ASGE JGES Primer ESD | September 2022-Abe

Abe_Handout Colorectal ESD

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This document provides an overview of colorectal endoscopic submucosal dissection (ESD) procedures and techniques. The author, Seiichiro Abe MD, PhD, FJGES, FASGE, discloses personal fees and research funding from various companies. The need for colorectal ESD is highlighted, citing studies that show the limited efficacy of piecemeal EMR (endoscopic mucosal resection) and the risk of local recurrence, invasive recurrence, and malignancy. The challenges of performing ESD in the colorectum are discussed, including the need for stable scope position and the higher risk of perforation compared to the stomach. Preoperative care recommendations include adequate bowel prep and the use of spasmolytic agents. High-definition slim pediatric colonoscopes and therapeutic gastroscopes are suggested for scope selection. Different devices for colorectal ESD are presented, including needle-type knives, CO2 insufflators, and high viscosity injection solutions. The optimal patient position for ESD is described, along with the techniques for mucosal flap creation, submucosal dissection, and mucosal incision. Strategies for managing intraoperative bleeding are discussed, including applying minimal electrocoagulation current and using suction and hemostatic forceps. Techniques for manipulating the endoscope are presented, emphasizing the use of the left hand. Traction devices, such as the SO Clip, are introduced for better control in the proximal colon. The pocket creation method is recommended for preventing injection leakage, achieving stable scope position, and ensuring good traction. The take-home messages for successful colorectal ESD include optimal scope and device selection, practice, meticulous device control, and satisfactory traction to minimize the risk of perforation.

Keywords

colorectal endoscopic submucosal dissection

ESD procedures

piecemeal EMR

local recurrence

risk of perforation

scope selection

intraoperative bleeding

minimal electrocoagulation current

left hand

pocket creation method