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Create a Free AccountProcedures - Endoscopic submucosal dissection (ESD)
Endoscopic submucosal dissection using an integrated needle-type knife and insulated-tip knife in a single device
Endoscopic submucosal dissection (ESD) allows for en bloc endoscopic resection of superficial lesions throughout the GI tract and is the first-line therapy for the endoscopic management of early gastric neoplasia.1,2 ESD requires familiarity with various specialized endoscopic knives that have been developed for mucosal incision and submucosal dissection.3 Currently, the most common knives used for ESD include the needle-type knife and the insulated-tip knife.4-6Peroral endoscopic myotomy using an endoscopic dissector: another novel device in our toolbox
Peroral endoscopic myotomy (POEM) is a safe and effective technique for the management of achalasia and other nonachalasia motility disorders.1 However, it is technically challenging and time consuming with the use of multiple instruments often required for performing various steps associated with the procedure. While the procedural technique has remained homogeneous, various electrosurgical knives continue to evolve to prevent injuries to the surrounding structures and reduce the need for device changes.Endoscopic adventitial dissection of a rectal GI stromal cell tumor
Endoscopic adventitial dissection (EAD) is a novel resection technique that involves dissection in the “fourth space,” the space between the outer longitudinal muscle and the tunica adventitia of the rectum. EAD is the retroperitoneal equivalent of endoscopic subserosal dissection (ESSD), which involves dissection between the serosa and muscularis propria. The space between these 2 layers mainly consists of loose connective tissue, similar to the submucosa. The submucosal layer has been coined as the “third space” in which endoscopic procedures can be performed.Utility of a super-soft hood for esophageal endoscopic submucosal dissection below an esophageal stricture
Endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) has been widely performed.1 ESCC is frequently associated with head and neck cancer.2 In patients with head and neck cancer, esophageal stricture because of radiation therapy sometimes occurs.3 For ESD for ESCC, a transparent hood is almost essential; however, in some cases, after radiation therapy for head and neck cancer, the hood or scope may not pass through the esophageal stricture. The super-soft hood (Space Adjuster; TOP, Tokyo, Japan) that adjusts to narrow spaces has recently become commercially available (Fig. 1).Endoscopic submucosal dissection of a gigantic gastric polyp aided by a novel retraction device and complicated by upper esophageal sphincter laceration during retrieval
An 87-year-old woman with chronic renal insufficiency and coronary artery disease on clopidogrel was found to have a sizable adenomatous gastric polyp. She was referred for endoscopic resection after declining surgery. On endoscopy, a gigantic polypoid lesion was found measuring 11 × 8 cm (Fig. 1) with a broad short stalk (Fig. 2). The surface pattern was irregular without ulceration. For the most part, the vascular pattern was a mesh of well-connected vessels. However, it contained an area of irregular vascular patterns worrisome for high-grade dysplasia.Novel simulator of endoscopic hemostasis with actual endoscope and devices
Endoscopic hemostasis is an essential skill for endoscopists and has been the first-line treatment.1 For example, we reported that 70% of bleeding ulcers were treated with endoscopic hemostasis.2 Endoscopic hemostasis, similar to most techniques, is currently acquired through on-the-job training with real patients. However, such high-risk situations are not preferable for trainees. To perform a hemostatic procedure safely, the operator needs skills such as maintaining an appropriate view, stabilizing the scope, and controlling hemostatic devices precisely.Emergent endoscopic submucosal dissection for a polypoid fibroadipose tumor accidentally disgorged from the mouth: an organ-preserving minimally invasive treatment
A 74-year-old woman presented with dysphagia. EGD at a previous hospital showed a giant pedunculated polyp from the entrance of the esophagus to the esophagogastric junction. She was referred to our hospital for treatment. On EGD, the polyp was covered with normal epithelium with a swollen and ulcerated head, measuring 17 cm in length. A CT scan revealed an intraluminal tumor in the esophagus with low density and no findings of metastasis (Fig. 1A). Positron emission tomography–CT revealed a highly concentrated area in the esophagus (Fig. 1B).Endoscopic submucosal dissection of appendiceal lesions by using a novel adjustable traction device: A-TRACT-2
Endoscopic submucosal dissection (ESD) allows for en bloc resection of various lesions of the GI tract.1 Nonetheless, the technical difficulty of the procedure limits its widespread adoption, especially in the appendix where the procedure remains a challenge, even for experienced operators, combining an often-bad exposition and difficult access to the submucosa, frequently compromising R0 resection. Thus, several tools, including traction devices, have been developed to assist the intervention,2-4 but they all tend to lose traction force as the intervention progresses.Endoscopic full-thickness resection with retroperitoneal dissection for duodenal myogenic cyst with adjustable traction from an independently controlled snare
A 58-year-old man was coincidentally found to have a duodenal subepithelial lesion in the bulb. Endoscopic ultrasonography revealed a 20-mm anechoic lesion with suspicious echogenic content or a hypoechoic lesion from the muscular propria (Figs. 1 and 2; Video 1, available online at www.giejournal.org ). Computed tomography revealed a lesion close to the hepatic hilum (Fig. 3). After a multidisciplinary discussion with endoscopists and surgeons, we decided to perform endoscopic full-thickness resection (EFTR) of the lesion with acceptable risk.Rare solitary giant hamartomatous polyp of the stomach removed by endoscopic submucosal dissection
The incidence of solitary gastric hamartomatous polyps (SGHPs) is extremely low, with fewer than 12 cases reported in the literature.1 Common symptoms include abdominal pain, bleeding, and anemia. While most SGHPs are benign, dysplastic changes have been reported.1,2 Hence, large lesions are typically referred for resection.1 In this video, we present a case of an SGHP resected with endoscopic submucosal dissection (ESD) (Video 1, available online at www.giejournal.org ).Endoscopic subserosal dissection for a GI stromal tumor
With the advancements in endoscopic resection techniques, subepithelial tumors (SETs) can be removed by transnatural orifice endoscopy with minimal invasiveness. Currently, available endoscopic procedures include endoscopic submucosal dissection, endoscopic submucosal excavation, endoscopic full-thickness resection, and endoscopic submucosal tunneling dissection, which have all been applied for SET management.1-3 Endoscopic subserosal dissection (ESSD) is a novel method for removal of SETs with origin beyond the muscularis propria layer in the upper GI tract.Hybrid resection of GI stromal tumor with endoscopic submucosal dissection and the full-thickness resection device
GI stromal tumors (GISTs) typically arise from the muscularis propria layer and are commonly seen in the stomach, although they can occur anywhere along the GI tract. Lesions larger than 2 cm should undergo surgical resection, although endoscopic resection can be considered for gastric GISTs 2 to 4 cm in size without high-risk features.1,2 Smaller lesions are monitored conservatively with surveillance EUS examinations, or endoscopically resected in patients who prefer to avoid frequent examinations.Wide-field ESD for Barrett's adenocarcinoma at the gastroesophageal junction: technical approaches to facilitate en bloc R0 resection
Endoscopic submucosal dissection (ESD) for Barrett's esophagus (BE) neoplasia is associated with high en bloc resection and an acceptable safety profile but with suboptimal curability rates (range, 56%-59%).1 Two large Western studies showed that low R0 resection rates resulted from the high rate of positive lateral margins in ESD specimens (range, 82%-86%), which prompted either salvage ESD or additional surgical treatment.2,3 A U.S. multicenter ESD study found positive lateral margins in up to 70% of Barrett's adenocarcinoma (BA) at the gastroesophageal junction (GEJ) because of the increased technical complexity, poor maneuverability, and difficulty in evaluating the lesion’s margin.Endoscopic submucosal dissection with the combination of a scissor-type knife and novel traction method for colonic neoplasm involving a diverticulum
As various devices and techniques emerge, colorectal endoscopic submucosal dissection (ESD) has become a relatively safe procedure despite the anatomical difficulty. However, ESD for colonic tumors near or involving a diverticulum remains challenging.1-6 We report a case of colonic neoplasm involving a diverticulum that was treated using ESD via a combination of a scissor-type knife and a novel traction method.Endoscopic submucosal dissection with reinforcement using a laparoscopic approach for a duodenal cavernous hemangioma
Duodenal cavernous hemangiomas are rare; however, when they occur, they may require hemostasis.1 Hemangiomas are classified into cavernous, capillary, or mixed tumors; the cavernous type is the most common.2 Cavernous hemangiomas are defined as congenital benign vascular lesions that are venous malformations. Because cavernous hemangiomas are derived from the submucosa, even minimally invasive endoscopic procedures—such as polyp resection, endoscopic mucosal resection, and argon plasma coagulation—may cause heavy bleeding or perforation.Use of a novel dual-action clip for closure of complex endoscopic resection defects
While there continues to be debate surrounding indications for closure, use of clips following endoscopic mucosal resection of large nonpedunculated polyps has been found to reduce risk of postprocedural bleeding,1-3 and clinically has also been performed to reduce risk of perforation because of muscularis propria injuries. While standard clips are effective for closure of 2- to 3-cm endoscopic mucosal resection sites in the colon, closure of endoscopic submucosal dissection (ESD) wounds is more technically challenging as the deeper dissection plane in ESD tends to result in a larger separation between the wound edges.Novel articulating through-the-scope traction device
Endoscopic submucosal dissection (ESD) has become a standard approach for treating superficial GI neoplasia, but its adoption remains limited because of its steep learning curve and extensive resource utilization when performed by endoscopists in the earlier stages of the ESD learning curve.1,2 Furthermore, although traction strategy has emerged to improve clinical outcomes and increase procedural efficiency, current techniques and devices own inherent limitations such as technical complexity, lack of adjustability, or demanding preparation.Recurrence after Zenker’s peroral endoscopic myotomy despite complete septotomy: how far to go with myotomy on the esophageal side
Zenker’s diverticulum (ZD) is the most common diverticular disease found in the pharyngo-esophageal region.1 Zenker’s peroral endoscopic myotomy (Z-POEM) has been used incrementally for ZD with good efficacy and safety.2 Although Z-POEM provides the platform of submucosal tunneling that ensures a complete septotomy, recurrence to the tune of 14.7% are still reported after Z-POEM.3 Here we present a case of ZD that had recurrence after Z-POEM because of incomplete myotomy on the esophageal side, which was subsequently tackled with flexible endoscopic division of the residual esophageal muscular bridge.Novel dual-action tissue through-the-scope clip for endoscopic closure
Third space endoscopy, also known as submucosal endoscopy, has continued to evolve and expand as a minimally invasive alternative to surgery for the management of various GI diseases. Safe and effective endoscopic mucosal defect closure during many of these procedures is crucial. Conventional through-the-scope (TTS) clips are the most used devices for defect closure given the familiarity and ease of use.1 However, large mucosal defects can be difficult to close by using conventional TTS clips alone, given the inherent restrictions in clip opening width and inability to approximate large gaps firmly and securely.Endoscopic submucosal dissection in the right lateral position for early gastric cancer in the fornix
Endoscopic submucosal dissection (ESD) of early gastric cancer located in the fornix is challenging because the lesion is difficult to approach. The lesion in the fornix, especially on the greater curvature side or the anterior wall side, tends to face vertically in the left lateral position (LLP) when in close proximity. Additionally, the lesion occasionally becomes immersed in gastric fluid and blood, which interferes with the procedure because of poor visibility (Fig. 1A). Despite the use of a multibending scope or clip traction techniques attempted previously,1,2 some technical difficulties remain.Endoscopic full-thickness resection with through-the-scope suture closure for gastrointestinal stromal tumor
Gastrointestinal stromal tumors (GISTs) greater than 2 cm are considered for resection.1 Those with muscularis propria (MP) involvement, as seen on endoscopic ultrasound and/or radiology, require full-thickness resection (FTR), surgery, or a combined laparoscopic/endoscopic approach.2 Dedicated endoscopic FTR (EFTR) devices are available but limited to lesions less than 2 cm.3,4 We present a GIST resected by EFTR and through-the-scope suture (TTSS) defect closure (Video 1, available online at www.giejournal.org ).A novel approach to the removal of a silastic band via the peroral endoscopic tunneling–silastic bandectomy technique
Managing outlet stenosis in patients who have undergone vertical banded gastroplasty (VBG) can be challenging.1,2 Endoscopic band removal can provide a noninvasive method to manage this serious adverse event. Transgastric cutting of the band has been reported, but this can be challenging if the band is not easily visible.3 We report a novel method for bandectomy using the peroral endoscopic tunneling–silastic bandectomy (POET-S) technique in a patient without an exposed band (Video 1, available online at www.giejournal.org ).Endoscopic submucosal dissection with ductotomy for the resection of a gastric duplication cyst with a communicating duct
A 40-year-old otherwise healthy woman with persistent upper abdominal pain was found to have a 3-cm subepithelial lesion in the prepyloric area and was referred to our center (Fig. 1). EUS showed an anechoic cyst in the submucosa with well-defined outer sonographic borders suggesting a gastric duplication cyst (GDC) (Fig. 2). The cyst was completely aspirated and yielded 40 mL of serous fluid with negative cytology for malignancy. The patient’s symptoms resolved for 3 weeks but then recurred. A CT scan showed the cystic lesion with diameters of 3.2 × 1.2 × 1.1 cm.Successful endoscopic resection by using gel immersion and the technique of endoscopic papillectomy for a tumor adjacent to the papilla of Vater
Superficial nonampullary duodenal epithelial tumors are rare, and the establishment of optimized strategies for their treatment is an area of active investigation.1 Endoscopic submucosal dissection (ESD) for superficial nonampullary duodenal epithelial tumors poses the risk of major adverse events (AEs), including a high rate of bleeding, intraoperative perforation, and delayed perforation.2,3 Lesions located in the duodenal flexure are associated with poor endoscope maneuverability.4 Moreover, endoscopic resection is particularly challenging for lesions on the descending duodenum’s medial wall, especially those adjacent to the papilla of Vater (POV).Duodenal subepithelial neuroendocrine tumor removed by endoscopic submucosal dissection using internal traction with magnets
We report the case of a 57-year-old woman with multiple endocrine neoplasia type 1 who was referred to us because of the presence of a 15-mm subepithelial lesion in the descendent duodenum. Earlier endoscopic ultrasound and biopsies confirmed the diagnosis of neuroendocrine tumor in the submucosa. The patient was asymptomatic, blood test results were unremarkable, and there were no metastases on positron emission tomography/CT.
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