Thus, our next step should be a “realistic model” including not only an organ but also the esophagus, stomach, and duodenum. However, there Regorafenib cell line are difficult hurdles to overcome to create such an ideal model by using this injection technique. Our preliminary

study of use of other organs (eg, esophagus, duodenum, and colon, but not the rectum, revealed that creation of blebs in the duodenum and colon was difficult because of the possibly easy perforation by the needle because of the thinner GI tract wall, and there was only a small space in the esophagus and duodenum in which to perform the procedures. Therefore, in this study, we selected the stomach and rectum. In fact, stomach and rectum but esophagus, duodenum and colon, are used in the ESD training models. Nevertheless,

if we could create blebs in the duodenum by using appropriate needles and/or injection materials with available EASIE-type tabletop ex vivo, it may be a realistic ERCP-related procedure model. Apart from EP, for the current “realistic ES,” the over-the-wire technique is mandatory. However, the concept of this study was to practice this website the specific isolated skills needed to perform ES and EP. Although an “all-in-one” model would be ideal, basic techniques like ES may be taught and practiced on simpler models. Therefore, more advanced models can be used to put component steps together in more integrated total procedures, which include, for example, coordination with assistants, wire work, and stent placement for a “realistic ERCP. In this preliminary study, a novel method was used to create an artificial papilla, not only for conventional ES by using a pull-type sphincterotome, but also for precutting by using a needle-knife. Important for the creation of an adequate artificial papilla by using this technique is the use of 0.4% hyaluronate solution. This was demonstrated in an experimental study that showed that injection of 0.4% hyaluronate solution was

superior Dimethyl sulfoxide to physiological saline solution, 50% dextrose, hypertonic saline solution (3.7% NaCl), and glycerol for submucosal injection.18 Because of this, hyaluronate solution has been used for EMR.19 and 20 Other agents for prolonged submucosal injection include succinylated gelatin21 and hydroxypropyl methylcellulose.22 In terms of stomach models, the choice of the injection site for the creation of a simulated papilla is also important. Our study suggests that the anterior wall of the proximal stomach is the ideal location for creating simulated papillae for realistic training of ES, both in vivo and ex vivo. We believe that creation of a mucosal bleb depends on mucosal thickness. This is based on the fact that the mucosa of the porcine stomach at the greater curvature and antrum is thicker than the proximal anterior, posterior, and lesser curvature.