Features of Therapeutic Devices for Gastric Endoscopic Submucosal Dissection and Basic Techniques

Experimental Endoscopic Submucosal Dissection Training in a Porcine Model: Learning Experience of Skilled Western Endoscopists

“…Indeed, in Japan ESD is performed with specialized endoscopic equipment that is not yet available in Europe. In the workshop, standard Exera GIF H180 gastroscopes (Olympus) were used, which do not feature a separate water jet channel (focused on the tip of the electric knife), nor increased angulation of the bending section or ergonomic alignment of the working channel outlet in contrast to Japanese ESD endoscopes, such as the gastroscope Lucera GIF‐H260Z (Olympus) 27 . The rate of complications, especially perforations, must be reduced by optimum maintenance of the endoscopic equipment, and more intense cognitive preparation and much more cautiousness.…”

“…The esophagus, comparably long as in an adult man, holds at least five imaginary ESD areas of that size. The areas were chosen with the piglets lying on the left lateral, back supine, or right lateral position, to locate the ‘ESD lesion’ on the top or lateral side (as compared to the fluid level in the organ), so that gravity of the mucosal specimen supports the dissection procedure (by tilting away of the specimen from the resection plane) 2,3,27 . Hemostasis was performed as contact hemostasis on small visible or slightly bleeding vessels with the three knives in the respective closed position using the electric setting for submucosal dissection.…”

“…Lifting of the mucosa and extension of the submucosal layer was achieved by submucosal injection 4–6 mL volumes of injection solution (10% glycerol in 0.9% saline solution containing 1:100 000 [or 0.5:100 000 for esophagus] epinephrine and 1:500 vol/vol indigo carmine) using standard 23 gauge injection needles (N3047030, and N3047730, Olympus) for dual and hook knife preparations, and 0.9% saline solution (1:500 vol/vol indigo carmine) as needed for lifting of the mucosa with the water‐jet injection mode of the hybrid knife (ERBE). The cutting strategy was chosen according to the literature for hook knife, 2 dual knife, 3,27 and the hybrid knife ESD 28 (Fig. 2).…”

“…In smaller‐diameter hollow organs, such as the porcine esophagus or colon, the whole ESD procedure, for all knife types, was done with the scope in an antegrade fashion, including the cutting of the mucosa and the dissection of the submucosa. This approach is even more skilful and may require stepwise change of the position of the animal rotating around its longitudinal axis, to support the procedure by gravity of the dissected part of the lesion 2,27 . Further details of the procedures and animal care are available from the corresponding author on request.…”

“…The areas were chosen with the piglets lying on the left lateral, back supine, or right lateral position, to locate the 'ESD lesion' on the top or lateral side (as compared to the fluid level in the organ), so that gravity of the mucosal specimen supports the dissection procedure (by tilting away of the specimen from the resection plane). 2,3,27 Hemostasis was performed as contact hemostasis on small visible or slightly bleeding vessels with the three knives in the respective closed position using the electric setting for submucosal dissection. Larger vessels (Ն1 mm diameter) were coagulated pre-emptively or in case of bleeding using the coagrasper forceps (Olympus) in soft coagulation mode (setting 40 W, effect 3).…”