Endoscopic Submucosal Dissection for Colorectal Lesions

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Recently in Japan, Endoscopic submucosal dissection (ESD) is beginning to become widely performed for the treatment of colorectal lesions. However, ESD is a very difficult technique which may lead to perforation of the colonic wall and also time consuming compared to Endoscopic mucosal resection (EMR). In this article, I would like to introduce the indications and the practical procedure of colorectal ESD. Since Endoscopic mucosal resection (EMR) is widely and safely performed throughout the world, the indications for colorectal ESD are as follows: 1) lesions which are difficult to remove en block with a snare EMR due to size, such as those in the LST-NG category, lesions exhibiting VI pit patterns, shallow submucosal invasive carcinoma, large depressed type tumors and large protruded type lesions suspected to be carcinoma. 2) lesions with fibrosis due to biopsy or peristalsis. 3) sporadic localized lesions in chronic inflammation, such as ulcerative colitis. 4) local residual carcinoma after EMR. This indication was proposed by Tanaka S et al and is widely applied in Japan.1) Since, most early colorectal lesions can be treated by EMR or Endoscopic piecemeal mucosal resection (EPMR), indications for ESD is relatively limited. The most beneficial point of ESD is the accuracy of en block resection of the lesion without regard to the specimen size. Needle knife, IT (Insulated Tipped) knife, Hook knife, Flex knife and Dual knife are representative knives for ESD.1) For colorectal ESD, Flex knife, Dual knife and Hook knife are mainly used. Also transparent hood is essential for colorectal ESD. Glycerol or sodium hyaluronate solution is necessary for submucosal injection.2) A good quality high-frequency power supplies like VIO300D, ICC200 (ERBE, Germany), or ESG-100 (Olympus, Japan) is also required. To decrease patient’s discomfort, the Carbon dioxide insulation system (UCR system, Olympus, Japan) is useful. Carbon dioxide can be absorbed into the human tissue more than 100 times faster than room air. The use of this system can decrease the distention of the colon. 3) In order to perform colorectal ESD, the most important point is to place the lesion opposite toward the gravity. You have to change the patient’s position to check this point before starting ESD. General anesthesia is not necessary because it becomes difficult to change the