Post written by Siddharth B. Javia, MD, from Confluence Health, Wenatchee Valley Medical Group, Wenatchee, Washington, USA.

This video is about removing a large cecal polyp using an endoscopic submucosal dissection (ESD) technique. We facilitate this ESD in the cecum by using a combination of pocket-creation method and saline-immersion technique.

ESD is a challenging technique to master, as it needs fine control of the endoscope tip. Performing ESD in the cecum or ascending colon becomes even more challenging, as one needs to go beyond the twists and turns of the rectosigmoid colon as well as hepatic and splenic flexures. This leads to difficulty in controlling the endoscope tip.

In addition, using a carbon dioxide gas medium for examination leads to looping issues and unstable colonoscope position. Gas distension makes the colon wall thinner and colon folds more pronounced. Therefore, removing lesions over a fold also could become challenging when using carbon dioxide.  

Because ESD procedures tend to be longer, gas distension can worsen as the procedure goes on and can cause further looping issues. Using underwater colonoscope insertion can overcome these challenges.

We use saline instead of water to better conduct electricity through the cautery knife and to avoid risk of water intoxication. We are mindful to ensure that we put only enough water so that the colon is not overdistended, and its shape remains tubular. The lesion tends to float because of the buoyancy effect. We do not change the patient position, as we are mainly relying on the floating effect in the saline-immersion environment rather than gravity to provide traction.

Therefore, ergonomics are maintained while performing a longer procedure. The pocket-creation method provides additional stability of the colonoscope tip and maintains submucosal injection longer.

Furthermore, this method allows completion of the procedure without using additional traction devices. Clip closure of the defect also is performed in the saline-immersion environment, keeping the defect smaller and easier to close.

This video is a good demonstration of 2 useful techniques: the saline-immersion technique and the pocket-creation method to achieve ESD completion in the right side of the colon. Using a combination of these 2 techniques allows completion of this difficult procedure with relative ease.

If the saline-immersion technique and the pocket-creation method are used together, one could perform ESD in the right side of colon with similar ease as in the left side of the colon or rectum.

I would like to thank Dr Wichit Srikureja for mentoring me for ESD as well as Dr Gottumukkala S. Raju for providing useful training of video editing.

Tubular adenoma with normal mucosa at lateral margin inked black and deep margin inked blue (H&E, orig. mag. ×4).

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