Underwater Endoscopic Submucosal Dissection Research Articles

Potential hazards of gas generation during underwater endoscopic submucosal dissection.

Potential hazards of gas generation during underwater endoscopic submucosal dissection.

Underwater endoscopic submucosal dissection with an insulated tip knife using diluted saline.

Watch a video of this article.

Continuous low water pressure dissection technique minimizing air bubbles during underwater endoscopic submucosal dissection.

Continuous low water pressure dissection technique minimizing air bubbles during underwater endoscopic submucosal dissection.

Comparing underwater endoscopic submucosal dissection and conventional endoscopic submucosal dissection for large laterally spreading tumor: a randomized controlled trial (with video)

Background and AimsColorectal endoscopic submucosal dissection (ESD) is challenging despite its usefulness. Underwater ESD (UESD) provides better traction and a clearer view of the submucosal layer than conventional ESD (CESD). This study compared the efficiency of UESD and CESD for large (20–50 mm) laterally spreading tumor (LST). MethodsPreplanned sample size was calculated from our previous experience. As a results, 28 patients were required to UESD group or CESD group, respectively. The primary outcome was total procedure time while the secondary outcome was dissection speed. ResultsFifty-six patients were enrolled and a total of 28 patients were assigned to each group. The mean size of LST was 31.6 mm and 31.3 mm in the UESD and CESD group, respectively. Fibrosis was observed in 67.9% and 60.7% patients in the UESD and CESD group. Total procedure time (mean [SD]) for the UESD group was significantly shorter than that for the CESD group, respectively (49.5 minutes [20.3] vs 75.7 minutes [36.1]; mean difference, -26.2 minutes; 95% CI, -42.0 to -10.5). Dissection speed of the UESD group was significantly faster than that of the CESD group (21.9 mm2/min [6.9] vs 15.2 mm2/min [7.3]; mean difference, 6.7 mm2/minutes; 95% CI, 2.8–10.4). There was no difference between groups in the R0 resection rate or en bloc resection rate. No perforations were observed in either group. ConclusionsUESD was superior to CESD in total procedure time and dissection speed. UESD can be recommended as the preferred method for the resection of large LST.

Automatic water irrigation synchronized with the electrosurgical unit: Bubble-free underwater endoscopic submucosal dissection.

Automatic water irrigation synchronized with the electrosurgical unit: Bubble-free underwater endoscopic submucosal dissection.

Combination of a permanent slow flow managed by the nurse and a rapid flow for bleeding management controlled by the doctor in underwater endoscopic submucosal dissection.

Combination of a permanent slow flow managed by the nurse and a rapid flow for bleeding management controlled by the doctor in underwater endoscopic submucosal dissection.

Underwater endoscopic submucosal dissection performed under general anesthesia for the safe resection of superficial esophageal squamous cell carcinoma with ductal involvement.

Underwater endoscopic submucosal dissection performed under general anesthesia for the safe resection of superficial esophageal squamous cell carcinoma with ductal involvement.

Treatment of a sessile serrated adenoma/polyp deeply invading the appendiceal orifice enabled by combined adaptive traction and underwater endoscopic submucosal dissection.

Treatment of a sessile serrated adenoma/polyp deeply invading the appendiceal orifice enabled by combined adaptive traction and underwater endoscopic submucosal dissection.

Multipolar traction pulley method combined with underwater endoscopic submucosal dissection for a large rectal laterally spreading tumor.

Multipolar traction pulley method combined with underwater endoscopic submucosal dissection for a large rectal laterally spreading tumor.

Underwater endoscopic submucosal dissection with dental floss traction for the treatment of early pharyngeal cancer.

Underwater endoscopic submucosal dissection with dental floss traction for the treatment of early pharyngeal cancer.

Underwater endoscopic submucosal dissection for colorectal tumors decreases the incidence of post-electrocoagulation syndrome.

Underwater endoscopic submucosal dissection (U-ESD) is a recently developed procedure that has the potential to prevent post-ESD coagulation syndrome (PECS) owing to its heat-sink effect. We aimed to clarify whether U-ESD decreases the incidence of PECS compared with conventional ESD (C-ESD). A total of 205 patients who underwent colorectal ESD (C-ESD: 125; U-ESD: 80) were analyzed. Propensity score matching analysis was performed to adjust for patient backgrounds. Ten C-ESD and two U-ESD patients with muscle damage or perforation during ESD were excluded when comparing PECS. The primary outcome was to compare the incidence of PECS between the U-ESD and C-ESD groups (54 matched pairs). Secondary outcomes were to compare procedural outcomes between the C-ESD and U-ESD groups (62 matched pairs). Among the 78 patients who underwent U-ESD, PECS occurred in only one patient (1.3%). Adjusted comparisons between the U-ESD and C-ESD groups demonstrated a significantly lower incidence of PECS in the U-ESD group (0% vs 11.1%; P=0.027). Median dissection speed was significantly faster in the U-ESD than in the C-ESD group (10.9mm2 /min vs 6.9mm2 /min; P<0.001). En bloc and complete resection rates were 100% in the U-ESD group. Although perforation and delayed bleeding occurred in one patient each (1.6%) as adverse events in the U-ESD group, there were no differences compared with the C-ESD group. Our study demonstrates that U-ESD effectively decreases the incidence of PECS and is a faster and safer method for colorectal ESD.

Device-assisted traction methods in colorectal endoscopic submucosal dissection and options for difficult cases.

Endoscopic submucosal dissection (ESD) procedure has a longer procedure time and higher perforation rate than endoscopic mucosal resection owing to technical complications, including a poor field of vision and inadequate tension for the submucosal dissection plane. Various traction devices were developed to secure the visual field and provide adequate tension for the dissection plane. Two randomized controlled trials demonstrated that traction devices reduce colorectal ESD procedure time compared with conventional ESD (C-ESD), but they had limitations, including a single-center fashion. The CONNECT-C trial was the first multicenter randomized controlled trial comparing the C-ESD and traction device-assisted ESD (T-ESD) for colorectal tumors. In the T-ESD, one of the device-assisted traction methods (S-O clip, clip-with-line, and clip pulley) was chosen according to the operator's discretion. The median ESD procedure time (primary endpoint) was not significantly different between C-ESD and T-ESD. For lesions ≥ 30 mm in diameter or in cases treated by nonexpert operators, the median ESD procedure time tended to be shorter in T-ESD than in C-ESD. Although T-ESD did not reduce ESD procedure time, the CONNECT-C trial results suggest that T-ESD is effective for larger lesions and nonexpert operators in colorectal ESD. Compared with esophageal and gastric ESD, colorectal ESD has some difficulties, including poor endoscope maneuverability, which may be associated with prolonged ESD procedure time. T-ESD may not effectively improve these issues, but a balloon-assisted endoscope and underwater ESD may be promising options and these methods can be combined with T-ESD.

Underwater endoscopic submucosal dissection of a relapsing neoplastic colorectal lesion after surgery and radiotherapy: water to the rescue!

Underwater endoscopic submucosal dissection of a relapsing neoplastic colorectal lesion after surgery and radiotherapy: water to the rescue!

Underwater endoscopic submucosal dissection and hybrid endoscopic submucosal dissection as rescue therapy in difficult colorectal cases.

Background and study aims Colorectal endoscopic submucosal dissection (ESD) is still not widely used due to its technical difficulty and the risk of complications. Rescue therapies such as hybrid ESD (H-ESD) have been proposed for very difficult cases, as has underwater ESD (U-ESD). This study evaluated the safety and efficacy of H-ESD and U-ESD in difficult cases. Patients and methods The hospital charts of consecutive patients referred for colorectal ESD between January 2014 and February 2021 because they were considered difficult cases were retrospectively analyzed. The primary outcome of the study was en bloc resection rate; secondary outcomes were the rate of complete resection, procedure speed, and incidence of adverse events (AEs). Results Fifty-nine colorectal neoplasms were considered, 22 of which were removed by U-ESD and 37 by H-ESD. The en bloc resection rate in the U-ESD group was 100 %, while it was 59.5 % in the H-ESD group. Dissection speed was 17.7mm 2 /min in the U-ESD group and 8.3 mm 2 /min in the H-ESD group. The AE rate was low in the U-ESD group and moderately high during H-ESD (5 % and 21.6 %, respectively; and perforation rate 0 % and 10.8 %, respectively). Larger lesions were treated with U-ESD, while more fibrotic ones were treated with H-ESD. Conclusions U-ESD and H-ESD are both effective and safe techniques in difficult colorectal situations. U-ESD is particularly effective and fast for large lesions when it is not possible to obtain comfortable knife position, while H-ESD is more suitable for very fibrotic lesions.

Tapered hood with wide holes in its sides for efficient air bubble removal during underwater endoscopic submucosal dissection

Tapered hood with wide holes in its sides for efficient air bubble removal during underwater endoscopic submucosal dissection

147 EFFECTIVE UNDERWATER ENDOSCOPIC SUBMUCOSAL DISSECTION FOR A SUPERFICIAL CERVICAL ESOPHAGEAL CANCER

Abstract Underwater method is now mainly used in endoscopic mucosal resection of colorectal and duodenal lesions based on the fact that mucosa and submucosa float into the lumen moving away from the muscularis propria after filling with water without submucosal injection. We performed underwater endoscopic submucosal dissection (ESD) for a cervical esophageal lesion. Methods Case report. Results An 81-year-old man with a history of drinking and smoking underwent endoscopy, revealing a 1/3 round superficial cancer in the cervical esophagus. ESD was performed under general anesthesia and tracheal intubation. The lumen was so narrow from natural constriction that a good view could not be secured under CO2 insufflation. Therefore, we tried the underwater method. As the lumen was expanded by filling with 0.9% saline solution, it was possible to secure a visual field. Because the submucosal layer floated up underwater, a circumferential incision and submucosal dissection were completed easily and quickly. Conclusion Endoscopic resection for lesions within a physiologic narrow space is difficult. The underwater method is reported to be useful for treatment of rectal tumors near the dentate line and cecal tumors in the appendiceal orifice. We found that the underwater method made ESD for the cervical esophageal cancer even easier by securing a good view. To our knowledge, this is the first report of underwater ESD for a cervical esophageal cancer.

Underwater endoscopic submucosal dissection for a duodenal neuroendocrine tumor using pocket creation and ring-shaped thread countertraction methods.

Underwater endoscopic submucosal dissection for a duodenal neuroendocrine tumor using pocket creation and ring-shaped thread countertraction methods.

Underwater endoscopic submucosal dissection of a non-granular laterally spreading tumor of the hepatic flexure.

Underwater endoscopic submucosal dissection of a non-granular laterally spreading tumor of the hepatic flexure.

Effectiveness of Underwater Endoscopic Submucosal Dissection for a Superficial Cervical Esophageal Cancer.

Effectiveness of Underwater Endoscopic Submucosal Dissection for a Superficial Cervical Esophageal Cancer.

Underwater endoscopic submucosal dissection of an obstructing giant colonic lipoma.

Underwater endoscopic submucosal dissection of an obstructing giant colonic lipoma.