Intraoperative bleeding model for swine gastric endoscopic submucosal dissection via heparinization

Abstract

Background and study aims: Live swine have a high degree of coagulation and aggregation and using them for training about how to manage intraoperative bleeding during endoscopic submucosal dissection (ESD) is unsatisfactory. This study aimed to identify the appropriate heparin dose in an intraoperative bleeding model and validate its applicability.

Methods: First, we explored the dose of heparin required for a swine bleeding model in which the activated clotting time reached and maintained the upper limit of measurement (1500 s) after 10 minutes. Second, we compared intraoperative bleeding and hematoma frequency during ESD for 2-cm lesions between the heparinized bleeding model and control groups. Intraoperative bleeding was classified according to the Forrest classification.

Results: The combination of a bolus (300 U/kg), continuous infusion (300 U/kg/h), and a bolus dose (150 U/kg) of heparin 10 minutes after the first infusion was identified as the dose for the bleeding model. Five ESDs were performed in each heparinized bleeding model and the control group. The median number of intraoperative bleeds was significantly higher in the heparinized model than in the control group (5 interquartile range [IQR] 4–7 vs. 3 [IQR 0–4, P = 0.028). All of the intraoperative bleeding events oozing (Forrest Ib) rather than spurting (Forrest Ia). The median number of hematomas was significantly higher in the heparinized model group than in the control group (3 [IQR 1–4] vs. 0 [IQR 0–1], P = 0.023).

Conclusions: High doses of heparin significantly increased intraoperative bleeding and hematoma during swine ESD.

Keywords

Endoscopy Upper GI Tract - Endoscopic resection (ESD, EMRc, ...) - Quality and logistical aspects - Training

Publikationsverlauf

Eingereicht: 07. März 2024

Angenommen nach Revision: 09. September 2024

Accepted Manuscript online:
18. Oktober 2024

Artikel online veröffentlicht:
28. November 2024

• References

• 1 McCarty TR, Aihara H. Current state of education and training for endoscopic submucosal dissection: Translating strategy and success to the USA. Dig Endosc 2020; 32: 851-860
• 2 Ohata K, Nonaka K, Misumi Y. et al. Usefulness of training using animal models for colorectal endoscopic submucosal dissection: is experience performing gastric ESD really needed?. Endosc Int Open 2016; 4: E333-E339
• 3 Horii J, Goto O, Shimoda M. et al. Which part of a porcine stomach is suitable as an animal training model for gastric endoscopic submucosal dissection?. Endoscopy 2016; 48: 188-193
• 4 Yamamoto S, Uedo N, Ishihara R. et al. Endoscopic submucosal dissection for early gastric cancer performed by supervised residents: assessment of feasibility and learning curve. Endoscopy 2009; 41: 923-928
• 5 Parra-Blanco A, Gonzalez N, Arnau MR. Ex vivo and in vivo models for endoscopic submucosal dissection training. Clin Endosc 2012; 45: 350-357
• 6 Tanaka S, Morita Y, Fujita T. et al. Ex vivo pig training model for esophageal endoscopic submucosal dissection (ESD) for endoscopists with experience in gastric ESD. Surg Endosc 2012; 26: 1579-1586
• 7 Gonzalez N, Parra-Blanco A, Villa-Gomez M. et al. Gastric endoscopic submucosal dissection: from animal model to patient. World J Gastroenterol 2013; 19: 8326-8334
• 8 Kato M, Gromski M, Jung Y. et al. The learning curve for endoscopic submucosal dissection in an established experimental setting. Surg Endosc 2013; 27: 154-161
• 9 Gromski MA, Cohen J, Saito K. et al. Learning colorectal endoscopic submucosal dissection: a prospective learning curve study using a novel ex vivo simulator. Surg Endosc 2017; 31: 4231-4237
• 10 Yoshida M, Kakushima N, Mori K. et al. Learning curve and clinical outcome of gastric endoscopic submucosal dissection performed by trainee operators. Surg Endosc 2017; 31: 3614-3622
• 11 Masunaga T, Kato M, Sasaki M. et al. Novel quantitative assessment indicators for efficiency and precision of endoscopic submucosal dissection in animal training models by analyzing an electrical surgical unit. Dig Endosc 2024; 36: 19-27
• 12 Mahmood T, Scaffidi MA, Khan R. et al. Virtual reality simulation in endoscopy training: Current evidence and future directions. World J Gastroenterol 2018; 24: 5439-5445
• 13 Mitsui T, Yoda Y, Sunakawa H. et al. Development of new gastric endoscopic submucosal dissection training model: A reproducibility evaluation study. Endosc Int Open 2022; 10: E1261-E1267
• 14 Parra-Blanco A. Endoscopic submucosal dissection training with pig models in a Western country. World J Gastroenterol 2010; 16: 2895-2900
• 15 Camus M, Marteau P, Pocard M. et al. Validation of a live animal model for training in endoscopic hemostasis of upper gastrointestinal bleeding ulcers. Endoscopy 2013; 45: 451-457
• 16 Byrom MJ, Bannon PG, White GH. et al. Animal models for the assessment of novel vascular conduits. J Vasc Surg 2010; 52: 176-195
• 17 Kubo Y, Yamashita K, Saito T. et al. Heparinized swine models for better surgical/endoscopic training. DEN Open 2021; 2
• 18 Forrest J, Finlayson N, Shearman D. Endoscopy in gastrointestinal bleeding. Lancet 1974; 2: 394-397
• 19 Chen VK, Marks JM, Wong RC. et al. Creation of an effective and reproducible nonsurvival porcine model that simulates actively bleeding peptic ulcers. Gastrointest Endosc 2008; 68: 548-553
• 20 Hu B, Chung SCS, Sun LCL. et al. Animal model of massive ulcer bleeding for assessing endoscopic hemostasis devices. Endoscopy 2005; 37: 847-851
• 21 Chiu PW, Hu B, Lau JY. et al. Endoscopic plication of massively bleeding peptic ulcer by using the Eagle Claw VII device: a feasibility study in a porcine model. Gastrointest Endosc 2006; 63: 681-685
• 22 Ghandour B, Bhullar FA, Szvarca D. et al. Effective, safe and efficient porcine model of Forrest Ib bleeding gastric and colonic ulcers. Indian J Gastroenterol 2023; 42: 118-127
• 23 Brown E, Clarke J, Edward K. et al. Point-of-care testing of activated clotting time in the ICU: is it relevant?. Br J Nurs 2016; 25: 608-612