Endoscopic submucosal dissection: How to be more efficient?

Abstract

Endoscopic submucosal dissection (ESD) allows an “en bloc” resection with safety margins (R0 resection) regardless of the size of the lesion. However, while R0 brings a real benefit for the patient, it is not considered sufficient by many experts to justify the technical difficulties and the longer procedure time compared to piecemeal mucosectomy. The aims of this review are to provide several technical and strategical tips to help you save time and become comfortable during ESD procedures. ESD is divided into several intertwined phases: injection, incision, access to the submucosae, and submucosal dissection itself. During injection there are some mistakes that should not be made: a superficial injection, or on the contrary, a too deep injection. A good needle and good injection technique are mandatory. Some techniques, such as repeated injection or prolonged lifting solution, can help maintain the lift. After this step, mucosal incision can be made, taking care to have a good margin to allow an R0 resection. Starting the mucosal incision from a small point allows calibration of the depth of the incision and then obtaining a nice incision. Trimming is also very important to widen submucosal access. Then comes the submucosal dissection itself. Strategies such as the tunnel strategy or the pocket creation method can help to facilitate dissection, but more importantly, traction systems have become unavoidable, especially in the stomach and colon. Most common complications are bleeding and perforation, and they usually can be managed endoscopically.

Publication History

Received: 01 April 2021

Accepted: 13 July 2021

Article published online:
12 November 2021

• References

• 1 Fuccio L, Repici A, Hassan C. et al. Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection.. Gut 2018; 67: 1464-1474
• 2 Baniya R, Upadhaya S, Khan J. et al. Carbon Dioxide versus air insufflation in gastric endoscopic submucosal dissection: a systematic review and meta-analysis of randomized controlled trials. Clin Endosc 2017; 50: 464-472
• 3 Maeda Y, Hirasawa D, Fujita N. et al. Carbon dioxide insufflation in esophageal endoscopic submucosal dissection reduces mediastinal emphysema: A randomized, double-blind, controlled trial. World J Gastroenterol 2016; 22: 7373-7382
• 4 Kim SY, Chung J-W, Kim JH. et al. Carbon dioxide insufflation during endoscopic resection of large colorectal polyps can reduce post-procedure abdominal pain: A prospective, double-blind, randomized controlled trial. United European Gastroenterol J 2018; 6: 1089-1098
• 5 Lee S-H, Park Y-K, Lee D-J. et al. Colonoscopy procedural skills and training for new beginners. World J Gastroenterol 2014; 20: 16984-16995
• 6 Lesne A, Rouquette O, Touzet S. et al. Adenoma detection with blue-water infusion colonoscopy: a randomized trial. Endoscopy 2017; 49: 765-775
• 7 Wei MT, Hwang JH, Watson RR. et al. Novel rigidizing overtube for colonoscope stabilization and loop prevention (with video). Gastrointest Endosc 2021; 93: 740-749
• 8 Jacques J, Sautereau D, Carrier P. et al. High-pressure injection of glycerol with HybridKnife for ESD is feasible and increases the ease and speed of the procedure: an in vivo study in pigs and first use in human. Surg Endosc 2015; 29: 3382-3385
• 9 Pioche M, Lépilliez V, Ciocîrlan M. et al. Endoscopic submucosal dissection with the Nestis^® jet injector system with a bifunctional catheter: first prospective clinical trial (NCT: 2012-A00272-41). Surg Endosc 2016; 30: 5140-5146
• 10 Córdova H, Cuatrecasas M, García-Rodríguez A. et al. Successful outcomes of a new combined solution of hyaluronic acid, chondroitin sulfate and poloxamer 407 for submucosal injection: animal survival study. Endosc Int Open 2019; 7: E576-E582
• 11 Giannino V, Salandin L, Macelloni C. et al. Evaluation of Eleview^® Bioadhesive Properties and Cushion-Forming Ability. Polymers. Basel: 2020: 12
• 12 Fujishiro M, Yahagi N, Kashimura K. et al. Different mixtures of sodium hyaluronate and their ability to create submucosal fluid cushions for endoscopic mucosal resection. Endoscopy 2004; 36: 584-589
• 13 Pioche M, Ciocirlan M, Lépilliez V. et al. High-pressure jet injection of viscous solutions for endoscopic submucosal dissection: a study on ex vivo pig stomachs. Surg Endosc 2014; 28: 1742-1747
• 14 Tall ML, Salmon D, Diouf E. et al. Aseptic process validation and stability study of an injectable preparation of fructose (5%)-glycerol (10%) as part of a hospital clinical research program on endoscopic curative treatment for early epithelial neoplastic lesions of the gastrointestinal tract. Ann Pharm Fr 2015; 73: 139-149
• 15 Pioche M, Mais L, Guillaud O. et al. Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy 2013; 45: 1032-1034
• 16 Zhang T, Zhang H, Zhong F. et al. Efficacy of endoscopic submucosal tunnel dissection versus endoscopic submucosal dissection for superficial esophageal neoplastic lesions: a systematic review and meta-analysis. Surg Endosc 2021; 35: 52-62
• 17 Li P, Ma B, Gong S. et al. Endoscopic submucosal tunnel dissection for superficial esophageal neoplastic lesions: a meta-analysis. Surg Endosc 2020; 34: 1214-1223
• 18 Huang R, Cai H, Zhao X. et al. Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal squamous cell carcinoma: a propensity score matching analysis. Gastrointest Endosc 2017; 86: 831-838
• 19 Sakamoto H, Hayashi Y, Miura Y. et al. Pocket-creation method facilitates endoscopic submucosal dissection of colorectal laterally spreading tumors, non-granular type. Endosc Int Open 2017; 5: E123-E129
• 20 Jacques J, Geyl S, Carrier P. et al. A combination of the clip-with-line method and the tunnel technique during esophageal endoscopic submucosal dissection: a technical solution?. Endoscopy 2015; 47 (Suppl. 01) E307-E308
• 21 Yamasaki Y, Takeuchi Y, Uedo N. et al. Traction-assisted colonic endoscopic submucosal dissection using clip and line: a feasibility study. Endosc Int Open 2016; 4: E51-E55
• 22 Jacques J, Charissoux A, Bordillon P. et al. High proficiency of colonic endoscopic submucosal dissection in Europe thanks to countertraction strategy using a double clip and rubber band. Endosc Int Open 2019; 7: E1166-E1174
• 23 Faller J, Jacques J, Oung B. et al. Endoscopic submucosal dissection with double clip and rubber band traction for residual or locally recurrent colonic lesions after previous endoscopic mucosal resection. Endoscopy 2020; 52: 383-388
• 24 Oung B, Rivory J, Chabrun E. et al. ESD with double clips and rubber band traction of neoplastic lesions developed in the appendiceal orifice is effective and safe. Endoscopy International Open 2020; 08: E388-E395
• 25 Nagata M, Fujikawa T, Munakata H. Comparing a conventional and a spring-and-loop with clip traction method of endoscopic submucosal dissection for superficial gastric neoplasms: a randomized controlled trial (with videos). Gastrointest Endosc 2020; 93: 1097-1109
• 26 Matsuzaki I, Hattori M, Hirose K. et al. Magnetic anchor-guided endoscopic submucosal dissection for gastric lesions (with video). Gastrointest Endosc 2018; 87: 1576-1580
• 27 Turiani Hourneaux de Moura D, 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
• 28 Oyama T. Counter traction makes endoscopic submucosal dissection easier. Clin Endosc 2012; 45: 375-378
• 29 Koike Y, Hirasawa D, Fujita N. et al. Usefulness of the thread-traction method in esophageal endoscopic submucosal dissection: randomized controlled trial. Dig Endosc 2015; 27: 303-309
• 30 Yoshida M, Takizawa K, Suzuki S. et al. Conventional versus traction-assisted endoscopic submucosal dissection for gastric neoplasms: a multicenter, randomized controlled trial (with video). Gastrointest Endosc 2018; 87: 1231-1240
• 31 Oung B, Chabrun E, Subtil C. et al. Traction strategy with clips and rubber band allows complete en bloc endoscopic submucosal dissection of sessile serrated adenoma/polyp invading the site of previous appendectomy. Endoscopy 2019; 51: E166-E168
• 32 Ritsuno H, Sakamoto N, Osada T. et al. Prospective clinical trial of traction device-assisted endoscopic submucosal dissection of large superficial colorectal tumors using the S-O clip. Surg Endosc 2014; 28: 3143-3149
• 33 Albouys J, Dahan M, Lepetit H. et al. Double-clip traction could be superior to the pocket-creation method with cylindrical cap for colonic ESD: a randomized study in an ex vivo model. Surg Endosc 2021; 35: 1482-1491
• 34 Yamasaki Y, Takeuchi Y, Uedo N. et al. Efficacy of traction-assisted colorectal endoscopic submucosal dissection using a clip-and-thread technique: A prospective randomized study. Dig Endosc 2018; 30: 467-476
• 35 Takeshita N, Ho KY, Phee SJ. et al. Feasibility of performing esophageal endoscopic submucosal dissection using master and slave transluminal endoscopic robot. Endoscopy 2017; 49: E27-E28
• 36 Chiu PWY, Ho KY, Phee SJ. Colonic endoscopic submucosal dissection using a novel robotic system (with video). Gastrointest Endosc 2020; 93: 1172-1177
• 37 Maehata T, Fujimoto A, Uraoka T. et al. Efficacy of a new image-enhancement technique for achieving hemostasis in endoscopic submucosal dissection. Gastrointest Endosc 2020; 92: 667-674
• 38 Fujimoto A, Saito Y, Abe S. et al. Haemostasis treatment using dual red imaging during endoscopic submucosal dissection: a multicentre, open-label, randomised controlled trial. BMJ Open Gastroenterol 2019; 6: e000275
• 39 Pioche M, Bertrand G, Rivory J. Endoscopic perforation during EMR corrected or ESD: who should take care of the patient?. Endosc Int Open 2018; 6: E313-E314
• 40 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854