Here we describe an in vivo and ex vivo simulated papilla by using live pig stomach and rectum easily created by injection of 0.4% hyaluronate solution that allows ES and EP. A 0.4% hyaluronate solution could create hemispheroidal bulgings similar to a human papillae. This study was performed in accordance with the rules for the protections of animals and approved by the Animal Ethical and Welfare Committee of Tokyo Medical University. A live 36-kg mixed Landrace and Yorkshire pig was

used as the animal model. Selleck SB431542 The animal was fasted 24 hours before the procedure. Intravenous ketamine (0.2 mg/kg) and 0.2% xylazine (Selactar; Bayer Yakuhin, Tokyo, Japan) (0.1 mg/kg) were used to induce general anesthesia, which was maintained by using 2% to 5% isoflurane. Atropine (1 mg) was administered to reduce

secretions. We used ex vivo methods as used for training in endoscopic submucosal dissection (ESD).14 We prepared a metal container with normal saline solution that stabilizes the pig stomach and allows electrocautery devices to be used (Johnson & Johnson, Tokyo, Japan) (Fig. 1). An overtube was sutured to the gastric antrum, allowing insertion of the duodenoscope. A resected porcine rectum was placed in an ESD container that allows the use of electrical cautery devices (ERBE Elektromedizin GmbH, Tubingen, Germany) (Fig. 2). One experienced ERCP endoscopist (T.I.) created all blebs. MucoUp, 1.5 to 2.5 mL (20 mL/V, 0.4% hyaluronic acid diluted with sodium chloride) (Johnson & Johnson) was injected submucosally by using a 25-gauge sclerotherapy needle (Hiflow, H-type; Top Co Ltd, Tokyo, DNA Damage inhibitor Japan) to create a mucosal bleb as a simulated major duodenal mTOR inhibitor papilla mound (Fig. 3, upper left). For the stomach model, the solution was mixed with 0.1% indigo carmine. As an alternative to MucoUp, 1% hyaluronic acid (Bioventus LLC, Durham, NC) can be diluted to 0.4%. For ES training, 3 more injections were made in the lesser and greater curvature and the anterior and posterior walls of the proximal gastric body of the in vivo

and ex vivo stomach models. An approximately 2-mm orifice was made in the mucosal bleb by using a needle-knife (KD-1L-1; Olympus Medical Systems, Tokyo, Japan) to simulate a papillary os (Fig. 3, upper right). In the ex vivo rectum model, the mucosal bleb was circumferentially and longitudinally created by means of to-and-fro movements of the duodenoscope and rotation of the box containing the pig rectum. In the in vivo model, ERCP was performed with the animal placed in the supine position and by using a conventional therapeutic duodenoscope (ED-530X T8; Fujifilm, Tokyo, Japan). A standard grounding pad was placed under the mid-dorsum of the animal. In the ex vivo stomach or rectum model, a conventional therapeutic duodenoscope (TJF-260V; Olympus Medical Systems) was used for ES and EP. Electrosurgical generators (VIO300D and ICC200; ERBE Elektromedezin, GmbH) were used to perform ES.