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Submucosal endoscopy with mucosal flap safety valve
Kazuki Sumiyama1, Christopher J Gostout, Elizabeth Rajan
1Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
Background:
There is no reliable endoscopic method to selectively resect deeper layers of the gut wall or to access the peritoneal cavity and prevent peritoneal soiling.
Objectives:
To determine the technical feasibility and safety of submucosal endoscopy with mucosal flap (SEMF) in accessing the peritoneal cavity through a large full-thickness gastric-muscle-wall resection.
Design:
Ex vivo feasibility exploration and survival animal study.
Settings:
Ex vivo samples were obtained from fresh harvested organs. In vivo procedures were conducted with the pigs under standard general anesthesia.
Interventions:
High-pressure carbon dioxide (CO(2)) injection and balloon dissection created a large submucosal working space for insertion of a cap-fitted endoscope. By using the EMR cap, a full-thickness resection of the muscularis propria was performed. This full-thickness defect was sealed with the overlying mucosal flap and the use of hemoclips or tissue anchors.
Results:
By using the SEMF technique in the ex vivo experiment, the gastric wall was successfully traversed in each stomach after submucosal dissection and full-thickness resection of the musclaris. Similarly, by using the SEMF technique in the in vivo procedures, the peritoneal cavity was successfully accessed and the defect was completely sealed by using the mucosal flap. All animals survived 1 week after the procedure. Ulceration was noted in 3 pigs, and a small bowel injury was noted in 1 pig. Leak testing was negative in all stomachs.
Conclusions:
By using the SEMF technique, submucosal space endoscopy and deep-layer gastric-wall resection were successfully performed. Furthermore, the mucosa overlying the dissected submucosal space served as a safe flap valve, preventing peritoneal leakage.
Insights
Submucosal endoscopy with mucosal flap (SEMF) allows safe access to the peritoneal cavity via gastric wall resection. This novel endoscopic technique successfully sealed defects, preventing leakage in animal studies.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Endoscopic Research
Background:
- Current endoscopic methods lack reliability for deep gut wall resection or safe peritoneal cavity access.
- Peritoneal soiling remains a significant risk with existing endoscopic techniques.
Purpose of the Study:
- To assess the technical feasibility and safety of submucosal endoscopy with mucosal flap (SEMF).
- To evaluate SEMF for accessing the peritoneal cavity through a full-thickness gastric resection.
Main Methods:
- Ex vivo and in vivo animal studies were conducted.
- A large submucosal working space was created using CO(2) injection and balloon dissection.
- Full-thickness gastric-muscle-wall resection was performed, and the defect was sealed with a mucosal flap and clips/anchors.
Main Results:
- SEMF successfully traversed the gastric wall and accessed the peritoneal cavity in ex vivo and in vivo models.
- The mucosal flap effectively sealed the full-thickness defect, preventing leakage (negative leak tests).
- All animals survived the 1-week follow-up, with minor noted injuries in some.
Conclusions:
- Submucosal endoscopy with mucosal flap (SEMF) is technically feasible for deep-layer gastric wall resection.
- The mucosal flap acts as a reliable valve, preventing peritoneal leakage after endoscopic resection.
- SEMF offers a promising endoscopic approach for accessing the peritoneal cavity.
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