The ESD-EMR Hybrid or Pre-Cutting EMR Endoscopic Resection Technique
A technique to improve complete entrapment and resection colorectal, esophageal and stomach lesions.
Traditionally, flat colorectal non-polypoid lesions have been resected using endoic submucosal dissection (ESD), endoscopic mucosal resection (EMR) or piecemeal EMR techniques. In addition, smaller, flat serrated lesions may be hard to catch and resect using polypectomy snares. These lesions have a slippery surface and often it is frustrating to see how the snare only catches a piece of the polyp or completely slips off.
Here we show you a technique to improve complete entrapment and resection colorectal, esophageal and stomach lesions. This technique of incision and resection is a hybrid ESD-EMR technique. Some experts also refer to it “precutting” EMR, as an incision is made around the lesion before the final resection takes places. This incision creates a groove where the snare can be perfectly placed for subsequent EMR. However, often, in addition to just incising around the lesion, we also perform submucosal dissection to decrease the size of the base that needs to be ensnared (see lipoma case, figure 2)
Our technique involves using a) submucosal injection, and b) just a snare. After we create the submucosal cushion (Fig. 1a and Fig 1b) we make a circumferential incision around the lesion just using the tip of the snare (Fig. 1 c and Fig 1 d). Usually, a 1-2 mm snare tip exposure is sufficient to achieve nice incision and submucosal dissection (Fig 1 c). Once the entire lesion has been circumferentially incised (Fig. 1 e), the snare is placed around the lesion and resection using EMR is achieved (Fig. 1 e and Fig 1f). This technique improves the R0 resection of the lateral aspect of the polyp. And if sufficient submucosal cushion has been injected, a nice R0 vertical resection is achieved as well. This technique is also useful to resect larger lesions, including lipomas (Figure 2), granular cell tumors of the esophagus, and small gastric mucosal neoplasia and submucosal lesions, such as ectopic pancreas or GIST. Very importantly, if the lesion is situated in a hard location, or you cannot see or control the entire circumferential incision, we proceed to use additional equipment such as IT-knife, which has a ceramic tip that prevents the transmission of energy beyond the tip of the knife and thus, there is less chances of perforation. In sum, here we show you a technique of advanced endoscopic resection or hybrid ESD-EMR technique using a simple needle and a snare.
In general, this technique is safest for lesions less than 4 cm. Importantly, we don’t use this technique in lesions that are located in awkward or difficult positions, as it is important to have view and control oft the distal exposed tip of the snare. In those situations it’s better to use ceramic tip knives.
What setting do you use for the circumferential dissection with the tip of the snare?