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Endoscopy
DOI: 10.1055/a-2298-1187
Editorial

A single common target across the world: to make colorectal endoscopic submucosal dissection safer, faster, and easier for R0 resection

Referring to Morikawa T et al. doi: 10.1055/a-2276-0546
Mathieu Pioche
1   Endoscopy Unit, Digestive Disease Department, L Pavillon – Edouard Herriot Hospital, Lyon, France
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There is no longer any debate about the value of obtaining an R0 resection for colorectal neoplasia when this is possible, such as during endoscopic submucosal dissection (ESD) because the histological analysis is then of optimal quality, with no information lost [1], and the risk of local recurrence becomes zero, making it possible to avoid checking the colonoscopy at 6 months to look for local recurrence. Recent advances in endoscopic mucosal resection, in particular thermal ablation of the margins, have significantly decreased the recurrence rate in expert centers [2], but these recurrences are still unpredictable and remain frequently very challenging to remove.

“This message is highly important, as even the simplest traction with a clip on the pocket directly attached to the opposite wall at a single point, without the rubber band and without multipolar or adaptive features, is enough to increase speed by 25% without compromising quality and safety ....”

On the other hand, there is still a lively debate about the choice between piecemeal and en bloc resection methods for technical reasons, with ESD suffering from its historical but in part outdated (>20 years) image as a difficult, time-consuming, and not cost-effective technique, with a long learning curve.

However, the arrival of traction techniques has revolutionized the game, offering an additional “hand” to doctors who are used to performing delicate maneuvers with a single micro tool, twisting and sliding it to finely dissect a millimeter layer of mucosa. The first major advances came with tunneling strategies, including the pocket-creation method, which meant that the physician no longer had to dissect in a balanced position, but instead had to nestle in a pocket, held and exposed naturally by the endoscope as it made its way between the two layers of tissue. However, faced with the difficulty of reproducing these meticulous gestures with the same efficiency and safety, traction strategies, very discreetly described in Japan since 2009 [3], were seen in France as a revolution in 2017 [4], and rapidly became an unavoidable game changer!

In this issue of Endoscopy, a prospective randomized study by Morikawa et al. from Japan [5] demonstrates the benefit of traction-assisted ESD against conventional strategies of pocket dissection from the early experience of colorectal ESD. This message is highly important, as even the simplest traction with a clip on the pocket directly attached to the opposite wall at a single point, without the rubber band and without multipolar or adaptive features, is enough to increase the speed by 25% without compromising quality and safety, including in the hands of nonexpert physicians. This study obviously has limitations because the procedures were mainly performed by trainees, with supervision by experts who could intervene to overcome any difficulties and thus possibly modify the speed during complex moments. Nevertheless, similar results with clip and thread traction were published in Japan [6], and showed a reduction in procedure duration of 40% and an improved success rate. Of course, single traction has its own limitation and the more elaborate traction strategies are also more difficult for trainees to master, with learning curves that are probably specific to each system; however, the speeds reached in the latest publications (40mm2/min) [7] with use of independent adaptive and multipolar traction methods suggest the potential of these “additional hands” to expose and condense the submucosa for cutting. If new ways of training, underwater ESD, and high pressure injection of new viscous solutions are requested today to further improve, by combination, the effectiveness of traction ESD, the future is probably a robot with two active hands able to work easily in the right colon. As these robots will probably arrive very soon in expert centers [8], costs related to these practices should be further outweighed by the benefits of treating a very frequent disorder, if all the colorectal neoplasia over 20 mm are treated with ESD.

While we await these robotic technologies, effective and low-cost independent traction devices should be implemented in the early stages of ESD practice to accelerate the learning curve and offer a safer, easier, and faster ESD to as many patients as possible – from tomorrow – thereby burying this old debate of resecting a neoplasia piecemeal, and damaging it in several places, only because the alternative technique is deemed too technically difficult.



Publication History

Article published online:
16 April 2024

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