Percutaneously assisted endoscopic surgery using a new PEG-minitrocar for advanced endoscopic submucosal dissection (with videos)

Background: For endoscopic submucosal dissection (ESD), adequate exposure and visualization of the submucosa for controlled dissection is of eminent importance. Objective: To determine the feasibility and safety of percutaneously assisted endoscopic surgery (PA-ES) with a new prototype PEG-minitrocar (PMT) for advanced ESD in a porcine model. Interventions: Placement of the PMT was done in all pigs by the use of a modified pull-through technique. After endoscopic incision of the mucosa, traction was provided for ESD by grasping the incisional margins of the mucosa with a rigid forceps introduced through the PMT, enabling stepwise dissection of the exposed submucosa under direct vision. Main Outcome Measurements: Feasibility and safety of the new PMT for PA-ES and en bloc resection of prespecified mucosal areas. Results: The study started with acute experiments in 8 animals, followed by a 10-day survival study in another 8 pigs. A total of 20 mucosal pieces were resected. The sizes of the resected pieces varied up to 7.5 × 4.0 cm ex vivo. All but one could be resected en bloc. Percutaneous assistance resulted in an excellent exposure of the submucosal space and enabled stepwise dissection of the submucosal connective tissue. Neither the PMT nor advanced ESD led to relevant complications. Conclusions: We demonstrated the feasibility and safety of a new PMT for advanced ESD. With the use of PA-ES, mucosal pieces of various sizes can be resected en bloc in gastric locations that are difficult to access by flexible endoscopy alone.