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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 4-5 Close the snare and resect the lesion in a piecemeal manner.
See Video 4-1 for example of endoscopic mucosal resection (EMR).
PEARLS AND PITFALLS
During injection, be dynamic. Start injecting and slowly withdraw the
needle.
Avoid excessive injectate as this can block the view during snaring.
If the lesion is not lifting (ie, the nonlifting sign), terminate the
procedure or consider endoscopic submucosal dissection (ESD) in
selected cases, as this may indicate submucosal fibrosis due to
underlying scarring or a lesion with high risk of malignancy.
Alternatively, a lesion with nonlifting sign may require advanced
surgical resection.
Use endoscopic hemoclips or coagrasper if coagulation does not suffice
to establish hemostasis.
Make sure majority of the pieces are collected through the suction
channel and a specimen trap is used; or alternatively, if there are larger
pieces, utilize a Roth Net or other endoscopic baskets.
ENDOSCOPIC SUBMUCOSAL DISSECTION
Perioperative Considerations
The procedure can be performed in regular endoscopy suites under
sedation or in the operating room under general anesthesia.
During the early learning curve with ESD, consider performing the cases
in the operating room setting with laparoscopy as backup as needed.
Decide the place you will perform the procedure based on the possibility
of creating a full-thickness defect and the general condition of the patient.
Previously resected and scarred lesions are typically stuck to the muscular
layer and may be impossible to enter the submucosal plane.
Observe the patient for at least 4 hours after the procedure, but be prepared
to keep a patient overnight if any concerns.
Having a height-adjustable examination bed is vital for the comfort and
ergonomics of the endoscopist.
The endoscopist typically stands on the right side of the patient in the
endoscopy suite or in between the legs in the operating room and performs
a standard colonoscopy prior to the procedure.
Leave the leg extension of the operating table in place and slide the patient
on the table way down while patient legs are suited in Yellowfins. This
will allow the bottom portion of the operating table to support the part of
the colonoscope that is not inserted—providing stability.
Change the patient position according to the location of the lesion and
apply abdominal pressure, when necessary, for better visualization.
Aim for the lesion to be at 6 o’clock (ie, midline inferior) during the
procedure.
For both EMR and ESD, different injectates are available.
In our practice, we use 100 mL hydroxyethyl starch and 1 mL of 0.1%
adrenaline solution; however, a variety of solutions are available and can
be used to prepare the injectate.
Methylene blue or indigo carmine dye is added to the injectate to establish
better visualization.
Alternatively, injectates that contain glycerol, hyaluronic acid, albumin
solutions, and sterile saline can be used, based on the availability and cost.
Hypromellose can be preferred as an inexpensive alternative when diluted
6-8 times with sterile saline.
Premixed recently Food and Drug Administration–approved solutions,
such as Eleview, can also be used alternatively.
Equipment
Colonoscope
Methylene blue or indigo carmine dye mixed with local anesthesia
Eleview or other premixed solution (as desired)
Select snares, baskets, and injection needles for the colonoscope
Bipolar/monopolar unit
100 mL hydroxyethyl starch and 1 mL of 0.1% adrenaline solution
DualKnife (Olympus America Inc., Center Valley, PA) or HookKnife
(Olympus America Inc., Center Valley, PA)
Available platforms such as DiLumen or ORISE
Available over-the-scope clips or endoscopic hemoclips
Technique (Fig. 4-6)
FIGURE 4-6 Overview of endoscopic submucosal dissection.
Injection
Determine your injection technique based on the location and shape of the
lesion.
If the polyp is situated on a fold, primary injection site should be along the
far aspect (oral site) of the lesion to avoid it falling forward into view.
100 mL hydroxyethyl starch and 1 mL of 0.1% adrenaline solution or a
readily mixed solution is injected into the submucosa with an injection
needle.
Advance the injection needle, aiming it tangential to the mucosa of the
lesion (Fig. 4-7).
FIGURE 4-7 Advance the injection needle and start injecting the solution. Reposition
and repeat injections for lesions located on difficult locations such as folds.
The assistant helps to advance the needle into the mucosal–submucosal
area to create the submucosal cushion.
Start the injection and observe the lesion for mucosal elevation.
Inadequate elevation can be due to entry into incorrect plane.
Reposition the injection needle and inject again.
Continue injecting the solution to the submucosal space while
withdrawing the needle (Fig. 4-8).
FIGURE 4-8 Steps of endoscopic submucosal dissection. A. Marking; B. Staining; C.
Incision; D. Dissection; E. Collection; F. Hemostasis
Dissection
After achieving the submucosal cushion, start the dissection by delineating
the borders of the lesion with circumferential incision.
DualKnife (Olympus America Inc., Center Valley, PA) or HookKnife
(Olympus America Inc., Center Valley, PA) can be used for dissection
(Fig. 4-9).
FIGURE 4-9 After adequate injection is completed, dissection is started with
circumferential incision. Partially completed incision with DualKnife can be seen on the
lower right of the image.
After incising the first half of the lesion, deepen your dissection into the
submucosal space.
After deep submucosal dissection is completed for the initial half,
continue circumferentially and dissect the lesion using the submucosal
plane with the guidance of blue dye. During this stage, distal disposable
cap aids to create traction–countertraction (Fig. 4-10).
FIGURE 4-10 After circumferential incision, submucosal dissection is carried with the
guidance of the blue dye to ensure correct plane. Distal disposable cap is used for secure
dissection.
When available, platforms such as DiLumen or ORISE can be used to
create a stable therapeutic zone.
These platforms can also be used to achieve retraction (Fig. 4-11).
FIGURE 4-11 ORISE platform (A), balloon-assisted retraction with DiLumen (B), and
clipping lesion to the bowel wall (C) can be used to achieve retraction.
After excising each portion, clean the field and obtain good visualization
of the dissection field and establish hemostasis.
Always keep your dissection instrument tangential to the submucosa to
prevent advancement of dissection to the muscular layer.
Continue incision and submucosal dissection until you dissect the lesion
completely.
When necessary, apply a hybrid method to complete dissection with
snaring for large lesions or lesions in a difficult dissection (Fig. 4-12).
FIGURE 4-12 Endoscopic submucosal dissection enables en bloc removal of the
lesion.
Use coagulation forceps to establish hemostasis and stop any minor
hemorrhage.
Use endoscopic hemoclips if any defects can be observed in the field
deeper than submucosa.
Over-the-scope clips can also be used for larger defects (Fig. 4-13).
FIGURE 4-13 Endoscopic hemoclips (A) or over-the-scope clip (B) can be used to
close the defect after endoscopic submucosal dissection.
See Video 4-2 for example of ESD.
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