Post written by Felipe Ramos-Zabala, MD, PhD, from the Department of Gastroenterology, HM Montepríncipe University Hospital, HM Hospitales Group, Department of Clinical Sciences, School of Medicine, University of CEU San Pablo, Madrid, Spain.
In this video case report, we describe an endoscopic submucosal dissection (ESD) of a large laterally spreading lesion in the cecum, which demonstrated the nonlifting sign, following the failure of previous endoscopic resection. Although nonlifting makes resection technically challenging, it does not necessarily imply cancerous invasion or preclude endoscopic therapy. This case report illustrates that in an obese patient, fatty tissue in the submucosal layer can be identified as a cause of the nonlifting sign. Using a combined method, we were able to overcome this and performed enbloc dissection without adverse events.
Our video demonstrates relevant aspects in ESD with fatty tissue submucosal that include: immersion in saline solution that improves the dissection plane, hybrid knife probe mode that allows a safely progressive dissection, and a new method to raise submucosal fatty tissue.
The immersion improves the vision of the endoscope lens because the visual field is not obstructed by splashing fat. Additionally, immersion in saline solution increases the visual field and acts as a magnifier and better identifies the vessels between the fatty tissue. It also provides an additional benefit in terms of traction effect when dissected fatty tissue floats within the water and facilitates exposure of the dissection plane between the fatty tissue and the muscle layer.
We performed the dissection using the hybrid knife “probe mode” that allows dissection while using small pulses of pressure. Probe mode allows a progressive cut, which provides greater safety in fatty tissue.
It has been our impression that in submucosa with substantial fatty tissue, the occurrence of lifting or nonlifting is related to the fluid injection pressure that separates the tissue in which the injected fluid spreads. The massive submucosal fatty tissue prevents fluid infiltration through the submucosal connective tissue, so the lesion cannot be elevated. The objective of the method we describe is to facilitate ESD by achieving a good elevation due to a selective-regulation high-pressure water-jet. In our case, high and controlled pressures are achieved through a microcapillary lumen with a diameter of 120 μm of the knife, and the effect achieved is effective injection and distribution of the liquid in the submucosa. The nozzle geometry is designed in such a manner that the water-jet forms a cone of water. This construction allows the entry of water-jet into the submucosal fat and helps to elevate the lesion, while reducing the risk of perforation in the distal part of the water-jet.
We believe that the regulation-selective water-jet method to perform ESD is a promising technique to resect colorectal polyps with non-ifting sign by submucosal fatty tissue. We believe that immersion in saline solution facilitates ESD in patients with submucosal fatty tissue. We also hope that this new combined method may be assessed prospectively to examine its efficacy and safety for the treatment of colorectal lesions with submucosal fatty tissue.
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