HybridKnife high-pressure glycerol jet injection for endoscopic submucosal dissection increases procedural ease and speed: a randomised study in pigs and a human case series

Replacing Needle Injection by a Novel Waterjet Technology Grants Improved Muscle Cell Delivery in Target Tissues

Current regimen to treat patients suffering from stress urinary incontinence often seems not to yield satisfactory improvement or may come with severe side effects. To overcome these hurdles, preclinical studies and clinical feasibility studies explored the potential of cell therapies successfully and raised high hopes for better outcome. However, other studies were rather disappointing. We therefore developed a novel cell injection technology to deliver viable cells in the urethral sphincter complex by waterjet instead of using injection needles. We hypothesized that the risk of tissue injury and loss of cells could be reduced by a needle-free injection technology. Muscle-derived cells were obtained from young male piglets and characterized. Upon expansion and fluorescent labeling, cells were injected into cadaveric tissue samples by either waterjet or injection needle. In other experiments, labeled cells were injected by waterjet in the urethra of living pigs and incubated for up to 7 days of follow-up. The analyses documented that the cells injected by waterjet in vitro were viable and proliferated well. Upon injection in live animals, cells appeared undamaged, showed defined cellular somata with distinct nuclei, and contained intact chromosomal DNA. Most importantly, by in vivo waterjet injections, a significantly wider cell distribution was observed when compared with needle injections (P < .05, n ≥ 12 samples). The success rates of waterjet cell application in living animals were significantly higher (≥95%, n = 24) when compared with needle injections, and the injection depth of cells in the urethra could be adapted to the need by adjusting waterjet pressures. We conclude that the novel waterjet technology injects viable muscle cells in tissues at distinct and predetermined depth depending on the injection pressure employed. After waterjet injection, loss of cells by full penetration or injury of the tissue targeted was reduced significantly in comparison with our previous studies employing needle injections.

Endoscopic submucosal dissection of gastric neoplastic lesions in Western countries: systematic review and meta-analysis

Endoscopic submucosal dissection (ESD) for gastric neoplastic lesions removal is largely performed in Asian countries. Unfortunately, ESD diffusion, particularly for gastric lesion removal, is still limited in Western countries. We performed a systematic review of available data coming from Western centers. The en bloc and the R0 resection rates for all neoplastic lesions, including early gastric cancer (EGC) and dysplasia, were calculated, as well as the curative rate for EGC. Complications and the 1-month mortality rates were computed. A total of 22 studies from Europe (N = 15), Latina America (N = 6), and Canada (N = 1) were retrieved, with 1152 patients and 1210 lesions. The en bloc resection was successful in 96% [95% confidence interval (CI) 93-98] with a significant heterogeneity (I2 = 63.5%; P < 0.0001). The R0 was achieved in 84% (95% CI 79-89; I2 = 79.9%; P < 0.001). The resection rate was curative in 72% out of 340 patients with EGC (95% CI 65-79, I2 = 8%; P = 0.36). Overall, complications occurred in 9.5% of patients, including bleeding (5.8%), perforation (3.4%), and stenosis (0.35%). A total of three (0.26%) patients deceased within 1 month, but none was directly related to the procedure. Lesion recurrence was observed in 38 (3.5%; 95% CI 2.3-4.4) cases, including 21 EGC and 17 dysplasia. In Western countries, the en bloc and the R0 resections were successful in the large majority of cases, whilst the resection was curative in 72% of patients with EGC. The complications rate was acceptably low.

Novel Techniques to Improve Precise Cell Injection

We noted recently that the injection of cells with a needle through a cystoscope in the urethral sphincter muscle of pigs failed to deposit them nearby or at the intended target position in about 50% of all animals investigated (n > 100). Increasing the chance for precise cell injection by shotgun approaches employing several circumferential injections into the sphincter muscle bears the risk of tissue injury. In this study, we developed and tested a novel needle-free technique to precisely inject cells in the urethral sphincter tissue, or other tissues, using a water-jet system. This system was designed to fit in the working channels of endoscopes and cystoscopes, allowing a wide range of minimally invasive applications. We analyze key features, including the physical parameters of the injector design, pressure ranges applicable for tissue penetration and cell injections and biochemical parameters, such as different compositions of injection media. Our results present settings that enable the high viability of cells post-injection. Lastly, the method is suitable to inject cells in the superficial tissue layer and in deeper layers, required when the submucosa or the sphincter muscle of the urethra is targeted.

Endoscopic submucosal dissection: an update on tools and accessories

Endoscopic submucosal dissection (ESD) is a minimally invasive therapeutic procedure to remove larger polyps or early non-metastatic lesions. It has long been used in Asia, but is now fast growing in popularity in the West. There are multiple challenges faced by ESD practitioners. While the practice of ESD in gastric lesions is relatively well established, the oesophagus with its narrow lumen and challenging workspace, and the colon with its tortuous course and folds are more challenging frontiers. The nature of performing a procedure endoscopically means that conventional methods offer no mechanism for providing counter-traction while performing dissection, impeding visibility and increasing the rate of complications. There are a multitude of tools available to those performing ESD for the different stages of the procedure. This article reviews the accessories currently used in regular ESD practice including the knives used to cut and dissect lesions, the cap and hood devices used to improve visibility and safety, injection fluids to lift the submucosal plane, haemostatic devices, generators, and finally, emerging traction apparatus. There is some evidence behind the use of these tools, however, ESD remains the domain of a small number of practitioners and the practice relies heavily on expert experience. Evolution of the ESD toolbox will make the procedure more accessible to more endoscopists, which in turn will drive the development of a more substantial evidence base to evaluate efficacy and safety of the multitude of tools.

A novel submucosal injection solution for endoscopic resection of large colorectal lesions: a randomized, double-blind trial

BACKGROUND AND AIMS

SIC-8000 (Eleview) is a new U.S. Food and Drug Administration (FDA)-approved solution for submucosal injection developed to provide a long-lasting cushion to facilitate endoscopic resection maneuvers. Our aim was to compare the efficacy and safety of SIC-8000 with those of saline solution, when performing EMR of large colorectal lesions.

METHODS

In a randomized double-blind trial, patients undergoing EMR for colorectal non-pedunculated lesions ≥20 mm were randomized in a 1:1 ratio between SIC-8000 and saline solution as control solution in 5 tertiary centers. Endoscopists and patients were blinded to the type of submucosal solution used. Total volume to complete EMR and per lesion size and time of resection were primary endpoints; the Sydney Resection Quotient (SRQ), as well as other EMR outcomes, and the rate of adverse events were secondary endpoints. A 30-day telephone follow-up was performed. An alpha level <0.05 was considered as statistically significant.

RESULTS

Of the 327 patients screened, 226 (mean age, 66 ± 10 years; males, 56%) were enrolled in the study and randomized between the 2 submucosal agents. Of these, 211 patients (mean size of the lesions 33 ± 13 mm; Paris class Is, 36%; proximal colon, 74%) were entered in the final analysis (SIC-8000, 102; saline solution, 109). EMR was complete in all cases. The total volume needed for EMR was significantly less in the SIC-8000 arm compared with saline group (16.1 ± 9.8 mL vs 31.6 ± 32.0 mL; P < .001). This corresponded to an average volume per lesion size of 0.5 ± 0.3 mL/mm and 0.9 ± 0.6 mL/mm with SIC-8000 and saline solution, respectively (P < .001). The mean time to completely resect the lesion tended to be lower with SIC-8000 than with saline solution (19.1 ± 16.8 minutes vs 29.7 ± 68.9 minutes; P = .1). The SRQ was significantly higher with SIC-8000 compared with saline solution (10.3 ± 8.1 vs 8.0 ± 5.7; P = .04) with a trend for a lower number of resected pieces (5.7 ± 6.0 vs 6.5 ± 5.04; P = .052) and a higher rate of en bloc resections (19/102, 18.6% vs 12/111, 11.0%; P = .1). The rate of adverse events was similar between the 2 arms (SIC-8000, 18.6%; saline solution, 17%), and none of the serious adverse events (SIC-8000, 8.8%; saline solution, 10.7%) were related to the study treatment.

CONCLUSIONS

In a double-blind, randomized clinical trial, a new FDA-approved agent for sub-mucosal injection appeared to be a more effective and equally safe submucosal agent for EMR injection than saline solution. (Clinical trial registration number: NCT02654418.).

Efficacy and safety of SIC-8000 (Eleview®) for submucosal injection for endoscopic mucosal resection and endoscopic submucosal dissection in an in vivo porcine model

BACKGROUND

Submucosal injection is generally required for both endoscopic-mucosal resection (EMR) and submucosal dissection (ESD). SIC-8000 (Eleview™) is a new FDA 510(k) cleared and CE marked liquid composition for submucosal injection, containing a biocompatible polymer as a cushioning agent.

AIMS

The aim of this randomized study was to compare Eleview with saline solution when performing upper- and lower-GI EMR/ESD in a porcine model.

METHODS

EMR/ESD procedures were performed in a total of 10 white domestic pigs comparing Eleview vs. NaCl 0.9% containing methylene blue at 0.001% (control solution) as submucosal solution to be injected. Animals were randomized between EMR (22 procedures) and ESD (22 procedures) and between upper- (8 animals) and lower-(2 animals) GI procedures. All procedures were performed aiming for a resection size of 1 cm × 1 cm for EMR and 2 cm × 2 cm for ESD. Volume of injected fluid, number of injections, time of resection, technical success, en-bloc resection, and adverse events were collected. Endoscopic surveillance was conducted each week for 4 weeks after the EMR/ESD, including biopsies on the margins of resection sites at week-1 of follow-up. After four weeks, pigs were sacrificed and necropsy performed.

RESULTS

Overall, 22 EMR and 22 ESD were performed in 10 live pigs. The average total volume needed for EMR and ESD was statistically significantly lower with Eleview as compared with control solution for both of the techniques (EMR: 5.6 ± 3.4 ml vs. 11.5 ± 6.7 ml; p = 0.02; ESD: 19.0 ± 10.0 ml vs. 36.3 ± 16.9 ml; p = 0.02). The rate of adverse events was statistically significantly lower in the Eleview than in the control group (2/26, 7.7% vs. 6/18, 33.3%; p = 0.03), but most of them were minor. No difference between Eleview and control solution was found in the rate of technical success (EMR: 11/13, 84.6% vs. 7/9, 77.8%; p = 0.7; ESD: 13/13, 100% vs. 9/9, 100%; p = 1), en-bloc resection (EMR: 6/13, 46.2% vs. NaCl: 5/9, 55.6%; p = 0.06; ESD: 12/13, 92.3% vs. 8/9, 88.9%; p = 0.8), and time of resection (EMR: 9.1 ± 7.75 min vs. 9.4 ± 9.6 min; p = NS; ESD: 38.4 ± 17.2 min vs. 40.2 ± 19.1 min; p = NS). At endoscopic follow up and necropsy, no difference in the process of healing of post-endoscopic ulcer and in the histological inflammation at the site of resection was shown between the two groups.

CONCLUSIONS

The new submucosal injection composition Eleview appeared to be an effective alternative to saline solution for submucosal injection for EMR/ESD, resulting in a substantial reduction of the volume administered to achieve an adequate lifting. No signs of adverse local or distant tissue reaction to Eleview were found at long-term follow up.

Standard needle versus needleless injection modality: animal study on different fluids for submucosal elevation

BACKGROUND AND AIMS

Submucosal injection is currently used in GI endoscopy to reduce resection risks and to perform submucosal dissection; it is usually performed via an injection needle or a needleless device. The aim of the study was to compare 2 submucosal injection modalities (needle-assisted vs needleless) by using substances with different viscosities.

METHODS

Needle and needleless injections were compared by assessing the efficacy of tissue elevation with 5 different substances in an ex vivo porcine model. The height of the submucosal elevation was measured 0(t0), 10(t1), and 30 minutes after injection (t2). Viscosity of the solution was also measured.

RESULTS

For both stomach and rectum, at t0, t1, and t2 no difference in the height of the elevation was found between the needle and needleless technique, irrespective of the substance. Tissue elevation in the stomach was similar between the 2 techniques at t0 (9.9 ± 1.58 vs 9.4 ± 1.3 mm, P = .3), t1 (7.2 ± 1.56 vs 6.9 ± 1.4 mm, P =. 26), and t2 (6 ± 1.6 vs 5.5 ± 1.3 mm, P = .18). No difference was found in the rectum at t1 and t2, whereas a slightly higher elevation with the needle-assisted technique was observed at t0 (t0: 12.4 ± 1.3 vs 11.2 ± 1.6 mm, P = .003; t1: 8.7 ± 1.3 vs 8.3 ± 1.5 mm; P = .32; t2: 7.0 ± 1.4 vs 7.2 ± .76 mm; P = .75). When comparing the substances with normal saline solution, more viscous solutions showed a significantly higher elevation at t0, t1, and t2 irrespective of the injection modalities and the location.

CONCLUSIONS

No differences were found in the height of submucosal injection or in the persistence of such elevation when comparing needleless with needle-assisted injection, with the only minor exception of the initial elevation in the rectum, which does not appear to be clinically relevant. Viscous solutions resulted in higher and more persistent elevations as compared with normal saline solution.

The "tunnel + clip" strategy standardised and facilitates oesophageal ESD procedures: a prospective, consecutive bi-centric study

INTRODUCTION

ESD is the treatment of choice for superficial neoplasms of the oesophagus; ESD is oncologically efficient and associated with less morbidity than the surgical alternative. ESD requires a high level of skill, being both technically challenging and time consuming. Therefore, ESD is often reserved for experts. A combination of a tunnel technique with clip-line traction may enable optimisation of oesophageal ESD.

PATIENTS AND METHODS

From January 2015 to December 2016, we performed a prospective two-centre case study of consecutive "tunnel + clip" oesophageal ESD. Four young operators (each of whom had performed fewer than 50 ESDs and fewer than five oesophageal ESDs) treated patients requiring ESD using the tunnel + clip method. This involves generation of a classic tunnel beneath the lesion, with constant traction being applied by a clip with a line placed at the oral side of the tunnel.

RESULTS

Sixty-two lesions (25 SCCs and 34 ADK/HGDs complicating Barrett's oesophagus) were consecutively resected. The en bloc, R0, and curative resection rates were 100% (62/62), 88.7% (55/62), and 74.2% (46/62), respectively. No perforation was noted. The mean ESD velocity was 24.5 mm²/min for lesions of mean length 59.6 mm. The tunnel + clip approach greatly aided the procedure. No pathological damage caused by clipping was evident.

CONCLUSION

Use of the tunnel + clip strategy to treat oesophageal ESD is effective and safe, even when performed by physicians with little prior experience. It is thus possible to standardise ESD of superficial oesophageal neoplasms and increase the velocity of dissection. Our procedure will encourage the use of oesophageal ESD in Western countries.