Endoscopic submucosal dissection using a pocket-creation method: a modified technique of endoscopic submucosal tunnel dissection

We read with great interest the article by Miura et al. [1] entitled “Duodenal endoscopic submucosal dissection is feasible using the pocket-creation method.” In this article, the authors described a novel endoscopic method for removal of nonampullary duodenal lesions, which they called endoscopic submucosal dissection (ESD) using a pocket-creation method (PCM). This new technique has several advantages over conventional duodenal ESD, including a lower rate of perforation and use in difficult locations such as duodenal angles.

This novel technique, to some extent, mimics another endoscopic method – endoscopic submucosal tunnel resection (ESTD) – which was first reported for the treatment of large esophageal neoplastic lesions [2] [3]. The standard procedure of ESTD is: submucosal injection – creation of tunnel entry (anal and then oral) – creation of submucosal tunnel – lateral resection. The pocket created in the Miura et al. study can be regarded as a submucosal tunnel, the only difference being that there is only one “tunnel entry;” thus, ESD using PCM can be regarded as a modification of ESTD. By eliminating the need for two tunnel entries, ESD using PCM possesses two advantages over ESTD. First, the smaller entry can decrease the dispersion speed of the injected solution. Second, creating both an anal and oral entry in the duodenal cavity is technically difficult owing to the specific physiological and structural characteristics. This novel modification could be applied to other locations in the gastrointestinal tract, such as the rectum and colon, in the near future, and may facilitate the procedure of colorectal ESD.

• References

• 1 Miura Y. Shinozaki S. Hayashi Y. et al. Duodenal endoscopic submucosal dissection is feasible using the pocket-creation method. Endoscopy 2016;
• 2 Linghu E. Feng X. Wang X. et al. Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy 2013; 45: 60-62
• 3 Pioche M. Mais L. Guillaud O. et al. Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy 2013; 45: 1032-1034