Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

Abstract

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.

Deep learning assists detection of esophageal cancer and precursor lesions in a prospective, randomized controlled study

“…Excluding the patients whose lesions were advanced cancer (n = 7), there were also patients with early esophageal cancer (n = 10), HGIN (n = 10), HGIN (n = 2), and LGIN (n = 17) who declined endoscopic or surgical interventions, preferring more intensive monitoring instead. Previous studies have shown a certain proportion of patients with early esophageal cancer or HGIN whose preoperative histopathology usually suggested esophageal LGIN (24). Therefore, endoscopic biopsies can result in the underestimation and misjudgment of esophageal lesions in the absence of postoperative pathology.…”

First report of gastric endoscopic intermuscular dissection

“…Although endoscopic intermuscular dissection (EID) has been used successfully to treat rectal pathology [1], its application in stomach procedures has not been reported. EID involves the dissection of the circular layer from the longitudinal layer of the muscularis propria to achieve a clear vertical dissection margin [2,3]. A 43-year-old woman was referred to our center for endoscopic resection of a 15-mm type 1 neuroendocrine tumor (NET) located in the lower gastric body (▶ Fig.…”

Multicenter prospective randomized controlled clinical trial comparing the pocket-creation method with and without single-clip traction of colonic endoscopic submucosal dissection

“…In order to manage lesions with severe submucosal fibrosis, we have developed the pocket-creation method (PCM) [5] [6]. PCM is one of the techniques recommended for colorectal ESD in the 2023 technical review from the European Society of Gastrointestinal Endoscopy (ESGE) [7]. However, during the pocket-opening process, the surrounding mucosa gradually loses traction, and the lesion becomes very 5 magnifying endoscopic findings and magnifying endoscopic findings using Japan Narrow Band Imaging Expert Team (JNET) classification [11] and/or Kudo's pit pattern [12].…”