Endoscopic submucosal dissection: an update on tools and accessories

Abstract

Endoscopic submucosal dissection (ESD) is a minimally invasive therapeutic procedure to remove larger polyps or early non-metastatic lesions. It has long been used in Asia, but is now fast growing in popularity in the West. There are multiple challenges faced by ESD practitioners. While the practice of ESD in gastric lesions is relatively well established, the oesophagus with its narrow lumen and challenging workspace, and the colon with its tortuous course and folds are more challenging frontiers. The nature of performing a procedure endoscopically means that conventional methods offer no mechanism for providing counter-traction while performing dissection, impeding visibility and increasing the rate of complications. There are a multitude of tools available to those performing ESD for the different stages of the procedure. This article reviews the accessories currently used in regular ESD practice including the knives used to cut and dissect lesions, the cap and hood devices used to improve visibility and safety, injection fluids to lift the submucosal plane, haemostatic devices, generators, and finally, emerging traction apparatus. There is some evidence behind the use of these tools, however, ESD remains the domain of a small number of practitioners and the practice relies heavily on expert experience. Evolution of the ESD toolbox will make the procedure more accessible to more endoscopists, which in turn will drive the development of a more substantial evidence base to evaluate efficacy and safety of the multitude of tools.

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends

“…One of the common traction approaches is the distal attachment (cap) attached at the endoscope's end, which helps move the lesion away and allows visualization of the dissection plane ( 12 , 218 ). Various traction devices have been developed to facilitate faster ESD with a lower complication rate ( 12 , 219 ).…”

Endoscopic diagnosis and treatment of gastric dysplasia and early cancer: Current evidence and what the future may hold

“… ‘Endo-lifter’ (Olympus-Tokyo, Japan)[ 192 ]. Citation: Harlow C, Sivananthan A, Ayaru L, Patel K, Darzi A, Patel N. Endoscopic submucosal dissection: an update on tools and accessories.…”

“…Initial feasibility studies were performed in 2010 in ex-vivo and in-vivo porcine stomachs, where 20 gastric lesions were successfully resected using MASTER assisted ESD with no difference in procedure time compared to conventional ESD[ 190 ]. Subsequently, a small case series was reported in 2012, using MASTER assisted ESD in 5 patients, demonstrating clear resection margins in all cases with no major complications[ 192 ]. More studies are required to further explore the role of robot-assisted ESD, however this technique will clearly be limited by the cost and availability of equipment, while proceduralists already successfully perform more conventional ESD techniques at a fraction of the cost.…”

Colorectal Endoscopic Submucosal Dissection: An Update on Best Practice

“…Standard ESD involves the following steps: marking the margin of the resection with the tip of the knife, injection of a lifting solution into the submucosa to elevate the mucosa, circumferential incision around the lesion using an electrosurgical knife (ITKnife and ITKnife nano, hook knife, triangle tip knife, flex knife, hybrid knife) followed by submucosal dissection via submucosal water jet or serial injections followed by hemostasis as needed. 49 Figure 1 illustrates post ESD resection bed in the rectum. Standard ESD is performed via an assisted cap to provide adequate visualization between the lesion and the endoscope.…”