We read, with great interest, the original article by Pioche et al. in [1]. Their article described a multicenter retrospective study on the efficacy and safety of endoscopic mucosal resection (EMR) with the anchoring of the snare tip procedure. The authors concluded that this technique may be promising for lesions 10 to 20 mm in size and showed 82.8 % of R0 resection with no perforation. The procedure could be an option for lesions 20 to 30 mm in size.
We completely agree with the authors’ conclusions and present suggestions for their study. We also believe in the feasibility of this technique. Notably our team has already reported on the efficacy of this technique, which we referred to as the "Tip-in EMR" in videos within the October 2016 issue of Gastrointestinal Endoscopy [2] and in the August 2019 issue of Digestive Endoscopy [3]. To the best of our knowledge – and as we stated in our first video – this technique was introduced in 2001 by Nomura M et al., out of Japan. The technique was described in Japanese literature (English abstract only).
Saline solution and an oval snare were used in the original method. Our team modified this technique to use glycerol solution and a stiff, rounded snare (Captivator II, Boston Scientific Ltd, United States) and provided an English name for the technique. Our video cases demonstrated wide-field en bloc resection and R0 resection in the deep submucosal layer using this technique.
We believe that this technique provides several technical benefits. First, it allows for easy access to the submucosal layer by creating a spot-shaped mucosal incision. This increases the ability to grasp the submucosal layer below the mucosal lesion. Second, fixation of the snare tip within the mucosal defect proximal to the lesion enables accurate and repeated capture of the lesion. Third, the technical simplicity of the technique increases the likelihood of worldwide dissemination into clinical practice. As the authors mentioned in this article, the potential efficacy of this technique for facilitating complete lesion removal should be examined in a well-designed study. Our group has conducted a randomized phase II trial comparing EMR with and without this technique (UMIN000025754). We have noticed in recent articles that other foreign groups have described a “Tip-in” EMR [4]
[5]. Similarly, a paper by Pioche et al. further highlighted the convenience and simplicity of this technique when used during the EMR procedure. We are happy to see that the technique, which was first described by our team, is now being performed by other groups outside Japan.
We assume that conventional EMR, Tip-in EMR, partial or circumferential incision with snaring (precutting EMR), hybrid endoscopic submucosal dissection (ESD), and standard ESD would require increased time, effort, and expertise – in that order – because of the increased procedural steps. Currently, direct comparisons among these techniques are absent. As the authors mentioned in their article, differences in the technical features or clinical benefits of these techniques will be clarified in future studies.
