Development of colorectal endoscopic submucosal dissection

Digestive EndoscopyEarly View EditorialFree Access Development of colorectal endoscopic submucosal dissection Naohisa Yahagi, Corresponding Author Naohisa Yahagi yahagi-tky@umin.ac.jp Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, JapanSearch for more papers by this author Naohisa Yahagi, Corresponding Author Naohisa Yahagi yahagi-tky@umin.ac.jp Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, JapanSearch for more papers by this author First published: 07 February 2022 https://doi.org/10.1111/den.14229AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Development of Endoscopic Submucosal Dissection (ESD) and Background of that Time In Japan, where gastric cancer incidence is remarkably high, many efforts had been made for its early detection and treatment. Since conventional endoscopic mucosal resection (EMR) was not reliable enough, Hosokawa developed a prototype of insulated tip knife in the middle 1990s and Ono et al.1 established a technique of safe mucosal incision around the lesion in the late 1990s at the National Cancer Center. Meanwhile, Yamamoto et al.2 at the Jichi Medical University developed a new technique of making safe mucosal incision even with a sharp needle knife by creating a thick submucosal fluid cushion using sodium hyaluronate. Our group at the University of Tokyo developed a method of using a slightly protruded a tip of thin-type snare as a knife, since we thought that a short knife with a blunt tip could be used for making safe mucosal incision without perforation.3 The resection technique with mucosal incision and submucosal dissection was first established in the stomach by the early 2000s. At the same time, Gotoda et al. investigated a large number of surgically treated early gastric cancer cases and clarified the low-risk conditions of early gastric cancer of lymph node metastasis. However, in the colon, the risk of perforation was considered extremely high due to the thin and soft colonic wall, and treatment by incision and dissection was regarded as contraindication. In addition, the colonic mucosa is thin enough to provide good mucosal lifting and soft protrusions are easier to snare than those of the stomach. And most of the lesions were adenomas or mucosal cancers, therefore, piecemeal resection was widely accepted even for large colorectal lesions at that time. Furthermore, unlike the stomach, there is almost no functional impairment after colonic surgery, and since laparoscopic surgery can be performed smoothly, most people agreed that there is no problem with laparoscopic surgery if it cannot be removed by conventional EMR. Introduction of ESD to Colorectal Lesions In spite of the above mentioned situation, we felt that it was unacceptable to send the patients with apparent intramucosal cancer or adenoma to surgery just because the snaring is not available, thus we started our challenge to change this situation. Yamamoto et al.4 and Gotoda et al.5 had already reported the resection of rectal tumor by incising the surrounding mucosa with a knife in 1999, but there were no reports of incision and dissection in the colon. However, we thought that we could perform the procedure in the colon without any problem if we used a thin-type snare that could keep the tip short, so we started with resection of a little over 1 cm of 0-IIc intramucosal cancer in the sigmoid colon and gradually expanded the resection target. The turning point was the resection of a large elevated lesion of more than 5 cm in the rectosigmoid colon.6 Since the maneuverability was poor due to the bended location, I made a perforation, but the resection was completed after clipping. A perforation in the colon meant emergency surgery at that time, but since we had been treating the lesion in a clean condition after washing the area with a water jet, and since the perforation was completely closed, our surgeon agreed to treat the patient conservatively. After that experience, we began to actively treat even larger lesions by incision and dissection. However, it was still all headwinds and was strongly criticized by the academic community. But, our group and Yamamoto's group at Jichi Medical University thought that we should aim for complete en bloc resection from the beginning, because preoperative diagnosis is not 100% even with the progress of magnifying endoscopy and piecemeal resection increases a risk of uncertain histological diagnosis and local recurrence. And of course, retreatment becomes very difficult after recurrence, thus we thought that we should aim for a complete en bloc resection even in the colon. Ingenuities and New Developments for Safe ESD in the Colon Most of the criticism of colorectal ESD had been against its risks. This was thought to be due to the fact that many of those who tried ESD in the colon in the same way as in the stomach experienced emergency surgery because of large perforations. Most of them did not understand the concept of how to ensure safety during incision and dissection in the colon, which we had always considered. Basically, our concept of ESD was to create a sufficient bulge by local injection and then incise and dissect only the safe area under direct vision using a blunt ended short needle knife, which could be performed in the colon or esophagus without any problem if the characteristics of the organ were properly understood.7 Although endoscopes with water jet function were rarely used at that time, we had already introduced a therapeutic endoscope with water jet function and a small hemostatic forceps for our procedures in cooperation with Pentax, this fact also contributed greatly to improve the safety. In addition, only the silicon band part of the EMRC cap was removed and fixed with tape to be used as a soft hood to secure the field of view. A soft hood was quickly commercialized by Olympus since there were many needs for it. On the other hand, sodium hyaluronate solution reported by Yamamoto et al. seemed excellent, but it was not clear that what kind of solution was suitable for ESD. Therefore, we investigated the characteristics of the available local injection solutions to find the suitable injection material for ESD.8 In addition, in order to perform procedures more smoothly even behind the colonic folds, we proposed to Olympus a special therapeutic colonoscope furnishing a short rigid tip and a small bending part with a 6 o'clock working channel and a water jet. Besides, a small sized Coaglasper and a balloon assisted overtube were also commercialized based on our proposal from the colorectal ESD study group. For knives, a Flex knife (Olympus, Tokyo, Japan) was developed because the tip of a thin-type snare was difficult to adjust and easily got dirty. Later, we developed a Dual knife (Olympus) as an improved version of the Flex knife, which enabled us to perform colorectal ESD more smoothly.9 Naturally, knives were constantly evolving, Hook knife (Olympus), Flush knife (Fujifilm, Tokyo, Japan), Hybrid knife (Erbe, Tübingen, Germany), Splashneedle (Pentax, Tokyo, Japan), Clutch cutter (Fujifilm), SB knife (Sumitomo Bakelite, Tokyo, Japan), Mucosectom (Pentax) and B knife (Zeon Medical, Tokyo, Japan) etc. were commercialized one after another. It is well known that many knives are now equipped with an injection capability to make ESD safer and smoother. In addition, the introduction of the carbon dioxide insufflation system has changed colorectal ESD drastically and is now indispensable because it can reduce discomfort during the procedure and simplifies management even after perforation.10 These innovations and the development of new equipment have established the basic principles of colorectal ESD as we know it today. Clinical Outcomes of Colorectal ESD Although the safety of colorectal ESD had been a concern, it has been covered by national insurance system in 2012 due to the good clinical outcomes of this procedure performed as an advanced medical care since 2009. Looking back at our review article based on early published data of colorectal ESD until that time,11-16 we found that ESD was performed on lesions with a median size of 26.8–37 mm, a mean time of 60–116 min, en bloc resection rate of 84−97.6%, and R0 resection rates ranged from 74.5–92.3%. The incidence of serious bleeding and perforation was 0.7–2.4% and 4.3–8.1%, respectively, but most of the cases could be treated conservatively. Long-term results showed that the local recurrence rate was very good, ranging from 0.2% to 2.0%. When it was first covered by national insurance system, it was limited to "early-stage cancers or adenomas with a maximum diameter of 2 cm to 5 cm" for safety reasons, and treatment of large lesions larger than 5 cm, which is the true advantage of ESD, was excluded.17 However, the size limitation was effectively eliminated in 2018 due to good clinical outcomes and our guideline was renewed accordingly.18 This has made it possible to treat large rectal cancers such as the lesions with almost complete circumference, which were previously not indicated, and available to provide treatment that preserves anal function by ESD (Fig. 1). Figure 1Open in figure viewerPowerPoint Large rectal lesion with a bulky nodule. A large LST-G with a bulky nodule was found in the lower rectum. There was severe fibrosis under the nodule and the muscle traction sign was clearly observed. However, the lesion was successfully resected in an en bloc fashion by dissecting a part of the muscle layer. Histopapthological diagnosis was a well-differentiated adenocarcinoma in adenoma, type 0-Is+IIa, 110 × 75 mm, tub1>tub2, pTis, ly(-), v(-), pHM0, pVM0. It turned out to be curative resection and anal function was preserved. Current Situation and Future of Colorectal ESD in the World Endoscopic submucosal dissection (ESD) is the ultimate local resection technique at this moment and is considered to be an extremely beneficial minimally invasive treatment. It has already become a popular practice in Asian countries, however, it is not popular yet in Western countries. The reasons for the delay in the spread of ESD in Western countries are as follows: the hurdle for learning ESD is too high because there are few gastric cancer cases, and one has to start with the colonic cases; it is difficult to perform delicate procedure because colonoscope is inserted by pushing manner under deep sedation using propofol; it is difficult to select appropriate candidate for ESD due to lack of precise diagnostic system using magnifying endoscopes; there is not much tolerance for long endoscopic procedures; and there is no resistance to laparoscopic surgery even for benign lesions in the USA. However, in the USA, there are some aggressive experts who are resecting colorectal lesions by ESD and suturing the wound completely with Overstich, even after perforation or what turned out to be full-thickness resection.19 Besides, a few robotic systems have been developed to perform colorectal ESD more reliably,20 although it looks still very rudimentary at this moment. In any case, I believe that colorectal ESD will become a global standard treatment option in the near future, as the technology advances and new instruments are developed. Conflict of Interest Author N.Y. has received royalties for resection devices from Olympus. He has patents for resection devices from Olympus and patents for endoscope and accessories from Pentax. N.Y. is a member of the guideline committee of colorectal ESD and EMR of the Japan Gastroenterological Endoscopy Society. Funding Information None. References 1Ono H, Kondo H, Gotoda T et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut 2001; 48: 225– 9. CrossrefCASPubMedWeb of Science®Google Scholar 2Yamamoto H, Yube T, Isoda N et al. A novel method of endoscopic mucosal resection using sodium hyaluronate. Gastrointest Endosc 1999; 50: 251– 6. CrossrefCASPubMedWeb of Science®Google Scholar 3Yahagi N, Fujishiro M, Kakushima N et al. 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