Post written by Georgios Mavrogenis, MD, from the Mediterraneo Hospital, Athens, Greece.

This video presents a complex ESD in the setting of postradiation stenosis and fibrosis. It illustrates several techniques that are useful in the management of severe fibrosis such as pocket ESD, clip and snare countertraction, and full-thickness resection.

ESD is a non-predictable procedure with a large variety of scenarios. Endoscopists should be trained to deal with unexpected findings and adverse events and learn to collaborate with surgeons for minimal invasive treatment of challenging cases.

Pocket ESD is a great way for safe and rapid dissection. In cases that countertraction is needed, there are various techniques that can be applied. One that I find very useful for lesions close to the anus is the clip and snare technique, which has the advantage of back and forward countertraction as needed. Full-thickness resection is not recommended on a routine basis. However, in difficult cases it is a viable option and needs the collaboration of the surgical team since the risk of peritonitis is high or even inevitable. Placement of surgical drain after the endoscopic procedure may spare the need for colostomy/colectomy under the condition that the site of perforation is completely closed with endoscopic clips.

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