Endoscopic resection of T1N0 gastrointestinal malignancies has shown
excellent long-term recurrence-free and overall survival rates when tumor-free
resection margins are achieved [1]
[2]. For en bloc resection of lesions larger than
20 mm, piecemeal resection or endoscopic submucosal dissection (ESD) is
required [3]. Although many different devices are
available, ESD remains technically difficult, time consuming, and associated
with perforation rates of up to 10 % [1]
[2]
[4]
[5]. The
laparoscopic Maryland dissector is a standard surgical instrument used for fine
dissection. A flexible version of this instrument that can be passed through a
3.7-mm endoscopic working channel has recently become available ([Video 1]).
Video
1 Demonstration of the
endoscopic Maryland dissector.
We used the endoscopic Maryland dissector (Ethicon Endo-Surgery,
Cincinnati, Ohio, USA) to perform colonic ESD in a female domestic pig. Under
general anesthesia resection margins were created by marking a circumferential
area with superficial mucosal burns. Saline and methylene blue were then
injected into the submucosa. A circular mucosal incision was performed using a
hook knife (Ethicon Endo-Surgery) and blunt dissection through the submucosal
plane was facilitated with the endoscopic Maryland ([Fig. 1], [Video 2]).
Fig. 1 a After marking a
circumferential area with superficial mucosal burns a circular submucosal
incision was performed using a hook knife. b d The
novel flexible endoscopic Maryland dissector (b) was
used for blunt submucosal dissection (c, d).
e Endoscopic view of the resection site with a 3-cm
endoscopic ruler in the lesion. f Resected specimen.
Video
2 Colonic endoscopic
submucosal dissection using the endoscopic Maryland dissector.
Time for circumferential precutting was 17 minutes. Time for blunt
submucosal dissection was 36 minutes. Complete resection in one piece including
all electrocautery markings was achieved. The size of the resection specimen
was 2.5 × 2.0 cm. The size of the electrocautery
markings was 1.7 × 1.9 cm. No procedure-related
complications such as bleeding or perforation occurred.
The concept and design of the endoscopic Maryland dissector are
similar to those of the laparoscopic dissector. Using this novel device, the
surgical technique of blunt dissection was successfully translated into an
endoscopic model. Blunt submucosal dissection is straightforward, and may be
widely applicable for removal of gastrointestinal lesions. Moreover, all used
instruments are approved by the Food and Drug Administration. A modified,
smaller endoscopic Maryland dissector with the possibility to apply
electrocautery might improve the usability of this device for colonic ESD.
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