Endoscopic submucosal dissection in the colon with adaptive traction device: resection strategy and device setup

The 2023 top 10 list of endoscopy topics in medical publishing: an annual review by the American Society for Gastrointestinal Endoscopy Editorial Board

Using a systematic literature search of original articles published during 2023 in Gastrointestinal Endoscopy (GIE) and other high-impact medical and gastroenterology journals, the GIE Editorial Board of the American Society for Gastrointestinal Endoscopy compiled a list of the top 10 most significant topic areas in general and advanced GI endoscopy during the year. Each GIE Editorial Board member was directed to consider 3 criteria in generating candidate topics-significance, novelty, and impact on global clinical practice-and subject matter consensus was facilitated by the Chair through electronic voting and a meeting of the entire GIE Editorial Board. The 10 identified areas collectively represent advances in the following endoscopic spheres: GI bleeding, endohepatology, endoscopic palliation, artificial intelligence and polyp detection, artificial intelligence beyond the colon, better polypectomy and EMR, how to make endoscopy units greener, high-quality upper endoscopy, endoscopic tissue apposition and closure devices, and endoscopic submucosal dissection. Each board member was assigned a topic area around which to summarize relevant important articles, thereby generating this overview of the "top 10" endoscopic advances of 2023.

Technical Advances in Endoscopic Resection Techniques for Lower GI Malignancies

Background

The management of bulky neoplastic lesions in the digestive tract has historically been a surgical pursuit. With advancements in endoscopic techniques, particularly endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), a paradigm shift toward organ preservation has been initiated. These endoscopic methods, developed incrementally since the 1980s, have progressively enabled curative management of lesions with minimal morbidity, challenging the previously unchallenged domain of surgery.

Summary

This review traces the evolution of endoscopic resection from snare polypectomy and EMR to sophisticated ESD, highlighting the technological innovations that have expanded the scope of endoscopic resection. It discusses the intricacies of various EMR techniques like underwater EMR, anchoring EMR, and hybrid EMR, alongside traction-assisted methods and the use of viscous solutions for submucosal injection. Additionally, the manuscript delves into the advancements in ESD, emphasizing traction strategies, knife technology, and the optimization of endoscopes. The benefits of these advancements are weighed against the challenges in anatomopathological interpretation posed by piecemeal resections.

Key Messages

The continuous amelioration of endoscopic resection techniques has significantly improved the outcomes of digestive tract lesion management, particularly in achieving R0 resections and reducing recurrence rates. These advancements represent a monumental step toward minimizing the invasiveness of lesion management. However, despite the progress, the necessity for early follow-up post-EMR remains due to the non-negligible recurrence rates, underscoring the need for a rigorous postoperative surveillance regimen. Furthermore, our review suggests that while ESD has transformed the therapeutic landscape, its widespread adoption hinges on further simplification, safety enhancement, and acceleration of the procedure, possibly through innovations like adaptive traction devices.

Endoscopic submucosal dissection assisted by adaptive traction: results of the first 54 procedures

BACKGROUND : Good submucosal exposure is key to successful endoscopic submucosal dissection (ESD) and can be achieved with various traction devices. Nevertheless, these devices have a fixed traction force that tends to decrease as the dissection progresses. In contrast, the ATRACT adaptive traction device increases traction during the procedure. METHODS : In this retrospective analysis of prospectively collected data (from a French database), we analyzed ESD procedures performed with the ATRACT device between April 2022 and October 2022. The device was used consecutively whenever possible. We collected details of lesion characteristics, procedural data, histologic outcomes, and clinical consequences for the patient. RESULTS : 54 resections performed in 52 patients by two experienced operators (46 procedures) and six novices (eight procedures) were analyzed. The ATRACT devices used were the ATRACT-2 (n = 21), the ATRACT 2 + 2 (n = 30), and the ATRACT-4 (n = 3). Four adverse events were observed: one perforation (1.9 %), which was closed endoscopically, and three delayed bleeding events (5.5 %). The R0 rate was 93 %, resulting in curative resection in 91 % of cases. CONCLUSION:  ESD using the ATRACT device is safe and effective in the colon and rectum, but can also be used to assist with procedures in the upper gastrointestinal tract. It may be particularly useful in difficult locations.

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.