Clin Endosc.  2022 Sep;55(5):655-664. 10.5946/ce.2022.009.

Efficacy of the pocket-creation method with a traction device in endoscopic submucosal dissection for residual or recurrent colorectal lesions

• Ide D
• Ohya TR
• Ishioka M
• Enomoto Y
• Nakao E
• Mitsuyoshi Y
• Tokura J
• Suzuki K
• Yakabi S
• Yasue C
• Chino A
• Igarashi M
• Nakashima A
• Saruta M
• Saito S
• Fujisaki J

• KMID: 2533305
• DOI: http://doi.org/10.5946/ce.2022.009

Abstract

Background/Aims
Endoscopic submucosal dissection (ESD) for residual or recurrent colorectal lesions after incomplete resection is challenging because of severe fibrosis. This study aimed to compare the efficacy of the pocket-creation method (PCM) with a traction device (TD) with that of conventional ESD for residual or recurrent colorectal lesions.
Methods
We retrospectively studied 72 patients with residual or recurrent colorectal lesions resected using ESD. Overall, 31 and 41 lesions were resected using PCM with TD and conventional ESD methods, respectively. We compared patient background and treatment outcomes between the PCM with TD and conventional ESD groups, respectively. The primary endpoints were en bloc resection and R0 resection rates. The secondary endpoints were the dissection speed and incidence of adverse events.
Results
En bloc resection was feasible in all cases with PCM with TD, but failed in 22% of cases of conventional ESD. The R0 resection rates for PCM with TD and conventional ESD were 97% and 66%, respectively. Dissection was significantly faster in the PCM with TD group (13.0 vs. 7.9 mm2/min). Perforation and postoperative bleeding were observed in one patient in each group.
Conclusions
PCM with TD is an effective method for treating residual or recurrent colorectal lesions after incomplete resection.

Keyword

Colorectum; Endoscopic submucosal dissection; Pocket-creation method; Residual or recurrent lesion; Traction device

Figure

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  Fig. 1. Procedure for the pocket-creation method with a traction device. (A) Sufficient local injection is performed on the oral side of the lesion, and incision/trimming is performed on approximately half of the lesion circumference. Sufficient local injection is performed on the anal side, and a traction device (TD) is attached approximately 10 mm away from the lesion on the anal side before starting the incision. (B) Another an endoscopic clip is fixed to the attached TD, which is then attached to the contralateral side of the colorectum to the lesion. The surrounding mucosa to which the TD is attached, including the submucosal layer immediately below, is under traction, exposing the submucosal layer as the incision is made. (C) Subsequently, if the submucosal layer is dissected, it forms a mucosal flap, facilitating the entry of the tip of the endoscope. Submucosal pockets rapidly form if dissection is continued without making a circumferential incision. When the submucosal pocket exceeds 50% of the lesion area beyond the center of the lesion, a circumferential incision is made to open the pocket. Then, dissection is performed in stages until it is fully completed.

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  Fig. 2. Schematic comparison of conventional endoscopic submucosal dissection (ESD) and pocket-creation method (PCM) with a traction device (TD). (A) Conventional ESD: a circumferential incision is made around the lesion, followed by a submucosal incision from the anal side to the oral side. (B) PCM with TD: the key feature of this method is connecting the TD to the anal mucosa 10 mm away from the lesion on the anal side before the initial mucosal incision. The formation of a mucosal flap and creation of a submucosal pocket using the TD becomes easier.

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  Fig. 3. Pocket-creation method view with a traction device (TD). (A) A 20-mm lesion in the transverse colon following endoscopic piecemeal mucosal resection. (B) Local injection is performed around the oral lesion, and incision/trimming is performed to approximately one-half of the circumference on the oral side of the lesion. (C) After local injection on the anal side, the TD is attached approximately 10 mm away from the lesion on the anal side. (D) Starting the incision from the anal side of the TD facilitates easy creation of a mucosal flap. (E) A submucosal pocket is formed. (F) Severe fibrosis of the submucosal layer immediately below the lesion scar. (G) Completed circumferential incision and continued dissection. (H) After dissection completion.

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