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First colorectal endoscopic submucosal dissection using flexible endoscopic robotic system

Wed, 09/16/2020 - 15:33
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The Faculty of Medicine at The Chinese University of Hong Kong (CU Medicine) has been collaborating with researchers from Singapore since 2010 to develop a flexible endoscopic robotic system. This novel system was specifically designed to enhance the safety and efficacy of endoscopic submucosal dissection (ESD) for the treatment of gastrointestinal cancer. Using the first prototype flexible endoscopic robot, the team at CU Medicine successfully performed ESD for treatment of early gastric cancer in 2011.

The flexible endoscopic robot is now further redesigned and developed for performing ESD in the colorectum, namely, The EndoMaster EASE (Endoluminal Access Surgical Efficacy) System. CU Medicine led the world's first clinical trial on robotic colorectal ESD using the EndoMaster EASE System, which commenced in May 2020 and has demonstrated satisfactory outcomes thus far. Researchers believe this innovative technology will enhance advanced endoscopic resection and benefit more patients with early colorectal cancer who will require ESD treatment.

Colorectal cancer is the most common cancer in Hong Kong as well as the second-leading cause of cancer-associated death. Management depends on cancer stages, and for patients in the early stages, surgery or endoscopic resection are the two main treatment options. As the government of the Hong Kong SAR has already implemented a population-based colorectal cancer screening program, more patients with colorectal cancer will be diagnosed at an early stage which is amenable to treatment by ESD.

"Open or laparoscopic resections are the conventional surgical treatment for colorectal cancer whereas endoscopic treatment including endoscopic mucosal resection and ESD are less invasive procedures to remove early-stage cancer. ESD enables en-bloc resection of lesions in-situ or those located at the submucosa with lower recurrence,” explained Professor Simon Siu Man NG, professor of the Division of Colorectal Surgery, Department of Surgery at CU Medicine. “However, this procedure takes a longer time and has a relatively higher risk of perforation if performed by inexperienced endoscopists. There was an urgent need to refine the technology as we have been seeing an increasing demand from the emerging number of early-stage cancer patients around the world discovered under universal screening programs. In Hong Kong, over 60% of confirmed cases under the community colorectal screening program were at an early stage of cancer."

One of the major difficulties in performing ESD is the lack of tissue retraction during submucosal dissection. Most operative time was spent in maintaining a good view of the submucosal plane while moving the endoscope with the ESD instruments for dissection. The design of the traditional endoscope with the attached dissection knife allows only a single degree of movement, which makes ESD difficult to learn and perform.

The recently developed second-generation flexible endoscopic robotic platform consists of an independently designed flexible platform with an endoscopic imaging system and allows the passage of two-minute robotic arms to achieve tissue retraction and dissection.

"Our previous pre-clinical and clinical studies confirmed that the robotic endoscopic platform can enhance both the safety and efficacy of ESD in stomach and esophagus. Performing ESD in the colorectum signifies a different level of technical challenge because of its long and winding shape, as well as the thin colonic wall that poses a higher risk of perforation,” said Professor Philip Wai Yan CHIU, director of the CUHK Jockey Club Minimally Invasive Surgical Skills Center (MISSC). “The EndoMaster EASE System allows tissue retraction with excellent visualization to enhance safety of submucosal dissection. At present, six patients have been successfully treated by colorectal ESD using the EndoMaster EASE System. There was no case of perforation and the patients were able to resume a normal diet and were discharged one day and two days after the procedure respectively. From our initial observation, the flexible endoscopic robotic system is a very promising armamentarium for performing ESD and treating early-stage colorectal cancer. Our clinical trial is still currently underway and we will continue to enroll suitable patients to participate."

Professor Chiu added that in their earlier pre-clinical study, novice clinicians without prior endoscopic experience could also complete ESD procedure with the help of the robotic platform. He believes that the introduction of the novel flexible endoscopic robotic system really marks a new era in therapeutic endoscopy and encourages more endoscopists to learn and perform safe ESD for the treatment of early gastrointestinal cancer. As the editorial on the first clinical trial of robotic ESD said: "Robotic Endoscopy, a small case series, a giant step for endoscopy."