Published online Jul 28, 2019. doi: 10.3748/wjg.v25.i28.3764
Peer-review started: March 4, 2019
First decision: April 8, 2019
Revised: May 24, 2019
Accepted: June 7, 2019
Article in press: June 8, 2019
Published online: July 28, 2019
Endoscopic en bloc and R0-resection is essential for adequate treatment of mucosal neoplasia. EMR is fast and safe but only adequate for lesions up to 20 mm of size. For lesions > 20 mm ESD is available. However, especially in the western world this technique might not be widely available and associated with higher risks for complications and longer procedure times.
To provide a fast and safe en bloc resection technique for lesions > 20 mm we developed a modified grasp and snare technique (EMR+) in a porcine model. We presumed that a novel technique might be interesting especially when ESD expertise is not available.
Major objective was to develop an effective, safe and fast technique for endoscopic en bloc resection for lesions > 20 mm of size.
EMR+ was first (October – December 2017) developed ex vivo in an explanted pig stomach. The technique included two novel components and was considered as a modified grasp and snare technique. We used an additional working channel (AWC®, Ovesco Endoscopy, Tübingen, Germany) to facilitate simultaneous application of a resection and grasping device. For submucosal injection we used a new agent with temperature-dependent viscosity (LiftUp®, Ovesco Endoscopy, Tübingen, Germany). EMR+ was then (April – July 2018) further evaluated in vivo (porcine model, stomach).
During the study period, 22 resections were performed ex vivo and 13 resections were performed in vivo. Median procedure time was fast (7 min ex vivo, 5 min in vivo) and median size of resections specimens was 30 mm × 26 mm × 11 mm/35 × 35 × 11 mm ex vivo/in vivo. Resection was macroscopically complete in vivo in 92.3%. Major adverse events were not observed.
EMR+ is a novel modified grasp and snare technique for endoscopic en bloc resection. The technique allowed safe and fast resection for lesions > 20 mm of size and was easy to perform in the porcine model. The novel injection agent allowed for sufficient protection of the muscular layer. Major limitation of our study was resection of regular mucosa in the stomach (imaginary lesions were created by circular coagulation).
To better define the role of EMR+ clinical and comparative trials are needed. Further studies need to address resection of apparent mucosal neoplasia in different anatomic locations.