An Easier Method for Efficacious and Safe Management of Epithelial Gastrointestinal Neoplasms by Dr. Andrew Leopold Endoscopy was performed by Dr. Raymond Kim. These are our disclosures. Endoscopic submucosal dissection has demonstrated efficacy for N-block resection of neoplasms limited to the epithelial layer of the GI tract. ESD leads to low recurrence rate and a high cure rate. The major limitations are technical difficulty, long procedure times, and risk of delayed bleeding and perforation, which can lead to repeat procedures. The endoscopic methods used are retraction wire deployment and endoscopic suturing. The retraction wire is a curved wire with a shaped memory attached to two clips. The clips attach to the leading edge of the dissection as well as distal to the lesion to provide continuous traction throughout the case that is independent to the scope. This increases procedural ease. Endoscopic suturing has been shown to decrease rates of bleeding in ESD and decreases the need for repeat procedures to manage subsequent complications. The first case where we employ these methods is a 41-year-old female with a history of moderate to severe Crohn's disease. She presented for ESD after rectal biopsy showed a 25-millimeter tubulovilus adenoma with low-grade dysplasia. On flexible sigmoidoscopy, the tubulovilus adenoma can be visualized. The perimeter of the lesion is marked with cautery. A lifting agent was used to separate the lesion from the muscularis propria. The initial mucosal incision is made and follows the outline in cautery marks in a circumferential manner. From there, submucosal dissection continues. Normal dye is continuously injected into the submucosa beneath the lesion to assist with dissection. When a flap is dissected free, the traction wire is attached to the leading edge and deployed. The trailing edge of the wires grasp with a second clip and attach to normal mucosa distal to the lesion. With continuous traction applied, the leading edge of the lesion and submucosa are provided greater exposure. Dissection now occurs with ease. The lesion is dissected entirely free from the surrounding healthy tissue. We can see here the entirety of the submucosal dissection as well as the lesion now dissected free. A grasping forceps detaches the clip from the healthy tissue which is withdrawn. The overlaying tissue is now approximated with endoscopic suturing. One continuous 2.0 polypropylene suture is used for closure. Here we can see the product of a precise closure. The patient was diagnosed with a 40-millimeter rectal tubular adenoma with focal high-grade dysplasia. This was a successful N-block resection with R0 margins while deploying one retraction strip. The case concluded with successful deployment of one endoscopic suture and resulted in same-day discharge without any re-bleeding or other adverse events. Case 2 is a 47-year-old male with a history of ulcerative pancolitis who was referred for a 20-millimeter rectal tubular adenoma with low-grade dysplasia on biopsy. Here we see the rectal adenoma. Procedure begins with demarcation of the lesion with cautery marks. The lesion is then circumscribed. Subsequently, a lifting agent aids in separation of the mucosa from the muscularis propria. Dissection begins to expose the leading edge of the dissection flap. The traction wire is then deployed. The second clip is deployed distally to the lesion to secure the traction wire. With greater exposure, dissection now occurs with greater ease. Improved exposure also allows for easy cautery of bloody lesions in this case. Part of the lesion is actually not fully retracted, so a second retraction wire is successfully deployed. Now dissection occurs to completion. The lesion is removed in one piece and subsequently retrieved with retraction forceps. Two endoscopic sutures are placed to securely approximate the mucosa. A 20-millimeter rectal tubular adenoma was successfully removed, and low-grade dysplasia was found on histology. This was a successful end block resection with R0 margins. The patient had no bleeding or adverse events and was discharged the day of the procedure. Case 3 is a 79-year-old male with peptic ulcer disease. He was referred for a 30-millimeter gastric polyp with high-grade dysplasia. The gastric neoplasm is visualized on upper endoscopy. Cautery is used to demarcate the borders of the lesion. A lifting agent is used to separate the mucosa from the muscularis purpurea. The borders of the lesion are traced prior to dissection. Dissection helps free a corner of the lesion for placement of the retraction wire. A clip securing the retraction wire is placed on the free edge of the lesion. The distal end of the retraction wire is grabbed by the second clip and brought over to a healthy tissue. It is then secured down. Here we see the traction provided by the wire as it folds up against itself. Dissection now occurs with greater ease. The retraction wire allows for long cuts of precise dissection. The retraction wire is detached using forceps. The tissue is then retrieved with a Roth net. Endoscopic suturing occurs to approximate the edges of the mucosa. Two sutures were placed. The mucosa was successfully approximated. A 35 millimeter gastric neoplasm was removed and found to be adenocarcinoma invasive only to the lamina purpurea on histology. This was a successful end blocker section with R0 margins. One retraction strip and two endoscopic sutures were deployed. The patient was discharged on the same day and there were no rebleeding or adverse events. ESD is technically challenging with a high learning curve and long procedure times. There is notable risk for rebleeding as well as perforation. Here we demonstrate how technical difficulty can be adroitly circumvented with a retraction strip and how complications can be mitigated with proficient and careful endoscopic suturing. In conclusion, ESD with employment of a retraction strip can be safe, efficacious, and improve procedural ease. Endoscopic suturing ensures safe and reliable closure after dissection. And application of both of these endoscopic techniques improves procedural ease without sacrificing effectiveness or safety. We are able to report 100% end blocker section rates, 100% R0 margins, and 100% same day discharge with no adverse events with usage of this technique.

endoscopic submucosal dissection

epithelial gastrointestinal neoplasms

ESD limitations

retraction wire deployment

endoscopic suturing