Selective Fluid Cushion in the Submucosal Layer by Water Jet: Advantage for Endoscopic Mucosal Resection

Abstract

Background/Aim: Numerous new techniques have recently been reported and described for the endoscopic mucosal resection of large superficial lesions of the gastrointestinal tract. We present here for the first time the application of a water jet dissector for mucosa elevation. Materials and Methods: In an ex vivo study, the effectiveness of a water jet dissector (Helix Hydro-Jet®) placed directly on the stomach walls of 8 pigs was examined to create a mucosal elevation. After having determined optimal pressures, angle of application, and application times, 13 submucosal fluid cushions were produced in different areas of the stomach walls of 8 pigs in vivo, and the sizes of the resulting submucosal cushions were measured. Results: Using pressures between 30 and 70 bar, it was routinely possible to create submucosal fluid cushions in the stomach wall ex vivo as well as in vivo. Histological examination showed a selective edema in the submucosa without damage to the deeper mucosal layers of the gastric wall. Conclusions: The capacity of a targeted high-pressure water jet to penetrate the mucosa and selectively create a fluid cushion in the submucosa facilitates endoscopic resection of the mucosa. This new method could contribute to ameliorate the endoscopic treatment of mucosal tumors which previously could not be resected endoscopically due to their size, extent, or location.

Combination of water-jet dissection and needle-knife as a hybrid knife simplifies endoscopic submucosal dissection

“…Following earlier studies performed by Farin [12], Schurr et al [13], and Ehrhardt et al [14], our study group demonstrated the suitability of the water-jet technology for mucosal elevation before EMR in experimental and clinical investigations [15,16]. The focused water-jet, which can be applied using a wide range of therapeutic pressures ranging from 20 to 80 bar, is capable of penetrating the mucosa from different angles and creates a selective accumulation of liquid exclusively in the submucosal lamina.…”

The Dissection Profile and Mechanism of Tissue-Selective Dissection of the Piezo Actuator-Driven Pulsed Water Jet as a Surgical Instrument: Laboratory Investigation Using Swine Liver

“…The water jet technology with a continuous pressure-driven water flow was initially used in liver surgery in the 1980s [13], and, thereafter, in neurosurgery [19], and stomach [20], colon [21], cardiovascular [22] and ophthalmological [23] surgeries. It might be beneficial in that the water jet, as a no-touch technique, is less traumatic to the vascular structures than the directly applied ultrasonic aspirator tip [24].…”

Endoscopic submucosal dissection

“…It has demonstrated a clear technical advantage over the conventional surgical dissection modalities. It allows: i) a selective dissection of fibrous and connectives tissues, preserving blood vessels for delayed ligation; [37][38][39] ii) 44 demonstrated that submucosal injection of a saline solution using WJ provides a selective long-lasting SFC for over 20 min. These results were confirmed by the same team in a study on humans obtaining long-lasting SFC for over 40 min using other solutions such as plasma expanders.…”