Colon Endoscopic Submucosal Dissection
Sergey V. Kantsevoy, MD, PhD
Endoscopic submucosal dissection (ESD) was developed in Japan for en bloc removal of gastric cancer and precancerous lesions located in the upper gastrointestinal (GI) tract.1,2 ESD is now also used for removal of lesions located in esophagus, colon, and small bowel.3,4
In United States, a well-established screening for colorectal cancer has led to increased detection of precancerous colonic lesions (polyps) and early colon cancer.5 Traditionally these lesions were removed with endoscopic mucosal resection (EMR) utilizing various endoscopic snares. However, en bloc resection rate during EMR is relatively low and only possible for relatively small lesions fitting the size of endoscopic snare.6 Removal of large colonic lesions with EMR requires a piecemeal resection with a high rate (16%) of residual polyps on follow-up colonoscopy.7
Compared to EMR, ESD allows en bloc resection even for large and flat colonic lesions.6
1. Nongranular-type polyps over 20 mm in size (Fig. 47.1).
2. Granular-type polyps above 30 mm in size and laterally spreading tumors.
3. Well-differentiated early (T1) colorectal cancer not involving deep submucosal layer.
4. Submucosal colorectal lesions not involving muscularis layer of colonic wall.
1. Noncorrectable blood coagulation disorders
2. Ulcerated lesions
3. Poorly differentiated, aggressive malignant lesions
FIG. 47.1 Large colonic polyp. Large, nongranular-type, sessile (Is) polyp located in transverse colon.
4. Malignant lesion infiltrating deep submucosal and muscularis layer of colonic wall
5. Enlarged lymph nodes suspicious for malignant involvement near colonic lesion
Extensive submucosal fibrosis under a colonic lesion could be a relative contraindication to ESD due to higher risk of full-thickness colonic perforation.
Traditional devices and accessories for colonic ESD include:
1. Colonoscope with a water jet.
Bleeding of various degrees (from capillary to arterial) is relatively common during ESD.8 When the bleeding is encountered, a special accessory for thermal (Coagrasper, ESD knives—see details below) or mechanical (endoscopic clips) hemostasis is inserted through the biopsy channel of the colonoscope. Because the biopsy channel is now occupied with hemostatic device, flushing the blood away from the view field can only be achieved through a dedicated water jet build into the colonoscope.
2. Equipment for carbon dioxide insufflation.
ESD usually requires prolonged period of time. Carbon dioxide is absorbed from GI tract much faster than room air.9 To
decrease abdominal distention during long endoscopic procedures, carbon dioxide insufflation should be used during ESD.
In addition, if colonic perforation happens during ESD, carbon dioxide is absorbed from peritoneal cavity more rapidly than room air decreasing the chance of abdominal compartment syndrome and postprocedural prolonged subcostal pain due to pneumoperitoneum.
3. Distal attachments (Olympus America, Center Valley, PA or Fujifilm, Saitama, Japan).
Distal attachment is a small transparent hood preloaded on the distal tip of the endoscope. Distal attachment pushes the tissue away from the endoscope’s lens facilitating entrance of the endoscope’s tip into submucosal space and dissection of the submucosal fibers.
4. Injection needles.
Multiple injection needles are currently available. We prefer 25 or 26 gauge injection needles (Injector Force Max and NeedleMaster, Olympus America, Center Valley, PA) although other injection needles (Interject injection needle made by Boston Scientific, Carr-Locke injection needle made by US Endoscopy, etc) can also be used during colonic ESD.
5. Dedicated ESD knives:
a. DualKnife and DualKnife J (Olympus America, Center Valley, PA)
DualKnife is a very versatile device, which can be used for all steps of ESD: marking, circumferential incision around the lesion, hemostasis, and dissection of submucosal fibers.
DualKnife and DualKnife J have fixed length of its protruding portion (2 mm for gastric length device and 1.5 mm for colonic length device) and small rounded ball at its tip. DualKnife can be used in two positions: (1) Fully open position—is used to make a circumferential incision and dissection of submucosal fibers. (2) Fully closed position—is used for marking and endoscopic hemostasis.
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