Feasibility Study of the Three-Dimensional Flexible Endoscope in Endoscopic Submucosal Dissection: An ex vivo Animal Study

Abstract

Background/Aim: Clinical application of 3-dimensional (3D) technology for flexible endoscopes has not been reported. We developed a 3D flexible endoscope and conducted a feasibility study of endoscopic submucosal dissection (ESD) in porcine stomach. Methods: Four endoscopists used a 3D flexible endoscope to perform a total of 8 ESD procedures on resected porcine stomachs. We assessed the en bloc resection rate, perforation rate, and mechanical issues that arise during ESD. A visual analog scale (0, 2D superior; 100, 3D superior) was used to evaluate the depth perception, sense of security of the procedure, and eyestrain of 3D visualization. Results: En bloc resection was achieved in all cases and there were no cases of perforation or mechanical issues. Depth perception and sense of security were rated 85.5 ± 12.4 and 70.7 ± 9.7 respectively (mean ± SDs). Eyestrain was rated high for 3D visualization (mean ± SDs, 12.6 ± 8.6). Conclusions: ESD using a 3D flexible endoscope was technically feasible. The endoscopists reported good depth perception and a high sense of security when using 3D visualization but also noted strong eyestrain.

How I do it: Flexible 3‐D endoscope for endoscopic submucosal dissection

“…Use of this 3-D flexible endoscopy system for performance of ESD has been reported in an ex vivo animal study, demonstrating excellent rating in depth perception and sense of security from four endoscopists. 10 In the present study, we aimed to translate the use of 3-D flexible endoscopy for carrying out submucosal dissection from preclinical animal study to clinical application of ESD in esophagus, stomach and colorectum.…”

First human application of a flexible 3‐D endoscope for gastrointestinal endoscopic submucosal dissection

“…Endoscopic submucosal dissection is widely adopted as an advanced endoluminal procedure to allow en bloc resection of superficial gastrointestinal neoplasia, but is still technically challenging when using conventional endoscopes that rely solely on 2‐D information, and thus lack depth appreciation . In this regard, an ex vivo study explored the feasibility of stereovision view using a 3‐D flexible endoscope in the simulated setting of ESD . This pilot study showed that endoscopists with experience of 30 or more gastric ESD in clinical practice carried out five or more porcine gastric ESD procedures, and were then able to complete all of the procedures without any mechanical problems or perforation.…”

“…This pilot study showed that endoscopists with experience of 30 or more gastric ESD in clinical practice carried out five or more porcine gastric ESD procedures, and were then able to complete all of the procedures without any mechanical problems or perforation. Moreover, ratings of depth perception and stability were recorded on a 100‐mm visual analog scale, and all of the participants reported a greater sense of security under 3‐D than 2‐D visualization . In the first part of ‘How Do I It?’ in the current issue, Chiu et al .…”

“…Nevertheless, enhanced visual differentiation of the submucosal plane by stereovision would serve as substantially important elements for safe performance with special reference to duodenal ESD. Meanwhile, 3‐D endoscopic imaging might improve procedural certainty in such advanced natural orifice transluminal endoscopic surgery as peroral endoscopic myotomy or when carrying out common or straightforward endoscopic procedures including snare polypectomy, endoscopic mucosal resection or endoscopic injection sclerotherapy through the enhancement of depth perception …”

“…We agree with the authors’ conclusive perspective that ‘3‐D ESD may not be necessary for all cases where 2‐D can achieve similar safety and efficacy’, whereas it evidently has advantages in some situations requiring more complex tasks such as duodenal or distant colonic ESD. Next‐generation 3‐D flexible endoscope will be instrumented with the system capable of switching from 2‐D to 3‐D view upon the push of a button similar to narrow band imaging, albeit frequent switching between 2‐D and 3‐D may risk worsening nausea, eye strain or headache. More importantly, further optimization of the endoscope as for mechanical functions including thinner diameter and multi‐bending maneuver can enable safe and efficacious performance throughout the overall ESD procedure or even in each process of tumor demarcation, marginal marking, cutting and dissection.…”