ASGE Advanced Endoscopic Lesion Resection Course | November 2022-10 Yang_Hybrid EMR Bringing ESD tricks to standard EMR

10 Yang_Hybrid EMR Bringing ESD tricks to standard EMR

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In this article by Dennis Yang, MD, the use of hybrid techniques in endoscopic mucosal resection (EMR) is discussed as a way to improve the success rate of en-bloc resection for colorectal lesions. EMR is a commonly used first-line treatment for non-malignant colorectal lesions, with a technical success rate of over 90%. However, there are limitations to EMR, such as a low rate of en-bloc resection for larger lesions and higher rates of recurrence with piecemeal EMR.<br /><br />Endoscopic submucosal dissection (ESD) is a more accurate and curative method for early cancer, but it is technically complex and associated with higher rates of adverse events. To address these challenges, two hybrid techniques are discussed: pre-cut EMR and hybrid ESD.<br /><br />Pre-cut EMR involves circumferential mucosal incision using the tip of the snare or an ESD knife followed by snare resection. This technique is ideal for en-bloc resection of smaller lesions (<20-30 mm) but has limitations with larger lesions.<br /><br />Hybrid ESD combines mucosal incision, submucosal dissection, and snare resection. This technique has shown promising outcomes, including shorter procedure times and decreased adverse events compared to conventional ESD. However, limitations in the current evidence include the predominance of observational studies and limited control for factors like endoscopist experience and lesion characteristics.<br /><br />A randomized trial comparing hybrid ESD versus non-hybrid ESD is currently ongoing to further evaluate outcomes such as procedural time, resection outcomes, adverse events, and recurrence.<br /><br />The article provides tips for performing mucosal incision and submucosal dissection during ESD, including using the right knife type and techniques for working close to the muscle.<br /><br />Overall, pre-cut EMR and hybrid ESD can increase the en-bloc resection rate, particularly for lesions of 20-30 mm in size. These techniques are useful for difficult cases with fibrotic lesions or a need for en-bloc resection. They can also serve as a modified stepwise approach towards learning conventional ESD.

Keywords

endoscopic mucosal resection

hybrid techniques

en-bloc resection

colorectal lesions

EMR

endoscopic submucosal dissection

ESD

pre-cut EMR

hybrid ESD

procedural time