Colorectal endoscopic submucosal dissection from a Western perspective: Today's promises and future challenges

Abstract

Over the last few years, endoscopic submucosal dissection (ESD) has shown to be effective in the management of early colorectal neoplasms, particularly in Asian countries where the technique was born. In the Western world, its implementation has been slow and laborious. In this paper, the indications for ESD, its learning model, the available methods to predict the presence of deep submucosal invasion before the procedure and the published outcomes from Asia and Europe will be reviewed. Since ESD has several limitations in terms of learning achievement in the West, and completion of the procedure for the first cases is difficult in our part of the world, a short review on colorectal assisted ESD has been included. Finally, other endoscopic and surgical treatment modalities that are in competition with colorectal ESD will be summarized.

Keywords: Assisted endoscopic submucosal dissection; Colorectal neoplasm; Colorectal surgery; Early colorectal cancer; Endoscopic full-thickness resection; Endoscopic mucosal resection; Endoscopic submucosal dissection; Hybrid endoscopic submucosal dissection; Learning curve; Magnification chromoendoscopy; Predictive factors; Submucosal invasion; Training.

Figure 1

Endoscopic assessment and endoscopic submucosal dissection for a laterally spreading tumor non granular pseudodepressed type in the transverse colon. A: High resolution white light endoscopy; B: Targeted chromoendoscopy with indigo carmine (0.4%) highlights the border and characteristics of the lesion; C: Magnification chromoendoscopy with crystal violet (0.05%) shows a Kudo’s Vi pit-pattern; D: Performing ESD with a 1.5 mm Flush-knife BT (Fujinon, Tokyo, Japan); E: Submucosal dissection of the lesion with an IT nano (Olympus, Tokyo, Japan); F: Residual scar after completion of the procedure; G: Resected specimen of CR-ESD stretched with pins on foam. Maximum diameter of the lesion was 32 mm; H: Specimen sectioned into pieces for histological assessment in the Department of Pathology. ESD: Endoscopic submucosal dissection; CR-ESD: Colorectal endoscopic submucosal dissection.