Gastric endoscopic submucosal dissection under steady pressure automatically controlled endoscopy (SPACE); a multicenter randomized preclinical trial

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Steady pressure automatically controlled endoscopy (SPACE) is a new modality that eliminates on-demand insufflation but enables automatic insufflation in the gastrointestinal tract. Though its use in porcine esophageal ESD was reported to be promising, its applicability and potential effectiveness to gastric procedures have not been evaluated.


The aims were (1) to evaluate feasibility and safety of SPACE in the stomach, and (2) to assess its potential advantages over conventional endoscopy in preventing “blind insufflation”-related complications.


A multicenter randomized preclinical animal study.


Laboratories at three universities.


Experiment 1: Gastric ESD was attempted in the swine (n = 17), under either SPACE or manual insufflation. Experiment 2: Gastroscopy was performed for 10 min in the perforated stomach (n = 10) under either SPACE or manual insufflation.

Main outcome measurements

Experiment 1: ESD time, energy device activation time, number of forceps exchanges, specimen size, en block resection rate, vital signs and any intraoperative adverse events. Experiment 2: Intra-gastric and intra-abdominal pressures, vital signs, and any adverse events.


Experiment 1: Gastric ESD was completed in all animals. ESD time tended to be shorter in SPACE than in the control, though the difference was not significant (p = 0.18). Experiment 2: Although both intra-gastric and intra-abdominal pressures remained within preset values in SPACE, they showed excessive elevation in control.


An animal study with small sample size.


SPACE is feasible and safe for complicated and lengthy procedures such as gastric ESD, and is potentially effective in preventing serious consequences related to excessive blind insufflation.

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CO2 :

Carbon dioxide


Endoscopic submucosal dissection


Steady pressure automatically controlled endoscopy


Abdominal compartment syndrome

EtCO2 :

End-tidal carbon dioxide

SpO2 :

Percutaneous oxygen saturation


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The co-author Kiyokazu Nakajima has received research funding from Top, Co., Ltd. (Tokyo, Japan) and Fujifilm Corp. (Tokyo, Japan).


Authors Takuya Yamada, Masashi Hirota, Shusaku Tsutsui, Motohiko Kato, Tsuyoshi Takahashi, Kazuhiro Yasuda, Kazuki Sumiyama, Masahiko Tsujii, Tetsuo Takehara, Masaki Mori, Yuichiro Doki and Kiyokazu Nakajima have no conflicts of interest or financial ties to disclose.

Author information

Correspondence to Kiyokazu Nakajima.

Additional information

Takuya Yamada and Masashi Hirota have contributed equally to this study.

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Yamada, T., Hirota, M., Tsutsui, S. et al. Gastric endoscopic submucosal dissection under steady pressure automatically controlled endoscopy (SPACE); a multicenter randomized preclinical trial. Surg Endosc 29, 2748–2755 (2015).

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  • ESD
  • Early gastric cancer
  • GI
  • Endoscopy
  • Technical