Endoscopic Submucosal Dissection (ESD) (In-person or Virtual) | December 2024-Schlachterman

Schlachterman_Principles of flap ESD technique

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The document is a presentation outline by Dr. Alex Schlachterman from Thomas Jefferson University discussing the principles of the ESD (Endoscopic Submucosal Dissection) flap technique. The presentation emphasizes the creation of the mucosal flap during endoscopic procedures and outlines several critical steps and considerations to achieve successful outcomes.<br /><br />The process begins with evaluating initial factors for incision such as gravity, incision site, angle of entry, and margin assessment. This is followed by the injection phase, which involves creating a peripheral lift and distal lift flop to aid in flap manipulation.<br /><br />Key steps in the mucosal flap creation include making precise incisions at the correct mucosal depth while ensuring hemostasis to control bleeding. A crucial component of this process is inserting a distal cap attachment, which enhances the dissection's safety and visibility. This cap also helps in counter-traction for easier submucosal layer dissection and acts as a tamponade in case of bleeding.<br /><br />Achieving a successful mucosal flap procedure requires high-level technical skills, particularly at the start of the case, setting the tone for the entire procedure. Safe entry is crucial and contributes greatly to patient safety and procedural efficacy.<br /><br />Pitfalls such as fibrosis and vascular complications like bleeding must be managed carefully by taking wide circumferential incisions and planning for traction. Ensuring the initial incision is in normal mucosa is essential for effective flap movement.<br /><br />Different anatomical sites, such as the esophagus, stomach, and various parts of the colon, have unique considerations in this procedure. Dynamics such as stability, gravity, approach type (oral vs. anal), and view orientation also influence the procedural plan.<br /><br />In summary, Dr. Schlachterman highlights the importance of planning, technical skill, and strategic decisions in ensuring a successful ESD mucosal flap technique, adapting these principles for different lesions and locations within the gastrointestinal tract.

Keywords

ESD

Endoscopic Submucosal Dissection

mucosal flap

incision factors

hemostasis

distal cap attachment

fibrosis

vascular complications

gastrointestinal tract

technical skills