Endoscopic Submucosal Dissection
Endoscopic submucosal dissection is a novel technique that aims en bloc removal of superficial gastrointestinal lesions. It consists of basic steps of injection and lifting the mucosa from the submucosa, incision and dissection of the lesion, and snare re
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Endoscopic Submucosal Dissection Ipek Sapci and Emre Gorgun
Abbreviations EMR Endoscopic mucosal resection ESD Endoscopic submucosal dissection HES Hydroxyethyl starch
Introduction This chapter will review the advanced endoscopic resection technique of endoscopic submucosal dissection. The steps of this novel method will be described in detail accompanying brief literature review on this approach. Equipment, tips, and key points for endoscopic submucosal dissection will be summarized with supplementary images and video clips.
Background Colorectal cancer is the second most common cause of cancer death in the US population and was estimated to result in 50,260 deaths in 2017 [1]. Screening colonoscopy with polypectomy has been shown to decrease the incidence of colorectal cancer and its related mortality [2]. Most colorectal polyps are suitable for snare or cold forceps removal; however, some lesions may not be fit for conventional resection. For these lesions, advanced oncological resections are performed frequently, and a recent study reported that it can be an overtreatment for 92% of the patients [3]. Advanced polypectomy techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal disElectronic Supplementary Material The online version of this chapter (https://doi.org/10.1007/978-3-030-15273-4_2) contains supplementary material, which is available to authorized users. I. Sapci · E. Gorgun (*) Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA e-mail: [email protected]; [email protected]
section (ESD) were developed to fill the gap in-between to prevent overtreatment and achieve complete resection of difficult lesions. EMR resulted in insufficient piecemeal specimens in the upper gastrointestinal tract, and this lead to the development of endoscopic submucosal dissection [4]. ESD became popularized mainly in Asia, and it is still not commonly performed in Western countries. In fact, 87% of the published literature is from Asia [5]. Regardless of the growing interest for ESD around the world, acceptance levels remain low. Recently, it became an integral part of the clinical practice for colorectal lesion removal in Japan [6]. In spite of reports of this procedure to be safe and feasible for colorectal lesions by a wide array of studies, a standardization is yet to be accomplished [5, 7]. ESD was developed to facilitate excision of the lesions that are difficult to remove with regular snaring [8, 9]. The main goals of ESD are to achieve an R0 resection for early cancerous lesions and accomplish an en bloc resection suitable for meticulous histopathological examination [6]. A recent meta-analysis reported R0 resection rates of 13,833 lesions as 83% with en bloc endoscopic resection rate of 92% for ESD. When R0 resection is achieved, risk of recurrence was reported to be 4 in 10,000 [5]. Widespread use of this novel method in the colon has also been restricted due to technical difficulties resulting from the anatomy and physiology of the colon [6, 10]. The colon is anatomical
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