Double-tunneling butterfly method for endoscopic submucosal dissection of extensive rectal neoplasms

Is there a best choice of equipment for colorectal endoscopic submucosal dissection?

INTRODUCTION

Endoscopic submucosal dissection (ESD) is a widely used technique to remove early neoplastic lesions. It was primarily used in the initial days to treat gastric lesions, but recently, the horizon of this endoscopic procedure has expanded, which has allowed us to manage other technically more complex locations, such as the colorectum.

AREAS COVERED

There has been an exponential growth regarding the wide range of devices available in the market for performing colorectal ESD. As a result, the aim of this review is to highlight the indication of this endoscopic technique, which device is best suited for which indication, as well as future trajectories in this field.

EXPERT OPINION

Although some devices have proven to be more advantageous than others in this area, very often the choice is still subjective, which is commonly attributed to individual preferences and experience. However, an accurate knowledge of the available tools and their functioning, with their pros and cons, is fundamental for any endoscopist venturing into the field of third space endoscopy. In this way, one can choose which device best suits a particular situation, along with simultaneously having the wealth of knowledge related to therapeutic armamentarium at our disposal in the endoscopy suite.

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of  > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.

Colorectal Endoscopic Submucosal Dissection: An Update on Best Practice

Endoscopic submucosal dissection (ESD) is a method of en-bloc resection of neoplastic colorectal lesions which is less invasive compared to surgical resection. Lesion stratification, architecture recognition and estimation of depth of invasion are crucial for patient selection. Expert endoscopists have integrated a variety of classification systems including Paris, lateral spreading tumor (LST), narrow band imaging (NBI), international colorectal endoscopic (NICE) and Japanese NBI expert team (JNET) in their day-to-day practice to enhance lesion detection accuracy. Major societies recommend ESD for LST-non granular (NG), Kudo-VI type, large depressed and protruded colonic lesions with shallow submucosal invasion. Chance of submucosal invasion enhances with increased depth as well as tumor location and size. In comparison to endoscopic mucosal resection (EMR), ESD has a lowerl recurrence rate and higher curative resection rate, making it superior for larger colonic lesions management. Major complications such as bleeding and perforation could be seen in up to 11% and 16% of patients, respectively. In major Western countries, performing ESD is challenging due to limited number of expert providers, lack of insurance coverage, and unique patient characteristics such as higher BMI and higher percentage of previously manipulated lesions.

GI endoscopic submucosal dissection using a calibrated, small-caliber-tip, transparent hood for lesions with fibrosis

Video 1The video shows the introduction of a calibrated, small-caliber-tip, transparent hood and its use in rectal, gastric, and duodenal endoscopic submucosal dissection with severe fibrosis.

Pocket-creation method versus conventional method of endoscopic submucosal dissection for superficial colorectal neoplasms: a meta-analysis

BACKGROUND AND AIMS

The pocket-creation method (PCM) is a newly developed strategy for colorectal endoscopic submucosal dissection (ESD). However, its superiority over the conventional method (CM) has not been established. The aim of this meta-analysis was to evaluate the efficacy and safety of PCM-ESD compared with CM-ESD for superficial colorectal neoplasms (SCNs).

METHODS

Literature searches were conducted using the Pubmed, Embase, and Cochrane Library databases, and a meta-analysis was performed. The primary outcome was the R0 resection rate, and the secondary outcomes were the en bloc resection rate, dissection speed, procedure time, and adverse event rate.

RESULTS

Five studies (2 randomized controlled trials and 3 retrospective studies) with 1481 patients were included in our meta-analysis. The pooled analysis showed that PCM-ESD achieved a higher R0 resection rate (93.5% vs 78.1%; odds ratio [OR], 3.4; 95% confidence interval [CI], 1.3-8.9; I² = 58%), a higher en bloc resection rate (99.8% vs 92.8%; OR, 9.9; 95% CI, 2.7-36.2; I² = 0), a shorter procedure time (minutes) (mean difference [MD], -11.5; 95% CI, -19.9 to -3.1; I² = 72%), a faster dissection speed (mm²/min) (MD, 3.6; 95% CI, 2.8-4.5; I² = 0), and a lower overall adverse event rate (4.4% vs 6.6%; OR, 0.6; 95% CI, 0.3-1.0; I² = 0) compared with CM-ESD.

CONCLUSIONS

This meta-analysis showed that PCM-ESD improves the efficacy and safety compared with CM-ESD for superficial colorectal neoplasms.

Rectal neoplasia extending to the dentate line: clinical outcomes of endoscopic submucosal dissection

BACKGROUND

The European Society of Gastrointestinal Endoscopy (ESGE) and the Japan Gastroenterological Endoscopy Society (JGES) give no specific recommendations on the best treatment for colorectal neoplasia involving the dental line (DLCN).

OBJECTIVE

Aim of this study was to analyse efficacy and safety of Endoscopic Submucosal Dissection in the treatment of colorectal neoplasia involving the dentate line (DLCN) compared to non-DLCN.

DESIGN

Retrospective study.

PATIENTS

We retrospectively evaluated all consecutive patients undergoing ESD for rectal neoplasia at two endoscopical tertiary referral centers (Italy and Japan) from January 2008 to December 2019.

MAIN OUTCOME MEASURES

Anthropometric, clinical, procedural, and follow-up data was collected, analysed, and compared between patients with DLCN and patients with non-DLCN.

RESULTS

Overall, 314 patients were enrolled (163 female, 51.9%). Mean age was 68 years (range, 32-92 years). En-bloc resection was achieved in 311/314 (99%) patients. Lesion size was higher in DLCN group than in the non-DLCN group (46.1 vs 38.9 mm; p = .03). Submucosal invasion rate was also higher in the DLCN group (29.6 vs 18.4%, p = .04). Procedure time was significantly longer in the DLCN group, (89.6 vs. 73.1 min; p = .002). Hospitalization length following ESD was similar in both groups.

LIMITATIONS

Retrospective study design.

CONCLUSIONS

ESD seems to be safe and effective in the treatment of colorectal neoplasia involving the dentate line and can be considered the best therapeutic strategy.