Abstract
Background and aims
With an external additional working channel (AWC) endoscopic mucosal resection (EMR) as well as endoscopic submucosal dissection (ESD) can be extended to techniques termed “EMR+” and “ESD+.” These novel techniques are systematically compared to EMR and ESD under the use of a double-channel endoscope (DC).
Methods
Our trial was conducted prospectively in a pre-clinical porcine animal model (EASIE-R simulator) with standardized gastric lesions measuring 3 or 4 cm.
Results
EMR+ and EMR DC showed both good results for 3 cm lesions with no adverse events and an en bloc resection rate of 73.33% (EMR+) and 60.00% (EMR DC, p = 0.70). They came to their limits in 4 cm lesions with muscularis damages of 20.00% (EMR+), 13.33% (EMR DC, p ≥ 0.99) and decreasing en bloc resection rates of 60.00% (EMR+) and 46.67% (EMR DC, p = 0.72).
ESD+ and ESD DC were both reliable concerning en bloc resection rates (100% in all groups) and adverse events (0.00% in 3 cm lesions, 12.50% muscularis damages in both ESD+ and ESD DC in 4 cm lesions).
Resection time was slightly shorter in all groups with the AWC compared to DC although only reaching significance in 3 cm ESD lesions (p < 0.05*).
Conclusions
With the AWC, a standard endoscope can easily be transformed to double-channel functionality. We could show that EMR+ and ESD+ are non-inferior to EMR and ESD under the use of a double-channel endoscope. Consequently, the AWC presents an affordable alternative to a double-channel endoscope for both EMR and ESD.
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Endoscopic mucosal resection (EMR) offers a safe, cost-effective, and well-established interventional endoscopic technique for the successful resection of many precancerous gastrointestinal lesions [1]. With its relatively low technical complexity, EMR features brief procedure times with a low risk of adverse events [2]. However, in larger lesions EMR shows a decreasing rate of en bloc resections [1, 3]. In particular, en bloc resection of laterally spreading adenomas or large sessile colorectal polyps ≥ 2 cm can be achieved in only about 30% [2, 4]. Of course, EMR can be performed in piecemeal technique. But this comes along with higher rates of incomplete resections leading to more cases of recurrence. Consequently, piecemeal resections also require more frequent follow-up endoscopies [5]. The spectrum of EMR can be extended by an external additional working channel (AWC, Ovesco Endoscopy, Tübingen, Germany). Its feasibility could already be shown in previous publications and the technique was termed “EMR+” [6,7,8,9]. Meanwhile, there have also been several reports and some studies published on the application of EMR+ in humans [7, 10, 11]. Experimental data systematically evaluating the AWC in EMR were provided by our group and others [6, 8, 9]. EMR+ with the AWC extends the range of en bloc resections beyond the relevant size of 2 cm, particularly with promising results in 3 cm lesions [6]. However, also EMR+ reaches its limits in 4 cm lesions with lower en bloc resection rates and a rising risk of perforations [6].
Consequently, endoscopic submucosal dissection (ESD) needs to be considered in lesions ≥ 3 cm. ESD has become a standard interventional endoscopic procedure also in western expert centers since its initial development in Japan [12,13,14,15,16]. In terms of the resection of flat lesions ≥ 3 cm, ESD offers an anatomically convincing method. Principally, with ESD en bloc resections regardless of lesion’s size can be achieved [12]. However, even for experienced endoscopists, ESD is technically challenging and associated with relevant adverse events, particularly a higher rate of perforations [2]. Moreover, it demands higher costs and more time resources. For the above reasons, also the optimization of ESD by additional endoscopic devices is needed. Many concepts of advancing ESD, e.g., by counter-traction devices, have been pursued. Taking up those approaches, also ESD can be enhanced by the AWC mounted on a standard endoscope [17]. This enables a simultaneous use of two instruments and thus the interaction of ESD knife with a grasper, ESD coagulation dissector, or other additional instruments. This technique is termed “ESD+” in analogy to EMR+ [17]. Recently, ESD+ was systematically evaluated in an animal model. Compared to conventional ESD, it could be shown that by its grasp-and-mobilizing technique, ESD+ allows potentially safer and faster resections of flat lesions [17].
In endoscopic expert centers, ESD is frequently performed with double-channel endoscopes. This offers a grasp and snare technique comparable to ESD+ [18, 19]. However, double-channel endoscopes are expensive and not cost-effective for many endoscopy centers. Consequently, in many endoscopy units, double-channel endoscopes are not available. Compared to the investment of a double-channel endoscope, additional endoscopic tools like the AWC are less expensive, and besides, they are easy to handle.
In a pre-clinical porcine ex vivo animal model, we prospectively compare the novel techniques EMR+ and ESD+ with EMR under the use of a double-channel endoscope and, respectively, ESD via a double-channel endoscope. This is carried out in order to investigate whether EMR+ and ESD+ are non-inferior to EMR and ESD via a double-channel endoscope.
Materials and methods
This trial was a prospectively designed ex vivo study. Since no living animals or humans were included, it was exempted from IRB. The experiments were conducted at the Laboratory for Experimental Endoscopy in the Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology of the University Medical Center Göttingen in Germany.
The cleaned porcine stomachs used for the experiments were defrosted prior to intervention. Afterward, they were placed into the EASIE-R simulator (Erlangen Active Simulator for Interventional Endoscopy, Endosim, LLC, Hudson, MA, USA), a well-established model for interventional endoscopic training and research that has also been evaluated at our research unit for several endoscopic procedures [6, 8, 17, 20, 21].
A well-trained senior endoscopist with previous EMR and ESD expertise in humans as well as in animal models performed all interventions (EMR+ and ESD+ with the AWC as well as EMR and ESD with the double-channel endoscope). The endoscopist was assisted by an experienced endoscopic nurse.
Preparation of the porcine stomachs
EMR becomes particularly challenging beyond a lesion size of 2 cm [6]. Therefore, standardized flat lesions were defined in the porcine stomachs prior to intervention, measuring 3 cm or 4 cm. This was done by thermal marking with coagulation dots around a defined template. Then, the stomachs were closed by surgical suture and transferred into the EASIE-R model with esophagus and stomach fixed to the model’s plastic shell [6, 21].
Additional working channel (AWC)
In analogy to the setup known from the full-thickness resection device (FTRD), the AWC can be mounted at the tip of a standard endoscope. The AWC features a shaft with a length of either 122 cm (endoscope insertion length: 103–110 cm) or 185 cm (endoscope insertion length: 160–170 cm). It has a flexible attachment for endoscope diameters from 8.5 to 13.5 mm. Via an adaptor, the AWC is fixed at the endoscope handle. A valve can be connected to the adaptor via Luer-lock. The AWC comes along with a sleeve and an adhesion tape.
Instruments with an outer diameter of up to 2.8 mm can be introduced via the AWC [6].
Principally, the AWC can be rotated 360° on the distal tip of the endoscope. In our experiments, all AWC procedures were conducted with the AWC in the counterpart position to the working channel (Fig. 1A). The AWC setup is also illustrated in Fig. 2.
Procedure of EMR+ and ESD+
EMR+ and ESD+ were conducted with a conventional gastroscope (EG-530WR Fujinon, Fujifilm, Tokyo, Japan), the AWC device (Ovesco Endoscopy, Tübingen, Germany) and, in the case of ESD+, with the AqaNife 2.5 mm needle length. Setup and principle of EMR+ and ESD+ technique with the help of the AWC are shown in Figs. 3, 4, 5, and 6.
Procedure of EMR and ESD with the double-channel endoscope
EMR and ESD were performed with the double-channel endoscope EG-530D Fujinon, Fujifilm, Tokyo, Japan and, in the case of ESD, with the AqaNife 2.5 mm needle length. The setup of EMR DC and ESD DC is shown in Figs. 3 and 4.
In all resections, the FTRD grasper (Ovesco Endoscopy, Tübingen, Germany) was used. In EMR and EMR+ resections, a 33-mm snare (Boston Scientific, Marlborough, Massachusetts, United States) was applied. In both ESD techniques, the ESD injection fluid was Hydroxyethyl starch (HAES) mixed with methylene blue dye for better visualization and optimal tissue differentiation. The electrosurgical unit was ERBE VIO 200 D (ERBE Elektromedizin, Tübingen, Germany) with the mode EndoCut Q.
Data collection
By an independent observer, the following parameters were recorded:
-
Primary end point Rate of en bloc resection.
-
Secondary end points Time of procedure for EMR+ and ESD+ as well as for EMR and ESD via double-channel endoscope (minutes), adverse events (muscularis damage, perforations).
After every resection the specimens were spread out and pinned on cork plates. The en bloc resection was evaluated and documented. En bloc resection was defined as the complete resection with all previously marked coagulation dots within the resected specimen. All procedures were intended to be en bloc resections. The procedure time was defined from submucosal injection of the lesion until its complete resection. Every resection site was visually inspected for muscular damage. By an insufflation test of the porcine stomach, potential perforations were evaluated.
Statistical analysis
Data analysis was performed with SPSS Version 28.0.1.1 (IBM, Armonk, NY, USA) and Prism 9 for macOS Version 9.4.1 (GraphPad Software, LLC, San Diego, CA, USA). The analysis of adverse events and en bloc resection rates was conducted with Fisher’s Exact Test. The time of procedure was analyzed by Mann–Whitney U Test. As usual, we considered p values less than 0.05 as statistically significant. They are marked by asterisk.
Results
Lesions with two different sizes with a diameter of 3 cm and 4 cm were set in the EMR as well as in the ESD groups (Fig. 7). Altogether, we used 11 porcine stomachs, each with 6–9 lesions, dependent on the lesions’ and stomachs’ sizes.
Overall, 96 endoscopic procedures were conducted in the porcine ex vivo model (Fig. 7). In detail, we performed 15 EMR+ vs. 15 EMR with the double-channel endoscope (DC) in 3 cm lesions and also 15 EMR+ vs. 15 EMR DC in 4 cm lesions. We conducted 10 ESD+ vs. 10 ESD DC in 3 cm lesions and 8 ESD+ vs. 8 ESD DC in 4 cm lesions (Fig. 7).
Primary end point
Rate of en bloc resection
In 3 cm lesions, EMR+ reached an en bloc resection rate of 73.33% (11/15) compared to 60.00% (9/15) with EMR DC, p = 0.70.
In 4 cm lesions, EMR+ reached an en bloc resection rate of 60.00% (9/15) compared to 46.67% (7/15) with EMR DC, p = 0.72.
Both ESD+ and ESD DC showed an en bloc resection rate of 100% in all lesions’ sizes (36/36).
Secondary end points
Time of procedure dependent on size
In all groups, the mean procedure time was shorter in 3 cm lesions compared to 4 cm lesions [EMR+ 6.07 (SD 2.28) vs. 8.13 (SD 2.97) min, p = 0.48; EMR DC 7.13 (SD 2.23) vs. 9.20 (SD 2.46) min, p = 0.02*; ESD+ 21.60 (SD 5.17) vs. 29.25 (SD 7.36) min, p = 0.03*; ESD DC 26.60 (SD 5.19) vs. 35.75 (SD 6.27) min, p < 0.01*].
Time of procedure dependent on technique
EMR+ vs EMR DC in 3 cm lesions
In 3 cm lesions, EMR+ was faster than EMR DC although without statistical significance [6.07 min (SD 2.28) vs. 7.13 min (SD 2.23), p = 0.12] (Fig. 8A).
EMR+ vs EMR DC in 4 cm lesions
Also, in 4 cm lesions, EMR+ was faster than EMR DC although without statistical significance [8.13 min (SD 2.97) vs. 9.20 min (SD 2.46), p = 0.28] (Fig. 8A).
ESD+ vs ESD DC in 3 cm lesions
In 3 cm lesions, ESD+ was significantly faster than ESD DC [21.60 min (SD 5.17) vs. 26.60 min (SD 5.19), p < 0.05*] (Fig. 8B).
ESD+ vs ESD DC in 4 cm lesions
In 4 cm lesions, ESD+ was faster than ESD DC although without statistical significance [29.25 min (SD 7.36) vs. 35.75 min (SD 6.27), p = 0.07] (Fig. 8B).
Safety and adverse events
In 3 cm lesions, no perforations or muscularis damages occurred neither in the EMR nor in the ESD groups.
In 4 cm lesions, we observed 3 (3/15, 20.00%) muscularis damages with EMR+ and 2 (2/15, 13.33%) muscularis damages with EMR DC (p ≥ 0.99). Also, in 4 cm lesions, there was 1 (1/8, 12.50%) muscularis damage under ESD+ as well as 1 (1/8, 12.50%) under ESD DC (p ≥ 0.99).
Throughout the whole study, no perforations with an air leakage in the insufflation tests occurred.
Discussion
EMR+ and ESD+ combine EMR and ESD with the grasp technique of the recently launched AWC. In this study, we aimed to evaluate EMR+ and ESD+ compared to EMR and ESD under the use of a double-channel endoscope in a porcine ex vivo model. To the best of our knowledge, this was conducted systematically for the first time.
Over time, the evolution of endoscopic resection techniques has continuously moved forward from EMR to ESD or e.g., endoscopic full-thickness resection (EFTR) with the full-thickness resection device (FTRD) in particular indications [22,23,24]. A lot of research effort has been undertaken in order to secure and accelerate endoscopic resections. In particular, the endeavor of achieving better intraluminal tissue traction has been a central focus of endoscopic research. For this purpose, a variety of additional endoscopic devices has been designed such as rubber bands, external forceps, clips with attached strings, magnetic anchors, or a pulley system with clips to facilitate endoscopic traction [25,26,27,28,29,30,31,32]. So far, the optimal traction device for endoluminal surgery has still not been found. That is why we need ongoing basic research on this aim.
Compared to EMR, ESD is a reliable and elegant technique for extended endoscopic resections featuring higher rates of R0 resections and consequently lower rates of recurrence [33]. With regard to the treatment of early gastric cancer, several meta-analyses compared ESD with EMR showing more en bloc resections, higher histologically complete resection rates, and lower recurrence frequencies for ESD [12, 34,35,36]. However, the superiority of ESD applies only for its use in the hand of an ESD-experienced endoscopic expert since ESD is complex and technically challenging. Therefore, ESD features a flat learning curve also for well-trained endoscopists and is associated with a relevant rate of adverse events, particularly perforations in up to 4–10% [12, 37].
To address these challenges, ESD+ was developed in order to improve feasibility and safety of ESD. Similar to EMR+, its principle is based on the AWC [8, 10, 17].
Certainly, in EMR as well as in ESD, a double-channel endoscope can be used to achieve better tissue traction with a simultaneous grasp and snare technique [18, 19, 38,39,40]. However, in many endoscopy units a double-channel endoscope is not available as it is an expensive investment. Its fixed and narrow distance between the two working channels of a double-channel endoscope and the fact that they are aligned in parallel, results in a lack of overview, flexibility, and sufficient triangulation [6, 17] (Figs. 1B, 3B, D, 4B, D). Compared with this, the AWC is more distant to the endoscope’s working channel and proceeds in a pointed angle. Also more variable positions of the AWC in relation to the endoscope’s working channel can be achieved by turning the AWC’s cap to the required position [7] (Figs. 1A, 2A). Altogether, this can lead to a more flexible triangulation of the endoscopic instruments consequently resulting in a better visibility and improved bimanual endoscopic working [6, 17]. The AWC might come along with certain disadvantages. Due to its external fixation outside the endoscope, the entire diameter of the scope tip increases which can possibly make the passage more difficult. Also, with the mounted AWC the endoscope becomes more rigid and maneuvers could become less comfortable to undertake. Although we did not encounter relevant drawbacks in our model these points could become relevant in clinical practice.
In our study, EMR+ and EMR DC provide convincing data in terms of en bloc resection rates and safety in 3 cm lesions but both come to technical limits in 4 cm lesions. This validates the previous data [6]. We can demonstrate that ESD is reliable concerning en bloc resection rates (100% in all groups) and safety, although there is a little increase of adverse events (muscularis damage) in 4 cm lesions with ESD+ as well as with ESD DC (both from 0.00 to 12.50%). This also confirms the previous data [17]. As well known from daily clinical routine, procedure time rises with size of the lesion. This can be recapitulated by our results in all applied techniques (EMR+, EMR DC, ESD+, and ESD DC). In our trial, all study arms with the AWC (EMR+ and ESD+) show shorter resection times compared to the study arms under use of the double-channel endoscope although this only reaches significance in 3 cm ESD lesions. However, our study fulfills its aim as it shows a non-inferiority of both EMR+ and ESD+ with the AWC compared to EMR and ESD under the use of a double-channel endoscope.
Our prospective study was conducted in a well-established porcine ex vivo model. This comes along with inherent limitations concerning transferability to living humans. The model can obviously not recapitulate bleeding, tissue movement, and other physiological features, e.g., neoplastic recurrence and stricture outcome. Also, a histopathological examination is not expedient. Furthermore, pigs have a thicker gastric mucosa and consequently a higher mucosal rigidity compared to humans. This may affect technical opportunities of all techniques applied in our study. Due to our experimental setup, in all groups we sought for a homogenous arrangement of the lesions’ positions (antegrade vs. retrograde). Since the study design would have become too confusing, we explicitly decided not to further subdivide our study arms to different positions of the lesions. Therefore, this study is not randomized which can also be regarded as a limitation.
Conclusion
EMR+ and ESD+ under use of the AWC allow fast and safe endoscopic resections. With the AWC, a standard single-channel endoscope can easily be transformed to double-channel functionality leading to better intraluminal tissue control.
In the ex vivo porcine model, we could show that EMR+ and ESD+ are not less than equivalent to EMR and, respectively, ESD under the use of a double-channel endoscope. As double-channel endoscopes are expensive investments for endoscopy units, the AWC presents an affordable alternative with good applicability in endoscopic everyday practice as well in the case of EMR+ as with ESD+.
Abbreviations
- AWC:
-
Additional working channel
- EFTR:
-
Endoscopic full-thickness resection
- EMR:
-
Endoscopic mucosal resection
- EMR+:
-
Endoscopic mucosal resection using the AWC
- EMR DC:
-
Endoscopic mucosal resection using a double-channel endoscope
- ESD:
-
Endoscopic submucosal dissection
- ESD+:
-
Endoscopic submucosal dissection using the AWC
- ESD DC:
-
Endoscopic submucosal dissection using a double-channel endoscope
- FTRD:
-
Full-thickness resection device
- HAES:
-
Hydroxyethyl starch
- IRB:
-
Institutional Review Board (Ethikkommission)
- min:
-
Minute
- R0:
-
No residual tumor
- SD:
-
Standard deviation
References
Ferlitsch M, Moss A, Hassan C, Bhandari P, Dumonceau JM, Paspatis G, Jover R, Langner C, Bronzwaer M, Nalankilli K, Fockens P, Hazzan R, Gralnek IM, Gschwantler M, Waldmann E, Jeschek P, Penz D, Heresbach D, Moons L, Lemmers A, Paraskeva K, Pohl J, Ponchon T, Regula J, Repici A, Rutter MD, Burgess NG, Bourke MJ (2017) Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 49:270–297
Holmes I, Friedland S (2016) Endoscopic mucosal resection versus endoscopic submucosal dissection for large polyps: a western colonoscopist’s view. Clin Endosc 49:454–456
Wang J, Zhang XH, Ge J, Yang CM, Liu JY, Zhao SL (2014) Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal tumors: a meta-analysis. World J Gastroenterol 20:8282–8287
Zhan T, Hielscher T, Hahn F, Hauf C, Betge J, Ebert MP, Belle S (2016) Risk factors for local recurrence of large, flat colorectal polyps after endoscopic mucosal resection. Digestion 93:311–317
Meier B, Caca K, Fischer A, Schmidt A (2017) Endoscopic management of colorectal adenomas. Ann Gastroenterol 30:592–597
Knoop RF, Wedi E, Petzold G, Bremer SCB, Amanzada A, Ellenrieder V, Neesse A, Kunsch S (2020) Endoscopic mucosal resection with an additional working channel (EMR+) in a porcine ex vivo model: a novel technique to improve en bloc resection rate of snare polypectomy. Endosc Int Open 8:E99–E104
Wedi E, Knoop RF, Jung C, Ellenrieder V, Kunsch S (2019) Use of an additional working channel for endoscopic mucosal resection (EMR+) of a pedunculated sessile serrated adenoma in the sigmoid colon. Endoscopy. https://doi.org/10.1055/a-0809-4814
Wedi E, Knoop R, Jung C, Gromski M, Ho CN, Conrad G, Maiss J, Milenovic S, Klemme D, Baulain U, Seif Amir Hosseini A, Ellenrieder V, Koehler P (2019) EMR+ with the AWC improves endoscopic resection speed compared to ESD: a porcine ex-vivo pilot study. Minim Invasive Ther Allied Technol. https://doi.org/10.1080/13645706.2019.1673778
Meier B, Wannhoff A, Klinger C, Caca K (2019) Novel technique for endoscopic en bloc resection (EMR+)—evaluation in a porcine model. World J Gastroenterol 25:3764–3774
Walter B, Schmidbaur S, Krieger Y, Meining A (2019) Improved endoscopic resection of large flat lesions and early cancers using an external additional working channel (AWC): a case series. Endosc Int Open 7:E298–E301
Sportes A, Jung CFM, Gromski MA, Koehler P, Seif Amir Hosseini A, Kauffmann P, Ellenrieder V, Wedi E (2020) Novel modified endoscopic mucosal resection of large GI lesions (> 20 mm) using an external additional working channel (AWC) may improve R0 resection rate: initial clinical experience. BMC Gastroenterol 20:195
Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A, Amato A, Berr F, Bhandari P, Bialek A, Conio M, Haringsma J, Langner C, Meisner S, Messmann H, Morino M, Neuhaus H, Piessevaux H, Rugge M, Saunders BP, Robaszkiewicz M, Seewald S, Kashin S, Dumonceau JM, Hassan C, Deprez PH (2015) Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 47:829–854
Gotoda T (2005) A large endoscopic resection by endoscopic submucosal dissection procedure for early gastric cancer. Clin Gastroenterol Hepatol 3:S71–S73
Repici A, Hassan C, Carlino A, Pagano N, Zullo A, Rando G, Strangio G, Romeo F, Nicita R, Rosati R, Malesci A (2010) Endoscopic submucosal dissection in patients with early esophageal squamous cell carcinoma: results from a prospective Western series. Gastrointest Endosc 71:715–721
Odagiri H, Yasunaga H (2017) Complications following endoscopic submucosal dissection for gastric, esophageal, and colorectal cancer: a review of studies based on nationwide large-scale databases. Ann Transl Med 5:189
Ono S, Fujishiro M, Niimi K, Goto O, Kodashima S, Yamamichi N, Omata M (2009) Long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms. Gastrointest Endosc 70:860–866
Knoop RF, Wedi E, Petzold G, Bremer SCB, Amanzada A, Ellenrieder V, Neesse A, Kunsch S (2021) Endoscopic submucosal dissection with an additional working channel (ESD+): a novel technique to improve procedure time and safety of ESD. Surg Endosc 35:3506–3512
Yonezawa J, Kaise M, Sumiyama K, Goda K, Arakawa H, Tajiri H (2006) A novel double-channel therapeutic endoscope (“R-scope”) facilitates endoscopic submucosal dissection of superficial gastric neoplasms. Endoscopy 38:1011–1015
Jung Y, Kato M, Lee J, Gromski MA, Chuttani R, Matthes K (2013) Prospective, randomized comparison of a prototype endoscope with deflecting working channels versus a conventional double-channel endoscope for rectal endoscopic submucosal dissection in an established experimental simulation model (with video). Gastrointest Endosc 78:756–762
Schöfl R, Buchmeier B, Hauder G (2006) Adaptation of the Erlangen Active Simulator for Interventional Endoscopy (EASIE) model for transmural pancreatic pseudocyst drainage. Endoscopy 38:100
Hochberger J, Matthes K, Maiss J, Koebnick C, Hahn EG, Cohen J (2005) Training with the compactEASIE biologic endoscopy simulator significantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy training alone. Gastrointest Endosc 61:204–215
Wedi E, Orlandini B, Gromski M, Jung CFM, Tchoumak I, Boucher S, Ellenrieder V, Hochberger J (2018) Full-thickness resection device for complex colorectal lesions in high-risk patients as a last-resort endoscopic treatment: initial clinical experience and review of the current literature. Clin Endosc 51:103–108
Meining A (2015) Endoscopic full-thickness resection: the logical step toward more extended endoscopic oncologic resections? Endoscopy 47:101–102
Hochberger J, Kruse E, Wedi E et al (2011) Training in endoscopic mucosal resection and endoscopic submucosal dissection. In: Cohen J (ed) Successful gastrointestinal endoscopy. Wiley-Blackwell, Oxford, pp 204–237
Kantsevoy SV, Bitner M, Piskun G (2016) New endoscopic platform for endoluminal en bloc tissue resection in the gastrointestinal tract (with videos). Surg Endosc 30:3145–3151
Sanchez-Yague A, Kaltenbach T, Yamamoto H, Anglemyer A, Inoue H, Soetikno R (2012) The endoscopic cap that can (with videos). Gastrointest Endosc 76(169–178):e161–e162
Rieder E, Makris KI, Martinec DV, Swanstrom LL (2011) The suture-pulley method for endolumenal triangulation in endoscopic submucosal dissection. Endoscopy 43(Suppl 2 UCTN):E319–E320
Kondo H, Gotoda T, Ono H, Oda I, Kozu T, Fujishiro M, Saito D, Yoshida S (2004) Percutaneous traction-assisted EMR by using an insulation-tipped electrosurgical knife for early stage gastric cancer. Gastrointest Endosc 59:284–288
Gotoda T, Oda I, Tamakawa K, Ueda H, Kobayashi T, Kakizoe T (2009) Prospective clinical trial of magnetic-anchor-guided endoscopic submucosal dissection for large early gastric cancer (with videos). Gastrointest Endosc 69:10–15
Aihara H, Kumar N, Ryou M, Abidi W, Ryan MB, Thompson CC (2014) Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video). Gastrointest Endosc 80:495–502
Imaeda H, Hosoe N, Ida Y, Kashiwagi K, Morohoshi Y, Suganuma K, Nagakubo S, Komatsu K, Suzuki H, Saito Y, Aiura K, Ogata H, Iwao Y, Kumai K, Kitagawa Y, Hibi T (2009) Novel technique of endoscopic submucosal dissection using an external grasping forceps for superficial gastric neoplasia. Dig Endosc 21:122–127
Scholvinck DW, Goto O, Bergman JJ, Yahagi N, Weusten BL (2015) The efficacy of an endoscopic grasp-and-traction device for gastric endoscopic submucosal dissection: an ex vivo comparative study (with video). Clin Endosc 48:221–227
Oka S, Tanaka S, Kaneko I, Mouri R, Hirata M, Kawamura T, Yoshihara M, Chayama K (2006) Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer. Gastrointest Endosc 64:877–883
Park YM, Cho E, Kang HY, Kim JM (2011) The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis. Surg Endosc 25:2666–2677
Lian J, Chen S, Zhang Y, Qiu F (2012) A meta-analysis of endoscopic submucosal dissection and EMR for early gastric cancer. Gastrointest Endosc 76:763–770
Facciorusso A, Antonino M, Di Maso M, Muscatiello N (2014) Endoscopic submucosal dissection vs endoscopic mucosal resection for early gastric cancer: a meta-analysis. World J Gastrointest Endosc 6:555–563
Hochberger J, Köhler P, Kruse E, Hûppertz J, Delvaux M, Gay G, Wedi E (2013) Endoscopic submucosal dissection. Internist (Berl) 54:287–301
von Renteln D, Schmidt A, Vassiliou MC, Rudolph HU, Caca K (2010) Endoscopic mucosal resection using a grasp-and-snare technique. Endoscopy 42:475–480
Shetty A, Suarez AL, Dufault DL, Mcvey MC, Elmunzer BJ (2016) Endoscopic mucosal resection with grasp-and-snare technique for challenging lesions. Gastrointest Endosc 84:738–739
de Melo SW Jr, Cleveland P, Raimondo M, Wallace MB, Woodward T (2011) Endoscopic mucosal resection with the grasp-and-snare technique through a double-channel endoscope in humans. Gastrointest Endosc 73:349–352
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Steffen Kunsch conducts hands-on trainings for the Ovesco AG. Ovesco AG provided the AWC device for the study. Richard F. Knoop, Ahmad Amanzada, Golo Petzold, Volker Ellenrieder, Michael Engelhardt, Albrecht Neesse, and Sebastian C. B. Bremer have no conflicts of interest or financial ties to disclose.
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Knoop, R.F., Amanzada, A., Petzold, G. et al. Endoscopic mucosal resection and endoscopic submucosal dissection with an external additional working channel (EMR+ and ESD+) are equivalent to using a double-channel endoscope: a systematic evaluation in a porcine ex vivo model. Surg Endosc 37, 7749–7758 (2023). https://doi.org/10.1007/s00464-023-10295-4
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DOI: https://doi.org/10.1007/s00464-023-10295-4