability of porcine stomach as animal training model for ESD. Methods: Study1; Five endoscopists who engaged in clinical gastric ESD routinely performed ESD for 6 hypothetical lesions located in 6 parts of an isolated porcine stomach (1. L/greater curvature (Gre); 2. L/anterior wall (Ant); 3. L/posterior wall (Post); 4. Upper third (U)/Gre; 5. U/Ant; 6. U/Post). Each lesion was 2cm in diameter. Procedure times per unit (sec./cm2) were compared between each part. Each participant was asked for a rating of maneuverability of endoscope in three steps of ESD (injection, incision and dissection) at the end of the procedure. The questionnaire was a score evaluation form that assumed 5 points were most similar to the L of human stomach. Study2; Histological characteristics were investigated in isolated porcine stomach and resected human gastric specimen. Thicknesses of mucosal layer were histologically evaluated at above-mentioned 6 parts both in porcine and human stomach. Results: Study1; Procedure times per unit tended to be longer in L/Gre and U/Gre of porcine
Arterial spurting in ex vivo porcine model
AB526 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org