Clin Endosc.  2023 Nov;56(6):778-789. 10.5946/ce.2022.268.

Significance of rescue hybrid endoscopic submucosal dissection in difficult colorectal cases

• Yamaguchi H
• Fukuzawa M
• Kawai T
• Muramatsu T
• Matsumoto T
• Uchida K
• Koyama Y
• Madarame A
• Morise T
• Kono S
• Naito S
• Nagata N
• Sugimoto M
• Itoi T

• KMID: 2547900
• DOI: http://doi.org/10.5946/ce.2022.268

Abstract

Background/Aims
Hybrid endoscopic submucosal dissection (ESD), in which an incision is made around a lesion and snaring is performed after submucosal dissection, has some advantages in colorectal surgery, including shorter procedure time and preventing perforation. However, its value for rescue resection in difficult colorectal ESD cases remains unclear. This study evaluated the utility of rescue hybrid ESD (RH-ESD).
Methods
We divided 364 colorectal ESD procedures into the conventional ESD group (C-ESD, n=260), scheduled hybrid ESD group (SH-ESD, n=69), and RH-ESD group (n=35) and compared their clinical outcomes.
Results
Resection time was significantly shorter in the following order: RH-ESD (149 [90–197] minutes) >C-ESD (90 [60–140] minutes) >SH-ESD (52 [29–80] minutes). The en bloc resection rate increased significantly in the following order: RH-ESD (48.6%), SH-ESD (78.3%), and C-ESD (97.7%). An analysis of factors related to piecemeal resection of RH-ESD revealed that the submucosal dissection rate was significantly lower in the piecemeal resection group (25% [20%–30%]) than in the en bloc resection group (40% [20%–60%]).
Conclusions
RH-ESD was ineffective in terms of curative resection because of the low en bloc resection rate, but was useful for avoiding surgery.

Keyword

Colorectal cancer; Endoscopic mucosal resection; Hybrid endoscopic submucosal dissection; Perforation

Figure

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  Fig. 1. Diagram showing the patient selection process. ESD, endoscopic submucosal dissection; C-ESD, con­ventional ESD; SH-ESD, scheduled hybrid ESD; RH-ESD, rescue hybrid ESD.

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  Fig. 2. Sample scheduled hybrid endoscopic submucosal dissection procedure. (A) A 30-mm flat elevated lesion located in the cecum. (B) After the injection of a mixture of 0.4% sodium hyaluronate solution, glycerol solution, and indigo carmine into the submucosal layer, a full circumferential incision was made outside the lesion. The submucosal layer was then dissected with an endoscopic submucosal dissection knife until it was large enough to be safely resected en bloc with a snare. (C, D) After adequate submucosal dissection, a local injection was administered in the submucosal layer, and the tip of the snare was placed on the mouth side of the lesion. The snare was then slowly opened to prevent the tip from shifting, and the lesion was strangulated for final resection.

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  Fig. 3. Sample rescue hybrid endoscopic submucosal dissection procedure. (A) Perforation that occurred during conventional endoscopic submucosal dissection. (B) Case with perforation in which endoclips were used for closure. (C, D) Because of the length of time taken for the treatment, a local injection was administered after submucosal dissection and snaring was performed for the lesion during dissection.

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