Endoscopic Mucosal Dissection

Abstract

Electronic supplementary material: Supplementary material is available in the online version of this chapter at 10.1007/978-3-319-48370-2_16. Videos can also be accessed at http://www.springerimages.com/ videos/978-3-319-48368-9. 16 Abbreviations CT Computerized tomography EMR Endoscopic mucosal resection ESD Endoscopic submucosal dissection LCS Laparoscopic colorectal surgery SM Submucosal invasion status Key Points• Up to 15% of colon polyps require advanced polypectomy techniques due to their size, location, or appearance; ESD has unique advantages over other methods in this setting. • The colonoscopy report and pathology results should be reviewed prior to ESD as these details can influence treatment decisions. • Polyps should be localized first endoscopically and marked using hyperosmolar injectate diluted with methylene blue. • Bleeding encountered during dissection should be coagulated immediately and potential perforations should be closed using endoclips.• If a target lesion demonstrates features of malignancy, the procedure can be converted to laparoscopic colectomy. • If endoscopic submucosal dissection is successful, but final pathology reveals carcinoma, patients may then require colectomy.

Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

“…3), and the selection can be made based on lesion size, morphology, location, and personal preference. 21,31 While small snares (10-15 mm) are preferred for lesions in the right colon, larger snares (20-25 mm) can be used in the rectum. 31 Electrosurgical knives are used for incision and dissection.…”

“…If the polyp is situated on a fold, the injection should start proximally, so that the polyp would not fall backward away from the view. 21,27 The ideal injection agent should be safe, inexpensive, and long-lasting. Injection solutions contain two common elements: a colloid (hyperosmolar) solution and an inert dye (e.g., indigo carmine or methylene blue) to facilitate visualization of tissue planes.…”

“…19 Thus, for lesions larger than 20 mm, ESD is recommended. 18 19 In addition to large-sized polyps, any lesion that is difficult to resect in an en bloc fashion using conventional techniques or EMR (e.g., difficult location, 20 underlying fibrosis due to previous resection attempts 21 ) can be a candidate for ESD. Similarly, residual, and recurrent lesions following EMR 21 can be resected with ESD.…”

“…If the polyp is situated on a fold, the injection should start proximally, so that the polyp would not fall backward away from the view. 21 27…”

“…Injection solutions contain two common elements: a colloid (hyperosmolar) solution and an inert dye (e.g., indigo carmine or methylene blue) to facilitate visualization of tissue planes. 21 Alternatively, there are readily available solutions that do not require mixing. ORISE Gel Submucosal Lifting Agent (Boston Scientific, USA) and Eleview (Medtronic, USA) are Food and Drug Administration-approved injection solutions that can be used for this purpose.…”