Endoscopic submucosal dissection: How to be more efficient?

Abstract

Endoscopic submucosal dissection (ESD) allows an "en bloc" resection with safety margins (R0 resection) regardless of the size of the lesion. However, while R0 brings a real benefit for the patient, it is not considered sufficient by many experts to justify the technical difficulties and the longer procedure time compared to piecemeal mucosectomy. The aims of this review are to provide several technical and strategical tips to help you save time and become comfortable during ESD procedures. ESD is divided into several intertwined phases: injection, incision, access to the submucosae, and submucosal dissection itself. During injection there are some mistakes that should not be made: a superficial injection, or on the contrary, a too deep injection. A good needle and good injection technique are mandatory. Some techniques, such as repeated injection or prolonged lifting solution, can help maintain the lift. After this step, mucosal incision can be made, taking care to have a good margin to allow an R0 resection. Starting the mucosal incision from a small point allows calibration of the depth of the incision and then obtaining a nice incision. Trimming is also very important to widen submucosal access. Then comes the submucosal dissection itself. Strategies such as the tunnel strategy or the pocket creation method can help to facilitate dissection, but more importantly, traction systems have become unavoidable, especially in the stomach and colon. Most common complications are bleeding and perforation, and they usually can be managed endoscopically.

Fig. 1

Steps in the ESD procedure. a Marking the lesion (optional in the colon). b Submucosal injection. c Circumferential mucosal incision (original techniques). d Submucosal dissection.

Fig. 2

The handle must be held in the palm of the left hand, with a middle finger positioned to accompany the crutches (especially the up/down crutch).

Fig. 3

An injection that is too superficial leads to a hematoma.

Fig. 4

To extend the area of submucosal injection, it is better to reinject at the edge of the already injected area (blue arrow) instead of injecting in an area not already injected (red arrow).

Fig. 5

A perpendicular incision is better to allow a deep incision.

Fig. 6

The incision must begin with a single small point (1), applying the knife perpendicular to the mucosa and with sufficient pressure. Once this point is made, the idea is to remove the knife to confirm that blue dye injected in the submucosa is visible. Then, all that remains to be done is to reinsert the knife into this small hole, while leaving the knife ceramic on the surface and to start widening the incision (2).

Fig. 7

Access to the submucosal layer before and after trimming.

Fig. 8

It is important to go deep into the submucosal layer to increase the safety margins and to reduce the risk of bleeding by only attacking the large vascular trunks that branch out into the superficial part of the submucosa.

Fig. 9

Traction at 90° or perhaps even slightly opposing the endoscope seems to be more effective than traction turning the lesion over.

Fig. 10

Our standardized strategy for the use of elastic traction in the colon.

Fig. 11

Management of the two main complications of ESD: bleeding and perforation.