Can mechanical balloon dissection be applied to cleave fibrotic submucosal tissues? A pilot study in a porcine model

Background and study aims: Removal of a lesion containing an ulcer scar is one of the most challenging applications of endoscopic submucosal dissection (ESD). The present study examined whether a novel balloon dissector could cleave fibrotic submucosal tissue beneath ulcer scars.

Methods: Six pigs were studied. Endoscopic mucosal resection (EMR) with ligation was performed at 7 or 8 sites in the stomach for each animal; 4 weeks later, 23 sites with a visible scar were selected for submucosal dissection. The procedure involved first creating a submucosal fluid cushion (SFC) by injecting either saline mixed with mesna or pure saline. A slender, compliant balloon with a diameter of 8, 13, or 18 mm was inserted into the SFC. The balloon was unfolded and thrust forward to cleave the fibrotic submucosa over approximately 5 cm.

Results: Fibrotic submucosa was dissected within 90 seconds in 17 of 23 attempts. Isolating the ulcer scar from the muscularis with the SFC prior to balloon dissection and using a thinner balloon catheter both ensured a better dissection.

Conclusions: The fibrotic submucosa underlying post-EMR scars can be dissected with the novel balloon dissector, although the technique is less effective in cases with no sign of lifting.

• References

• 1 Ono H, Kondo H, Gotoda T et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut 2001; 48: 225-229
• 2 Watanabe K, Ogata S, Kawazoe S et al. Clinical outcomes of EMR for gastric tumors: historical pilot evaluation between endoscopic submucosal dissection and conventional mucosal resection. Gastrointest Endosc 2006; 63: 776-782
• 3 Cao Y, Liao C, Tan A et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 2009; 41: 751-757
• 4 Neuhaus H. Endoscopic submucosal dissection in the upper gastrointestinal tract: present and future view of Europe. Dig Endosc 2009; 21: 4-6
• 5 Goto O, Fujishiro M, Kodashima S et al. Is it possible to predict the procedural time of endoscopic submucosal dissection for early gastric cancer?. J Gastroenterol Hepatol 2009; 24: 379-383
• 6 Ahn JY, Choi KD, Choi JY et al. Procedure time of endoscopic submucosal dissection according to the size and location of early gastric cancers: analysis of 916 dissections performed by 4 experts. Gastrointest Endosc 2011; 73: 911-916
• 7 Nagata S, Jin YF, Tomoeda M et al. Influential factors in procedure time of endoscopic submucosal dissection for gastric cancer with fibrotic change. Dig Endosc 2011; 23: 296-301
• 8 Sumiyama K, Gostout CJ, Rajan E et al. Transesophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique. Gastrointest Endosc 2007; 65: 679-683
• 9 Sumiyama K, Gostout CJ, Rajan E et al. Submucosal endoscopy with mucosal flap safety valve. Gastrointest Endosc 2007; 65: 688-694
• 10 Sumiyama K, Gostout CJ, Rajan E et al. Chemically assisted endoscopic mechanical submucosal dissection by using mesna. Gastrointest Endosc 2008; 67: 534-538
• 11 Ohya TR, Sumiyama K, Takahashi-Fujigasaki J et al. In vivo histologic imaging of the muscularis propria and myenteric neurons with probe-based confocal laser endomicroscopy in porcine models (with videos). Gastrointest Endosc 2012; 75: 405-410
• 12 Gostout CJ, Knipschield MA. Submucosal endoscopy with mucosal resection: a hybrid endoscopic submucosal dissection in the porcine rectum and distal colon. Gastrointest Endosc 2012; 76: 829-834
• 13 Uno Y, Munakata A. The non-lifting sign of invasive colon cancer. Gastrointest Endosc 1994; 40: 485-489
• 14 Sumiyama K, Tajiri H, Gostout CJ et al. Chemically assisted submucosal injection facilitates endoscopic submucosal dissection of gastric neoplasms. Endoscopy 2010; 42: 627-632
• 15 Fu K, Sano Y, Kato S et al. Hazards of endoscopic biopsy for flat adenoma before endoscopic mucosal resection. Dig Dis Sci 2005; 50: 1324-1327
• 16 Schumacher B, Charton JP, Nordmann T et al. Endoscopic submucosal dissection of early gastric neoplasia with a water jet-assisted knife: a Western, single-center experience. Gastrointest Endosc 2012; 75: 1166-1174