Post written by Jun Arimoto, MD, PhD, from the Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan.

In this study, we evaluate the safety and efficacy of colorectal ESD using the SOUTEN snare. Although the SOUTEN snare was introduced for hybrid ESD, hybrid ESD involves partial submucosal dissection. So, we thought that “SOUTEN-ESD,” mean conventional ESD using the SOUTEN snare, would be a successful technique. The aim of this prospective pilot clinical feasibility study was to evaluate the safety and efficacy of SOUTEN-ESD.

The number of colorectal ESDs is expected to increase in the future in association with the increase of colorectal cancer. So, cost reduction is a very important issue in clinical practice. Since ESD devices cost 2 to 4 times more than the SOUTEN snare, cost effectiveness is a notable advantage of SOUTEN-ESD. If ESD using the SOUTEN snare can be performed safely, it means that the same therapeutic effect as conventional ESD can be obtained at a lower cost. We thought that this study was important to clinical practice and needed to be performed.

The mean procedure time was about 26 minutes. En bloc resection and R0 resection were obtained in all cases. In addition, no cases required conversion to hybrid ESD or conversion to dedicated ESD device. We completed SOUTEN-ESD in all cases in this study. Regarding adverse events, the rate of perforation was 0%, the rate of delayed bleeding was 2.2%. The results of this study are not inferior to previous reports on colorectal ESD. Overall, SOUTEN-ESD was safe and had good outcomes. However, only a limited number of endoscopists and patients were included in this study. The mean procedure time was about 26 minutes, and this was shorter than that of most studies conducted in Asia and Japan. The results of this study were treatment outcomes evaluated by experts (11 endoscopists). All endoscopists at our hospitals have experience with at least 100 colorectal ESDs and have performed more than 250 total ESDs. In addition, the results of this study were for patients who happened to be enrolled during the study period, and the proportion of serrated lesion was high. So, the patients included in this study were not representative of the entire population of lesions with indications for colorectal ESD. Therefore, it is difficult to apply these results to all hospitals or all endoscopists. In addition, this study did not compare SOUTEN snares and dedicated ESD devices. What should come next?  To overcome these limitations, I plan to conduct a prospective, multicenter, randomized control trial to confirm our results. We think that the indications for lesions appropriate for SOUTEN-ESD is the next agenda item of this issue. SOUTEN-ESD was safe and had good outcomes, and the SOUTEN snare is an effective option for colorectal ESD.

Figure 1. Details of the SOUTEN snare. A, The SOUTEN snare, developed for hybrid endoscopic submucosal dissection. B, A 1.5-mm needle-knife with a knob-shaped tip is attached to the top of the loop. The width of the needle-knife at the tip of the knife is .9 mm, and the diameter of the insertion sheath part is 2.35 mm. C, The working length of the knife is adjustable.

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