Advanced Endoscopy Fellows Program | September 2022-7_How to Prevent Complications at ESD of Colorectal Lesions

Video Transcription

Here we see a laterally spreading tumour with a granular phenotype in the lower rectum. The diameter of the tumour is 50 mm.  First, inject sodium hyaluronate into the submucosal layer to provide mucosal elevation. Now perform a shallow mucosal incision to avoid damaging any submucosal vessels.  Afterwards, deeper dissection of the small ramified vessels can be safely performed with force coagulation mode, effect 2, 40 watts, using the flush knife with a ball tip.  A large horizontal vessel is exposed and both edges of the vessel are pre-coagulated by flush knife BT with soft coagulation mode, effect 7, 100 watts, and dissected afterwards  with forced coagulation mode.  After timely additional dissection, the transparent hood itself can get into the submucosal layer quickly.  The most important step is to form the mucosal flap after obtaining the appropriate depth of submucosal dissection in the ESD procedure.  Pay attention not to cut larger blood vessels by mistake. Once the blood vessels are damaged, the field of vision is lost and following procedures become difficult and dangerous.  The most important measure to prevent unintended cutting of vessels during dissection is exact recognition of the vessels and the muscular layer,  followed by additional local injection beneath the vessel network and above the muscular layer, and safe coagulation of the vessels with soft coagulation.  The subsequent mucosal incision with endocut mode is performed after an additional local saline injection with the water jet emitting function of the flash knife.  Then a freeing of the lesion edge is carried out.  The dissection under the edge of the incision is carefully made.  If there are horizontal branches of vessel network, the dissection should be done below these.  While if there are vertical penetrating vessels, the dissection at the base of vessels should be done after exposure and appropriate pre-coagulation.  The final dissection is easily carried out because the freeing of the lesion edge has been already done.  There is no major bleeding or injury of the mucosal layer in the resected area. Histological assessment reveals that the lesion is a 48-millimeter intramucosal cancer without  lymph vascular invasion and the margins are free of tumor.

Video Summary

The video transcript describes a procedure for removing a laterally spreading tumor in the lower rectum. The tumor has a granular phenotype and measures 50 mm in diameter. The procedure involves injecting sodium hyaluronate to elevate the mucosal layer and then making a shallow mucosal incision to avoid damaging submucosal vessels. The small ramified vessels are dissected using force coagulation mode, and a large horizontal vessel is pre-coagulated and dissected. Attention is given to avoid cutting larger blood vessels to prevent vision loss and complications. The procedure includes additional dissection, forming a mucosal flap, preventing unintended vessel cutting, and completing the final dissection without major bleeding or injury. Histological assessment confirms a 48-mm intramucosal cancer without lymph vascular invasion and clear margins. No credits were mentioned in the transcript.

Keywords

laterally spreading tumor

lower rectum

sodium hyaluronate

mucosal incision

intramucosal cancer