New methods Clinical endoscopy| Volume 96, ISSUE 1, P140-147, July 2022

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Simplified robot-assisted endoscopic submucosal dissection for esophageal and gastric lesions: a randomized controlled porcine study (with videos)

Published:January 18, 2022DOI:

      Background and Aims

      Effective countertraction is a main challenging issue in endoscopic submucosal dissection (ESD). Several countertraction methods have been developed to address this issue. The aim of this study was to compare the efficacy of ESD using a novel simplified robot, the flexible auxiliary single-arm transluminal endoscopic robot (FASTER), with a traditional technique.


      This was a prospective, randomized animal study. Forty-eight ESDs in 6 pigs were carried out at 8 different locations (gastric antrum, gastric body, lower esophagus, and middle esophagus) by the conventional method (n = 24) and by the FASTER-assisted method (n = 24). The primary outcomes were total procedure time, dissection time, and rate of direct-vision dissection. Secondary endpoints were completeness of en-bloc resection and adverse event rate.


      The total procedure time was significantly shorter in FASTER-assisted ESD than in conventional ESD (18.8 vs 32.8 minutes; P < .001). In contrast to the median direct-vision dissection rate of 73% with conventional ESD, the FASTER-assisted group had a significantly higher rate of 96% (P < .001). The number of sites of muscular damage was significantly lower using the FASTER-assisted method than the conventional method (6 vs 21, respectively; P = .018). This improvement was more apparent in esophageal lesions compared with gastric lesions.


      This study demonstrated that using a simplified robot during ESD is technically feasible and enables the endoscopist to dynamically use countertraction. This device could significantly reduce procedure time compared with conventional ESD techniques.


      ESD (endoscopic submucosal dissection), FASTER (flexible auxiliary single-arm transluminal endoscopic robot), IQR (interquartile range)
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        • Bourke M.J.
        • Neuhaus H.
        • Bergman J.J.
        Endoscopic submucosal dissection: indications and application in Western endoscopy practice.
        Gastroenterology. 2018; 154: 1887-1900
        • Ono H.
        • Yao K.
        • Fujishiro M.
        • et al.
        Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition).
        Dig Endosc. 2021; 33: 4-20
        • Odagiri H.
        • Yasunaga H.
        Complications following endoscopic submucosal dissection for gastric, esophageal, and colorectal cancer: a review of studies based on nationwide large-scale databases.
        Ann Transl Med. 2017; 5: 189
        • Yamamoto S.
        • Uedo N.
        • Ishihara R.
        • et al.
        Endoscopic submucosal dissection for early gastric cancer performed by supervised residents: assessment of feasibility and learning curve.
        Endoscopy. 2009; 41: 923-928
        • Fukami N.
        What we want for ESD is a second hand! Traction method.
        Gastrointest Endosc. 2013; 78: 274-276
        • He Y.
        • Fu K.
        • Leung J.
        • et al.
        Traction with dental floss and endoscopic clip improves trainee success in performing gastric endoscopic submucosal dissection (ESD): a live porcine study (with video).
        Surg Endosc. 2016; 30: 3138-3144
        • Mortagy M.
        • Mehta N.
        • Parsi M.A.
        • et al.
        Magnetic anchor guidance for endoscopic submucosal dissection and other endoscopic procedures.
        World J Gastroenterol. 2017; 23: 2883-2890
        • Jeon W.J.
        • You I.Y.
        • Chae H.B.
        • et al.
        A new technique for gastric endoscopic submucosal dissection: peroral traction-assisted endoscopic submucosal dissection.
        Gastrointest Endosc. 2009; 69: 29-33
        • Imaeda H.
        • Iwao Y.
        • Ogata H.
        • et al.
        A new technique for endoscopic submucosal dissection for early gastric cancer using an external grasping forceps.
        Endoscopy. 2006; 38: 1007-1010
        • Ho K.Y.
        • Phee S.J.
        • Shabbir A.
        • et al.
        Endoscopic submucosal dissection of gastric lesions by using a Master and Slave Transluminal Endoscopic Robot (MASTER).
        Gastrointest Endosc. 2010; 72: 593-599
        • Hourneaux de Moura D.T.
        • Aihara H.
        • Jirapinyo P.
        • et al.
        Robot-assisted endoscopic submucosal dissection versus conventional ESD for colorectal lesions: outcomes of a randomized pilot study in endoscopists without prior ESD experience (with video).
        Gastrointest Endosc. 2019; 90: 290-298
        • Okamoto Y.
        • Nakadate R.
        • Nakamura S.
        • et al.
        Colorectal endoscopic submucosal dissection using novel articulating devices: a comparative study in a live porcine model.
        Surg Endosc. 2019; 33: 651-657
        • Legner A.
        • Diana M.
        • Halvax P.
        • et al.
        Endoluminal surgical triangulation 2.0: a new flexible surgical robot. Preliminary pre-clinical results with colonic submucosal dissection.
        Int J Med Robot. 2017; 13: e1819
        • Uyama I.
        • Kanaya S.
        • Ishida Y.
        • et al.
        Novel integrated robotic approach for suprapancreatic D2 nodal dissection for treating gastric cancer: technique and initial experience.
        World J Surg. 2012; 36: 331-337

      Linked Article

      • Will robots take over our jobs as endoscopists?
        Gastrointestinal EndoscopyVol. 96Issue 1
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          Robot-assisted surgery was introduced more than 20 years ago. The procedure is associated with several benefits, including 6 degrees of freedom with the endowrist, 3-dimensional optics, eradication of hand tremor, and image-enhanced endoscopic views.1 The approach is widely adopted in urological procedures and is increasingly adopted in general surgery.2,3 However, evidence is lacking on what clinical advantages to the patient the robotic approach could provide over conventional minimally invasive surgery.
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