Basic Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 28, 2019; 25(28): 3764-3774
Published online Jul 28, 2019. doi: 10.3748/wjg.v25.i28.3764
Novel technique for endoscopic en bloc resection (EMR+) - Evaluation in a porcine model
Benjamin Meier, Andreas Wannhoff, Christoph Klinger, Karel Caca
Benjamin Meier, Andreas Wannhoff, Christoph Klinger, Karel Caca, Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg 71640, Germany
Author contributions: Meier B and Caca K have performed the ex vivo and in vivo experiments; Meier B has analyzed the data; Meier B, Andreas W and Christoph K have prepared the manuscript; and Caca K has approved the final version.
Institutional review board statement: Study was approved by local authority.
Institutional animal care and use committee statement: This study was approved by Regierungspräsidium Baden-Württemberg, Germany (approval number C1/15).
Conflict-of-interest statement: Karel Caca has received lecture fees for FTRD-training courses. Benjamin Meier, Andreas Wannhoff and Christoph Klinger have nothing to disclose.
Data sharing statement: No additional unpublished data are available.
ARRIVE guidelines statement: The ARRIVE guidelines have been adopted.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Benjamin Meier, MD, Adjunct Professor, Doctor, Klinikum Ludwigsburg, Department of Gastroenterology, Posilipostraße 4, Ludwigsburg 71640, Germany.
Telephone: +49-7141-9967201 Fax: +49-7141-9967219
Received: March 4, 2019
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
Research background

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.

Research motivation

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.

Research objectives

Major objective was to develop an effective, safe and fast technique for endoscopic en bloc resection for lesions > 20 mm of size.

Research methods

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).

Research results

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.

Research conclusions

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).

Research perspectives

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.