The ESD-EMR Hybrid or Pre-Cutting EMR Endoscopic Resection Technique

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.

Learn More About EMR on EndoCollab

1. Sudden onset(?) of colitis after EMR

2. A novel technique - hybrid-argon plasma coagulation (APC) - to prevent colon polyp recurrence after EMR

3. Flat colon polyps: do you use cold or hot snare or EMR?

4. What type of endoscopic resection - EMR versus ESD - is required for superficial esophageal cancers < 20 mm?

5. Hybrid endoscopic mucosal resection and endoscopic submucosal dissection (EMR ESD) for polypoid laterally spreading tumor (LST-p)

6. Is Underwater Endoscopic Mucosal Resection Better Than Conventional EMR for Large Colon Polyps?

7. A short history of one of the most successful endoscopic interventions ever invented.