ESD (Endoscopic Submucosal Dissection)
This is a relatively new technique that is slowly being adopted in the western world which has been developed in Japan and where it has been widely practiced for many years. It was initially developed to manage early gastric cancer but this has since been applied to lesions in the esophagus, colorectum, and now even in the duodenum. It is a technique that requires considerable skills that are associated with a very steep learning curve in addition to the important requirement of patience and good judgment in deciding which lesions would be amenable to safe removal. It is a procedure that carries some increase in risk, particularly for lesions in the esophagus, colorectum and more so in the duodenum and in order to adapt this technique and recommend this as an acceptable safe alternative option of treatment to patients, dedicated training with a skilled and experienced mentor from a high volume center in addition to practice on animal models is strongly recommended.
This procedure has applications in patients with early-stage cancer (intramucosal cancer) or large lesions that are > 2cms and which may be associated with high-grade dysplasia in these easily accessible parts of the GI tract. Once formally trained and have become satisfactorily skilled with animal models, gastric lesions in the body of the stomach can be pursued first before tackling other locations. The main advantage of ESD is to perform an en bloc resection for curative intent and which also facilitates accurate histologic evaluation and reduces the risk of recurrence or residual lesion compared to piecemeal endoscopic resection. However, despite the benefits of ESD over EMR, the safety of the type of technique used for the resection is the most important priority and should be decided with good judgment and confidence of technical skills, especially for larger lesions and those in difficult locations.
This is an approximately 4 cm type 0-ls + lla, lllL lobular and laterally spreading lesion in the cecum away from the appendiceal orifice. En bloc ESD was performed by intent given the surface pattern features concerning for at least high-grade dysplasia.
Upper photos from left to right demonstrate the lesion, the initial mucosal incision with the adjacent flat 0-lla component of the lesion, and during submucosal dissection. Lower photos from left to right demonstrates complete ESD with a somewhat fibrofatty base, complete clip closure of resection margins, and en bloc final specimen. Final pathology revealed tubulovillous adenoma and focal HGD but no invasive cancer and was an R0 resection though a focal cautery margin was close to adenoma
ESD of low rectal tubulovillous adenoma with flat laterally spreading granular component close to the dentate line and associated with high-grade dysplasia (HGD) with clear lateral and deep margins (R0 resection).
ESD of Rectosigmoid tubular adenoma with high-grade dysplasia on the initial specimen with attempted removal and additional biopsy. ESD was encountered with severe submucosal fibrosis and pathology of the specimen revealed multifocal high-grade dysplasia (HGD) but with clear lateral and deep margins (R0 resection):
Clockwise from top left:
White light imaging of large laterally spreading granular Type 0-Is, 0-IIc adenoma biopsy confirmed adenoma with HGD; same lesion under NBI; submucosal injection in preparation for ESD; Initiation of submucosal dissection after completion of mucosal incision using an Olympus Dual Knife; Severe fibrosis encountered during submucosal dissection towards the center and lateral side of lesion related to prior attempted resection and chronicity of prolapse along the fold; appearance after ESD; retrieved specimen pin mounted measuring approximately 3.5 cms
This is a 3 cm type 0-ls + llc laterally spreading granular lesion in the low rectum. En bloc ESD was performed.
The upper left two photos define the lesion under white light and NBI. The upper extreme right image demonstrates the initial mucosal incision. Middle photos from left to right demonstrates circumferential incision, submucosal dissection, and final dissection of the lesion. Lower photos from left to right demonstrates the post-resection submucosal base and en bloc pinned specimen. Final pathology revealed superficial adenocarcinoma extending into the superficial submucosal layer (sm1) in a tubular adenoma and all margins are clear, indicating an R0 resection.
This is a 3 cm type 0-lla +llb laterally spreading lesion on the IC valve, with surface pattern features suggestive of a sessile serrated adenoma/polyp (SSA/P). En bloc ESD was performed with some challenges given the fat-laden submucosa layer of the IC valve. Upper photos from left to right demonstrates the lesion under NBI, submucosal injection with a fair lift of the lesion, and the initial mucosal incision. Lower photos from left to right demonstrates circumferential incision before submucosal dissection, final resection with fatty deep submucosa layer, and retrieved en bloc pinned specimen. Final pathology revealed SSA/P with cytologic dysplasia but all margins are clear indication an R0 resection.
This is an 18 mm type 0-lla + llc, Kudo V mixed laterally spreading granular and non-granular lesion in the rectosigmoid region as an incomplete resection/recurrence after prior attempted EMR 4 months earlier and with pathology revealing tubular adenoma with multifocal high-grade dysplasia. Given the previous pathology, current endoscopic findings that are concerning for possible adenocarcinoma and patient comorbidities, ESD was planned after a multidisciplinary discussion to help with accurate histologic characterization and hopeful curative intent.
Upper photos from left to right, lesion under white light and NBI with the evidently depressed surface and dense scarring of the surrounding mucosa, initial mucosal incision, and circumferential incision with notable poor/limited left from the submucosa. Lower photos from left to right, initial submucosal dissection, dense fibrosis in the submucosa with tethering to the muscularis propia, completed ESD with focal areas of muscularis propia exposure and injury towards the center, and final en bloc specimen. Final pathology revealed tubular adenoma with multifocal high-grade dysplasia and sm1 cancer but all margins were clear indicating R0 resection
This is an approximately 3 cm type 0-ls + lla, Kudo IV lobular and laterally spreading granular lesion in the sigmoid colon. This was a technically difficult ESD due to the location, size, and severe submucosal fibrosis but was nevertheless successful. Upper photos from left to right demonstrate the lesion in forward view under white light and NBI, submucosal injection, and initial mucosal incision. Middle photos from left to right submucosal dissection with initial no fibrosis at the periphery and the white muscularis propia could be seen, further submucosal dissection revealing dense submucosa fibrosis and difficult dissection in a poorly defined submucosa layer. Lower photos from left to right, tethering of submucosa fibrosis to the muscularis propia resulting in muscle injury and inadvertent areas of superficial resection, post-resection base immediately after complete ESD, with distal attachment off in retroflexed view and clips placed to areas of muscularis injury/penetration to prevent delayed perforation. Final pathology revealed tubulovillous adenoma with multifocal high-grade dysplasia.
Case 8: ESD of large gastric antral-pyloric adenoma extending into pyloric channel.
This is a case of a 69-year old male noted with this approximately 4 cm type 0-ls adenomatous lesion during diagnostic EGD for abdominal pain and anemia. En bloc ESD was performed extending into the pyloric ring with some technical difficulties with mucosal incision and submucosal dissection to the anal/distal margin at the junction of the pyloric ring and duodenal bulb. En bloc resection was achieved and the post ESD defect was suture closed with the Apollo Overstitch™ device and the patient was discharged home the same day. No post-procedure complications were reported with phone follow-up at day 1 and 7 post-procedure. Final pathology revealed tubular adenoma with multifocal intestinal metaplasia and HGD with clear margins/ R0 resection.
Case 9: ESD of gastric tubular adenoma and suture closure in a patient with FAP.
This is a case of a 35-year-old male with FAP who is s/p total proctocolectomy and noted with abnormal mucosa/thickened fold in the stomach on screening EGD. Biopsies revealed tubular adenoma and he was referred for endoscopic resection. There was poor distensibility of the stomach and the lesion was located along the greater curvature/posterior wall of the body of the stomach. The lesion was estimated as a 3 cm type 0-lla granular type. ESD was performed using the pocket creation technique and en bloc resection was achieved. The post-resection defect was suture closed with the Apollo Overstitch™ device and the patient was discharged home the same day. There were no reported post-procedure adverse events on days 1 and 7 by phone inquiry. Final pathology revealed tubular adenoma and focal HGD. R0 resection was achieved.