Rajan Elizabeth, Gostout Christopher J, Lurken Matthew S, Talley Nicholas J, Locke Giles R, Szarka Lawrence A, Sumiyama Kazuki, Bakken Timothy A, Stoltz Gary J, Knipschield Mary A, Farrugia Gianrico
Division of Gastroenterology and Hepatology, Developmental Endoscopy Unit, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
Gastrointest Endosc. 2008 Aug;68(2):301-7. doi: 10.1016/j.gie.2007.10.017. Epub 2008 Feb 11.
The etiology of several common gastric motility diseases remains largely unknown. Gastric wall biopsy specimens that include the muscularis propria to evaluate the enteric nervous system, interstitial cells of Cajal, and related cells are essential to promote our understanding of the pathophysiologic mechanisms. On the basis of our previous work, a double EMR technique provided sufficient tissue to identify myenteric ganglia. A serious limitation to the technique was the resultant gastric wall perforation after tissue resection. The optimal procedure would seal the gastric wall defect before tissue resection, eliminating the risk of peritonitis.
The aims of this study were to (1) determine the technical feasibility and reproducibility of a full-thickness gastric biopsy by use of a novel double EMR technique without creating a perforation ("no hole") and to (2) determine safety of the procedure.
Preclinical study of 6 pigs. Each animal underwent a "no hole" double EMR survival procedure. To prevent perforation, detachable endoloops and prototype T-tag tissue anchors were placed before resection. At 2 weeks repeat endoscopy was performed followed by necropsy.
Hematoxylin-eosin staining was used to determine which muscle layers were included in the resected specimen, and an antibody to neuronal nitric oxide synthase was used to visualize myenteric ganglia in the sample. Technical feasibility, reproducibility, and safety of the procedure were evaluated.
Full-thickness gastric biopsy specimens were obtained from all animals without overt perforation. There were no procedural complications. Histologic examination showed muscularis propria with all layers of muscle present, and immunochemical studies demonstrated myenteric ganglia in all tissue samples. Four animals had an uneventful clinical course, and repeat endoscopy at week 2 showed ulceration with stellate fibrosis. Necropsy showed mild localized adhesions. Two animals were killed at days 3 and 6, respectively, because of suspected peritonitis. At necropsy, delayed perforations at the resection sites were noted with displaced endoloops and tissue anchors.
This study explored the concept of obtaining deep muscle wall biopsy specimens with use of a unique approach of resection without perforation. The novel "no hole" double EMR technique was technically feasible and reproducible with sufficient tissue obtained to identify myenteric ganglia. However, there was a high delayed perforation rate associated with displaced endoloops and tissue anchors. On the basis of this early experience, improved safety data may be anticipated with future studies using improved tissue closure devices.
几种常见胃动力疾病的病因在很大程度上仍不清楚。包含固有肌层以评估肠神经系统、 Cajal间质细胞及相关细胞的胃壁活检标本对于增进我们对病理生理机制的理解至关重要。基于我们之前的工作，一种双内镜黏膜下剥离术（EMR）技术能提供足够组织来识别肌间神经节。该技术的一个严重局限是组织切除后会导致胃壁穿孔。最佳操作应在组织切除前封闭胃壁缺损，消除腹膜炎风险。
本研究的目的是：（1）确定使用一种新型无穿孔（“无孔”）双EMR技术进行全层胃活检的技术可行性和可重复性；（2）确定该操作的安全性。
对6头猪进行临床前研究。每只动物均接受“无孔”双EMR存活手术。为防止穿孔，在切除前放置可拆卸的内圈套器和原型T形标签组织锚。2周后进行重复内镜检查，随后进行尸检。
苏木精-伊红染色用于确定切除标本中包含哪些肌层，神经元型一氧化氮合酶抗体用于显示样本中的肌间神经节。评估该操作的技术可行性、可重复性和安全性。
所有动物均获得了全层胃活检标本，无明显穿孔。无手术并发症。组织学检查显示存在各肌层的固有肌层，免疫化学研究在所有组织样本中均显示出肌间神经节。4只动物临床过程平稳，第2周重复内镜检查显示有星芒状纤维化的溃疡。尸检显示有轻度局部粘连。2只动物分别在第3天和第6天因疑似腹膜炎而处死。尸检时，在切除部位发现延迟穿孔，内圈套器和组织锚移位。
本研究探索了使用一种独特的无穿孔切除方法获取深层肌壁活检标本的概念。新型“无孔”双EMR技术在技术上是可行且可重复的，获得了足够组织来识别肌间神经节。然而，与内圈套器和组织锚移位相关的延迟穿孔率较高。基于这一早期经验，预计未来使用改进的组织封闭装置进行研究会有更好的安全性数据。
