Post written by Phillip S. Ge, MD, from the Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.
The video describes a 68-year-old male who underwent successful resection of a large near-circumferental laterally spreading tumor in the distal rectum. The lesion extended from within 1 mm from the dentate line, across the first rectal valve. The pocket creation method is demonstrated in this video, with the creation of a submucosal tunnel extending along the entire length of the lesion, followed by opening of the sides and eventual en bloc resection of the lesion. The final specimen measured 10.0 cm x 9.5 cm in size, with a histopathologic diagnosis of tubulovillous adenoma with high-grade dysplasia. The margins were clear, and a curative resection was thus achieved. On 6-month follow-up, the ESD scar was completely healed without evidence of recurrence or stenosis.
Although rectal ESD has been well described in the literature, we reported this video primarily to highlight and describe the transition from ESD training to ESD practice in the United States. The adoption of ESD in the United States has been challenging due to a number of factors, which include lack of training opportunities. In 2017-2018, during my ASGE Advanced Endoscopy Fellowship at Brigham and Women’s Hospital, I was given a unique opportunity by my mentors John R. Saltzman, MD, FASGE, Christopher C. Thompson, MD, MHES, FASGE, and Hiroyuki Aihara, MD, PhD, FASGE, to participate in a formal 1-year ESD training experience–this experience was published separately (Ge PS, Thompson CC, Aihara H; “Development and clinical outcomes of an endoscopic submucosal dissection fellowship program: early United States experience”; Surg Endosc. 2020 Feb;34(2):829-838). Following completion of the combined Advanced Endoscopy and ESD Fellowship, I joined the University of Texas MD Anderson Cancer Center as a junior faculty in the Department of Gastroenterology, Hepatology, and Nutrition. Under the continued mentorship of senior colleagues including our chair John R. Stroehlein, MD, FASGE, an endoscopic polyp resection practice combining traditional EMR and colorectal ESD was carefully envisioned, created, and supported. As the video suggests, starting a colorectal ESD practice is not as simple as just doing the first case, and many aspects with respect to patient selection, staff/anesthesia support, peri-procedure preparation, and handling unexpected challenges need to be considered. The practice has grown tremendously as a result of careful planning and broad support from colleagues and senior leadership in both gastroenterology and surgical oncology. Our initial thoughts and considerations are described in the video and its accompanying text.
Especially as a junior faculty, starting a colorectal ESD practice in the United States is fraught with challenges. However, with careful planning and with proper support, a successful endoscopic resection practice can be readily established. This video and its accompanying text are meant to highlight how to overcome some of these challenges and provide a framework for future junior colleagues seeking to enter this niche. We hope you find this video to be highly educational. We are grateful to Angela Diehl who provided the medical illustrations supplied in this video.
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