The development of endoscopic submucosal dissection (ESD) has enabled en bloc resection of lesions regardless of size and shape. However, ESD of colorectal tumors is technically difficult. Early stage colorectal tumors can be removed by endoscopic mucosal resection (EMR) but larger tumors may require piecemeal resection. Therefore, ESD with snaring has been proposed for more reliable EMR and easier ESD. This is a good option to fill the gap between EMR and ESD, and a good step to the introduction of full ESD.
Key points
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Endoscopic submucosal dissection (ESD) with snaring (simplified or hybrid ESD) is a good option for filling the gap between conventional endoscopic mucosal resection and full ESD.
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ESD with snaring is considered a good introductory step to ESD.
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The simplification of ESD through the development of new devices and modified methods is still required because ESD is often the best treatment for early stage colorectal tumors.
Introduction
Endoscopic submucosal dissection (ESD) theoretically enables en bloc resection regardless of size and shape; however, it has pitfalls such as the technical difficulty, long procedure time, and high frequency of perforation. In the colorectum, the lumen is narrow, it bends, and the wall is thin; therefore, the risk of complication is much higher than in the stomach. The use of ESD in the colorectum should be carefully considered.
With endoscopic mucosal resection (EMR), used in cases in which the size of the lesion is larger than 2 cm, the rate of piecemeal resection increases significantly. However, even if a lesion is smaller than 2 cm, it may be difficult to remove by EMR because of the location and/or the existence of nonlifting signs. The most difficult locations are the backside of folds, the corners, and the areas neighboring diverticulum. Nonlifting signs are a result of either severe fibrosis or massive invasion into the submucosal layer.
Colorectal tumors that can be treated by endoscopic resection vary greatly from small sessile and 0–IIc type lesions to huge lateral spreading tumors that occupy almost the whole round of the rectum. The treatment methods of colorectal lesions also diverge into many branches, including hot biopsy, polypectomy, EMR, and ESD. In the colorectum, detailed preoperative diagnoses with magnified observation clearly show whether lesions must be removed by en bloc resection or require piecemeal resection. It is important to choose the proper treatment method for each lesion, taking the clinicopathological background and technical aspects into account, as well as the resources that are needed to make EMR more reliable and ESD easier, safer, and quicker. To fill the gap between conventional EMR and full ESD, ESD with snaring, termed simplified or hybrid ESD (S/H-ESD) was proposed. This article compares the performance of S/H-ESD with full ESD.
Introduction
Endoscopic submucosal dissection (ESD) theoretically enables en bloc resection regardless of size and shape; however, it has pitfalls such as the technical difficulty, long procedure time, and high frequency of perforation. In the colorectum, the lumen is narrow, it bends, and the wall is thin; therefore, the risk of complication is much higher than in the stomach. The use of ESD in the colorectum should be carefully considered.
With endoscopic mucosal resection (EMR), used in cases in which the size of the lesion is larger than 2 cm, the rate of piecemeal resection increases significantly. However, even if a lesion is smaller than 2 cm, it may be difficult to remove by EMR because of the location and/or the existence of nonlifting signs. The most difficult locations are the backside of folds, the corners, and the areas neighboring diverticulum. Nonlifting signs are a result of either severe fibrosis or massive invasion into the submucosal layer.
Colorectal tumors that can be treated by endoscopic resection vary greatly from small sessile and 0–IIc type lesions to huge lateral spreading tumors that occupy almost the whole round of the rectum. The treatment methods of colorectal lesions also diverge into many branches, including hot biopsy, polypectomy, EMR, and ESD. In the colorectum, detailed preoperative diagnoses with magnified observation clearly show whether lesions must be removed by en bloc resection or require piecemeal resection. It is important to choose the proper treatment method for each lesion, taking the clinicopathological background and technical aspects into account, as well as the resources that are needed to make EMR more reliable and ESD easier, safer, and quicker. To fill the gap between conventional EMR and full ESD, ESD with snaring, termed simplified or hybrid ESD (S/H-ESD) was proposed. This article compares the performance of S/H-ESD with full ESD.
Methods
S/H-ESD is shown in Fig. 1 . Lesions were resected by snaring after circumferential incision and submucosal dissection to a certain degree. Sodium hyaluronate was used for the local injection solution. The tip of snare, Flex knife (Olympus Co, Tokyo, Japan), and Flush knife (Fujifilm Co, Tokyo, Japan) were used for the mucosal incision. This method was considered a good adaptation for lesions that were less than 3 to 4 cm. In cases in which snaring was difficult even after some amount of submucosal dissection, full ESD was attempted. The cases were classified as S/H-ESD when snaring was planned from the beginning and as ESD when snaring was only performed after a trial of full ESD.
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