Colonic endoscopic submucosal dissection – increasing attraction with improved traction?

Abstract

Colonic endoscopic submucosal dissection (ESD) is a challenging procedure involving a learning curve and showing substantial complication rates in unexperienced hands [1]. For this reason, ESD of colonic neoplasms has not become a standard procedure and is still restricted, especially in Western countries, to a few expert centers. Various modifications of the technique have been developed over recent years to overcome technical difficulties, to make ESD easier, and to shorten the learning curve. Key points of the ESD technique are the accessibility of the submucosal layer, which is influenced by the lifting capacity of the submucosal layer (degree of fibrosis), and the traction of the targeted lesion toward the colonic lumen. Consequently, one of the main focuses for modification of the ESD technique has been the development of strategies and devices aimed at improving tissue traction. Modified resection strategies include the optimum use of gravity, tunneling techniques, and pocket creation techniques. In 2002, Oyama et al. first described the clip and line method for esophageal and gastric ESD [2]. After circumferential incision of the target lesion, a hemoclip with a line is fixed at the edge of the lesion, allowing stable access into the submucosal layer. For lesions located in the distal colon and rectum, the double scope technique was introduced by Uraoka et al. in 2007 [3]. The edge of the target lesion is grasped and lifted using a snare or forceps inserted through a second thin endoscope. During subsequent years, several randomized controlled trials were published by Japanese experts investigating different modifications of the clip and line tech-Referring to Faller J et al. p. 383-388