How I do it: Flexible 3‐D endoscope for endoscopic submucosal dissection

Abstract

Endoscopic submucosal dissection (ESD) is technically challenging as a result of a lack of depth perception. The present article investigated the 3‐D endoscope for carrying out ESD and translated the technique from bench to clinical use. In a preclinical porcine experiment, ESD using a 3‐D endoscope was compared between an experienced and a novice endoscopist. All ESD were completed without perforation. Median operative time per surface area was significantly lower for the experienced endoscopist than for the novice (197.9 s/cm2 vs 434.7 s/cm2; P = 0.05). The second part was a prospective clinical experience to evaluate use of the 3‐D endoscope for carrying out ESD. Ten patients received ESD using the 3‐D endoscope. Four patients had gastric ESD, two had duodenal ESD and four had sigmoid and rectal ESD. There were no complications, whereas ESD failed in one patient who had gastric neoplasia at anastomosis. Mean operative time was 99.4 min, and operative time per surface area resection was 391 s/cm2. The operating endoscopist did not complain of motion sickness, whereas the assistants had some dizziness upon prolonged ESD procedure. This study showed that carrying out ESD was safe and effective using a 3‐D endoscope with an excellent 3‐D view enhancing depth perception. Future study should be conducted to compare 3‐D against 2‐D endoscopes for ESD.

First human application of a flexible 3‐D endoscope for gastrointestinal endoscopic submucosal dissection

“…Mean operative time per resected area was significantly less for the experienced than for the novice endoscopist. Procedural speed plateaued after the third ESD procedure for both the study participants, suggesting a potential benefit of education and training in ESD using the 3‐D endoscope for novices or trainees, whereas expert trainers could compensate by converting 2‐D images into stereoscopic configurations based on their skill and experience.…”

“…In the second part, endoscopists demonstrated successful translation of 3‐D endoscopic technology from bench to bedside during clinical performance of ESD . To our knowledge, this is the first report on the clinical application of 3‐D endoscopy to carry out ESD.…”

“…Endoscopic submucosal dissection is widely adopted as an advanced endoluminal procedure to allow en bloc resection of superficial gastrointestinal neoplasia, but is still technically challenging when using conventional endoscopes that rely solely on 2‐D information, and thus lack depth appreciation . In this regard, an ex vivo study explored the feasibility of stereovision view using a 3‐D flexible endoscope in the simulated setting of ESD .…”

“…According to case series experience conducted by one experienced endoscopist, the initial outcomes of 10 consecutive cases consisting of four gastric, two duodenal and four colorectal intramucosal neoplasia were feasible without complications, whereas ESD failed in one patient who had gastric neoplasia at anastomosis. Reason for failure was dense adhesions with oozing, which caused loss of view during the procedure . The 3‐D endoscope was equipped with water jet function, possibly facilitating ESD by removal of sticky mucus or blood during on‐going ESD, but massive liquid collection by irrigation or arterial bleeding related to the procedure could hinder 3‐D visualization .…”

“…However, the prototype flexible 3‐D endoscope equipped with narrow band imaging lacking magnifying function was useful for identifying tumor margins, and to allow clear vascular identification (i.e. penetrating arterioles), linking to pre‐emptive control of hemorrhage by cautery of visible arterioles under 3‐D visualization . Moreover, the study participant achieved better differentiation between the submucosal and the muscularis propria layer through 3‐D images to avoid accidental perforation .…”