title: Endoluminal surgical triangulation: overcoming challenges of colonic endoscopic submucosal dissections using a novel flexible endoscopic surgical platform: feasibility study in a porcine model.
abstract: BACKGROUND
  Colonic endoscopic submucosal dissection (ESD) is challenging as a result of the limited ability of conventional endoscopic instruments to achieve traction and exposure. The aim of this study was to evaluate the feasibility of colonic ESD in a porcine model using a novel endoscopic surgical platform, the Anubiscope (Karl Storz, Tüttlingen, Germany), equipped with two working channels for surgical instruments with four degrees of freedom offering surgical triangulation.
  
  
  METHODS
  Nine ESDs were performed by a surgeon without any ESD experience in three swine, at 25, 15, and 10 cm above the anal verge with the Anubiscope. Sixteen ESDs were performed by an experienced endoscopist in five swine using conventional endoscopic instruments. Major ESD steps included the following for both groups: scoring the area, submucosal injection of glycerol, precut, and submucosal dissection. Outcomes measured were as follows: dissection time and speed, specimen size, en bloc dissection, and complications.
  
  
  RESULTS
  No perforations occurred in the Anubis group, while there were eight perforations (50 %) in the conventional group (p = 0.02). Complete and en bloc dissections were achieved in all cases in the Anubis group. Mean dissection time for completed cases was statistically significantly shorter in the Anubis group (32.3 ± 16.1 vs. 55.87 ± 7.66 min; p = 0.0019). Mean specimen size was higher in the conventional group (1321 ± 230 vs. 927.77 ± 229.96 mm(2); p = 0.003), but mean dissection speed was similar (35.95 ± 18.93 vs. 23.98 ± 5.02 mm(2)/min in the Anubis and conventional groups, respectively; p = 0.1).
  
  
  CONCLUSIONS
  Colonic ESDs were feasible in pig models with the Anubiscope. This surgical endoscopic platform is promising for endoluminal surgical procedures such as ESD, as it is user-friendly, effective, and safe.
authors.affiliation: Department of General, Digestive and Endocrine Surgery, IRCAD-IHU, University of Strasbourg, 1, Place de l'Hôpital, 67091, Strasbourg, France, michele.diana@ircad.fr.
authors.forename: Michele
authors.initials: M
authors.lastname: Diana
authors.forename: Hyunsoo
authors.initials: H
authors.lastname: Chung
authors.forename: Keng-Hao
authors.initials: KH
authors.lastname: Liu
authors.forename: Bernard
authors.initials: B
authors.lastname: Dallemagne
authors.forename: Nicolas
authors.initials: N
authors.lastname: Demartines
authors.forename: Didier
authors.initials: D
authors.lastname: Mutter
authors.forename: Jacques
authors.initials: J
authors.lastname: Marescaux
mesh_terms: D017130:Angioplasty / Q000379:methods*; D000818:Animals; D003106:Colon / Q000601:surgery*; D005240:Feasibility Studies; D005858:Germany; D007416:Intestinal Perforation / Q000209:etiology / Q000517:prevention & control*; D010535:Laparoscopy / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D023421:Models, Animal; D009092:Mucous Membrane; D013525:Surgical Instruments; D034421:Sus scrofa; D013552:Swine