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 54-year-old woman who underwent a screening colonoscopy at which time a rectal neuroendocrine tumor was removed in piecemeal fashion, with positive lateral and deep margins. She was referred for colorectal surgery consultation for transanal resection. She was given the options of close interval surveillance versus definitive excisional biopsy of the polypectomy scar. She elected to undergo excisional biopsy, and therefore ESD was recommended.
Endoscopically, a fibrotic polypectomy scar was visualized, with a prominent central tattoo. ESD is demonstrated using the suture pulley countertraction method, which allowed for en bloc resection without perforation. Histopathology showed no residual neuroendocrine tumor, therefore providing definitive confirmation of curative resection without requiring further close surveillance.
Dense fibrosis, such as those encountered in lesions with prominent tattoo and in prior polypectomy scars, pose special challenges in colorectal ESD. By obscuring the dissection plane, fibrosis not only raises the technical difficulty and procedure time of ESD but may increase the risk of adverse events.
Multiple strategies have been proposed to facilitate ESD of densely fibrotic lesions. Broadly speaking, they include strategies such as pocket creation, large countertraction devices, and simpler countertraction setups with strategic placement of clips, rubber bands, or sutures. The suture pulley method was previously shown in an ex vivo study to facilitate ESD when performed by an expert (Aihara H, et al, Gastrointest Endosc 2014;80:495-502). Recently, we demonstrated in a prospective randomized ex vivo study that the suture pulley method reduced procedure time and technical demand of ESD among endoscopists of all skill levels who were new to ESD (Ge PS, et al, Gastrointest Endosc 2019;89:177-84).
However, very few practical videos currently exist that clearly demonstrate how to perform the suture pulley method. The use of the suture pulley method was previously shown for gastric ESD (Aihara H, et al, VideoGIE 2016;1:36-7); however, to our knowledge, it has not been shown for colorectal ESD. We therefore wanted to share this video of rectal ESD being performed using the suture pulley method. Our thoughts, resection strategies, and technical considerations are described in the video and its accompanying text.
As ESD continues to be increasingly adopted in the United States, endoscopists look to various options for facilitating countertraction. This can include resection strategy such as with gravity and pocket creation, or the use of additional countertraction devices. These additional devices run the spectrum from simple inexpensive setups using clips and rubber bands (Ge PS, Aihara H, “A novel clip-band traction device to facilitate colorectal endoscopic submucosal dissection and defect closure,” VideoGIE 2020, in press), to expensive large devices such as double-balloon platforms and robotic platforms. The suture pulley method is a useful “middle ground” given that the same suturing device can be used to both set up countertraction, as well as for closure of the resection defect. We hope that endoscopists seeking to adopt ESD into their practice will find this video to be highly educational.
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