Endoscopic submucosal dissection assisted by adaptive traction: results of the first 54 procedures

Technical Advances in Endoscopic Resection Techniques for Lower GI Malignancies

Background

The management of bulky neoplastic lesions in the digestive tract has historically been a surgical pursuit. With advancements in endoscopic techniques, particularly endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), a paradigm shift toward organ preservation has been initiated. These endoscopic methods, developed incrementally since the 1980s, have progressively enabled curative management of lesions with minimal morbidity, challenging the previously unchallenged domain of surgery.

Summary

This review traces the evolution of endoscopic resection from snare polypectomy and EMR to sophisticated ESD, highlighting the technological innovations that have expanded the scope of endoscopic resection. It discusses the intricacies of various EMR techniques like underwater EMR, anchoring EMR, and hybrid EMR, alongside traction-assisted methods and the use of viscous solutions for submucosal injection. Additionally, the manuscript delves into the advancements in ESD, emphasizing traction strategies, knife technology, and the optimization of endoscopes. The benefits of these advancements are weighed against the challenges in anatomopathological interpretation posed by piecemeal resections.

Key Messages

The continuous amelioration of endoscopic resection techniques has significantly improved the outcomes of digestive tract lesion management, particularly in achieving R0 resections and reducing recurrence rates. These advancements represent a monumental step toward minimizing the invasiveness of lesion management. However, despite the progress, the necessity for early follow-up post-EMR remains due to the non-negligible recurrence rates, underscoring the need for a rigorous postoperative surveillance regimen. Furthermore, our review suggests that while ESD has transformed the therapeutic landscape, its widespread adoption hinges on further simplification, safety enhancement, and acceleration of the procedure, possibly through innovations like adaptive traction devices.

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

BACKGROUND

The pocket-creation method (PCM) was developed to overcome the technical difficulties of endoscopic submucosal dissection (ESD), although opening the pocket remains challenging. We developed a novel technique of PCM with single-clip traction (PCM-CT), which uses a reopenable clip as a traction device to maintain stability during the procedure. No prospective study has compared the efficacy of PCM-CT and PCM. This study aimed to investigate the effectiveness of PCM-CT vs. PCM in a randomized controlled trial.

METHODS

This randomized controlled clinical trial was conducted at four Japanese institutions. Patients with superficial colorectal neoplastic lesions were included following Japanese guidelines for colorectal cancer. Seven moderately experienced endoscopists performed the ESD procedures using either PCM-CT or PCM.

RESULTS

100 patients were enrolled in the study. Compared with PCM, PCM-CT achieved significantly faster mean (SD) dissection speed (21.4 [10.8] vs. 27.0 [14.5] mm2/min [95%CI 0.5 to 10.7], P = 0.03), and reduced the mean procedure time (81.8 [57.9] vs. 64.8 [47.6] minutes [95%CI -38.2 to 4.3], P = 0.12) and pocket-opening time (37.8 [33.0] vs. 30.0 [28.9] minutes [95%CI -20.2 to 4.6], P = 0.22). En bloc and R0 resection rates were not significantly different between the two groups (100% vs. 100%, P >0.99; 100% vs. 96%, P = 0.50, respectively). No significant differences were observed in adverse events between the two groups.

CONCLUSION

ESD facilitated by the novel PCM-CT method appeared to be significantly faster than PCM. Both methods achieved high R0 resection rates.

Conventional Versus Traction Endoscopic Submucosal Dissection for Colorectal Tumors: A Meta-analysis of Randomized Controlled Trials

INTRODUCTION

Compared with conventional endoscopic submucosal dissection (C-ESD) for colorectal lesions, the traction method (T-ESD) allows the lesion to be stabilized with easier dissection. However, randomized controlled trials (RCTs) have reported conflicting results on the clinical outcomes of T-ESD as compared with C-ESD. We conducted a meta-analysis to compile the data.

METHODS

Multiple databases were searched for RCTs evaluating C-ESD versus T-ESD for colorectal tumors. The end points of interest were procedure time (min), resection speed (mm²/min), R0 resection, en bloc resection, delayed bleeding, and perforation. Standard meta-analysis methods were employed using the random-effects model.

RESULTS

Six RCTs with a total of 566 patients (C-ESD n=284, T-ESD n=282) were included. The mean age was 67±10 y and 60% were men. As compared with the T-ESD technique, the C-ESD group was associated with longer procedure time (SMD 0.91, 95% CI 0.58 to 1.23, P<0.00001) and lesser resection speed (SMD -1.03, 95% CI -2.01 to -0.06, P=0.04). No significant difference was found in the 2 groups with respect to R0 resection rate (RR 1.00, 95% CI 0.94 to 1.06, P=0.87), en bloc resection (RR 0.99, 95% CI 0.97 to 1.01, P=0.35), delayed bleeding (RR 0.66, 95% CI 0.17 to 2.59, P=0.55) and perforation (RR 2.16, 95% CI 0.75 to 6.27, P=0.16).

DISCUSSION

On meta-analysis, pooled procedure time was significantly faster with T-ESD compared with C-ESD. The clinical outcomes, however, were comparable.