Multi-strategy endoscopic submucosal dissection of a challenging lesion

Over the years, advancements in endoscopic submucosal dissection (ESD) have significantly refined and simplified the technique, allowing for successful endoscopic resection of increasingly complex lesions. Determining the right strategy or tool can be challenging and is not bound by strict rules – sometimes, in complex cases, you end up using every tool available.

A 79-year-old woman was referred for endoscopic resection of a 25-mm, Paris-IIa non-granular lesion, described as a sessile serrated lesion. Assessment with virtual chromoendoscopy revealed a focal JNET-2B pattern, raising suspicion of superficial submucosal invasive cancer, leading to the decision to perform ESD ([Video 1]). The lesion was situated in a challenging position in the right colon, where scope maneuverability was poor. The saline-immersion technique was utilized to stabilize the scope and improve lesion assessment [1]. Circumferential incision and trimming were performed with a 1.5-mm HYBRIDknife flex T-type (Erbe Elektromedizin Gmbh, Tübingen, Germany), while also benefiting from the buoyancy effect of the saline [2]. A double-clip and rubber band were placed (while still underwater) to create traction and improve exposure of the plane ([Fig. 1] a, b) [3]. High-pressure injection through the knife allowed efficient submucosal lifting, and dissection was performed using EndoCut I mode (VIO 3, Erbe Elektromedizin GmbH). Large vessels were precoagulated with the plate at the tip of the knife using SoftCoag mode ([Fig. 1] d). Traction with the tip of the knife of the submucosal fibers allowed safe completion of the dissection ([Fig. 1] c). The 50 × 30-mm specimen was successfully removed en bloc in 28 minutes.

Endoscopic submucosal dissection of a suspicious lesion in the right colon in a difficult position, involving multiple strategies and tools to remove the lesion en bloc.Video 1

Fig. 1 a After completing the circumferential incision, a clip and rubber band are placed at the edge of the lesion to provide traction in the submucosal plane. b Traction is created (while still underwater) on the exposed submucosal fibers, making the dissection plane clearly visible. c The plate on the tip of the knife is used to hook, apply traction to, and cut the submucosal fibers in a precise way. d Large vessels are preemptively coagulated with the plate on the tip of the knife before cutting.

Histology revealed R0-resection of a poorly differentiated pT1 adenocarcinoma with 930-µm submucosal invasion, presence of lymphatic invasion and low grade tumor budding ([Fig. 2]). Absence of local or distant metastasis was confirmed by computed tomography, and the patient was referred for completion surgery.

Fig. 2 Histological image of the pT1 adenocarcinoma of the right colon, with presence of high risk features.

Although the different strategies used to optimize ESD are often presented as competitors, we believe that they should be combined because of their complementary advantages.

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Publication History

Article published online:
06 February 2025

• References

• 1 Lambin T, Rivory J, Wallenhorst T. et al. Endoscopic submucosal dissection: How to be more efficient?. Endosc Int Open 2021; 9: E1720-E1730
• 2 Nagata M. Usefulness of underwater endoscopic submucosal dissection in saline solution with a monopolar knife for colorectal tumors. Gastrointest Endosc 2018; 87: 1345-1353
• 3 Jacques J, Charissoux A, Bordillon P. et al. High proficiency of colonic endoscopic submucosal dissection in Europe thanks to countertraction strategy using a double clip and rubber band. Endosc Int Open 2019; 7: E1166-E1174