Abstract
Endoscopic submucosal dissection (ESD) is rapidly becoming the standard treatment for superficial gastrointestinal tumors because ESD can achieve complete local resection facilitating thorough pathological examination of the resected specimen. The pocket-creation method (PCM) has been established to perform safe and reliable ESD obtaining a high-quality pathological specimen. A minimal mucosal incision using PCM minimizes leakage of submucosally injected solution, which results in prolonged mucosal elevation. A limited-space submucosal pocket created using PCM makes the endoscope tip stable. A conical cap, small-caliber-tip transparent (ST) hood is used when performing PCM. The submucosa can be cut along the ideal dissection line just above the muscularis with minimal thermal damage because the tip of the ST hood produces both traction and countertraction to stretch the submucosal tissue in the pocket. PCM is recommended as the standard strategy not only for colorectal ESD but also for upper-gastrointestinal ESD. It is expected that the use of traction techniques will make PCM easier to perform.
Highlights
Endoscopic treatments have gradually been preferred over surgical resection because of their less invasiveness and their ability to preserve the original organs
When endoscopically resecting the tumors an R0 resection, which means resection of a specimen including the whole tumor with a negative margin, and the less-damaged thick submucosa of the specimen is required to predict the risk of lymph node metastases
Even if colonic Endoscopic submucosal dissection (ESD) using pocket-creation method (PCM) were not performed by highly experienced endoscopists but rather by less experienced endoscopists, PCM resulted in better performance than conventional ESD[6]
Summary
Endoscopic treatments have gradually been preferred over surgical resection because of their less invasiveness and their ability to preserve the original organs. PCM with a small initial mucosal incision minimizes leakage of the injected solution and makes the endoscope tip stable in the submucosal pocket [Figure 1]. Advantages of PCM include: (1) maintaining a thick submucosal layer because the minimal mucosal incision prevents leakage of injected solution; (2) the endoscopic view facilitates recognition of the surface of the muscularis because ST-hood traction in the narrow submucosal pocket stretches the submucosal tissue to identify the correct dissection line just above the muscularis; (3) obtaining a high-quality pathological specimen with a thick, less-damaged submucosal layer under the tumor; (4) adjusting the orientation in the pocket to make the tip of the endoscope horizontal to the muscularis; and (5) synchronization of the endoscope tip with fluctuations of the heartbeat and breathing in the pocket results in visual stability.
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