- Email: [email protected]
Two-point fixed endoscopic submucosal dissection in rectal tumor (with video)
Two-point fixed ESD in rectal tumor
13. Verdonk RC, de Ruiter AJ, Weersma RK. Treatment of complex biliary stones by cholangioscopy laser lithotripsy in 10 patients [In German with English abstract]. Ned Tijdschr Geneeskd 2010;154:A2085. 14. Neuhaus H, Hoffmann W, Gottlieb K, et al. Endoscopic lithotripsy of bile duct stones using a new laser with automatic stone recognition. Gastrointest Endosc 1994;40:708-15. 15. Hochberger J, Hahn EG, Ell C. Laser lithotripsy in the treatment of bile duct calculi. Ther Umsch 1993;50:596-601. 16. Cho YD, Cheon YK, Moon JH, et al. Clinical role of frequency-doubled double-pulsed yttrium aluminum garnet laser technology for removing difficult bile duct stones (with videos). Gastrointestinal Endosc 2009;70:684-9. 17. Chan KF, Vassar GJ, Pfefer TJ, et al. Holmium:YAG laser lithotripsy: a dominant photothermal ablative mechanism with chemical decomposition of urinary calculi. Lasers Surg Med 1999;25:22-37.
Motohashi
18. Vassar GJ, Chan KF, Teichman JM, et al. Holmium: YAG lithotripsy: photothermal mechanism. J Endourol 1999;13:181-90. 19. Draganov PV, Lin T, Chauhan S, et al. Prospective evaluation of the clinical utility of ERCP-guided cholangiopancreatoscopy with a new direct visualization system. Gastrointest Endosc 2011;73: 971-9. 20. Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video). Gastrointest Endosc 2007; 65:832-41. 21. Waxman I, Dillon T, Chmura K, et al. Feasibility of a novel system for intraductal balloon-anchored direct peroral cholangioscopy and endotherapy with an ultraslim endoscope (with videos). Gastrointest Endosc 2010;72:1052-6.
Two-point fixed endoscopic submucosal dissection in rectal tumor (with video) Osamu Motohashi, MD, PhD1 Kanagawa, Japan
Background: Polypectomy, EMR, transanal endoscopic microsurgery, and surgery have been performed as treatments of rectal tumors. Endoscopic procedures are the least-invasive treatments for patients. Complete resection of the lesion is required to prevent its recurrence, and endoscopic submucosal dissection (ESD) has begun to be performed. With increasing requirements for safety, reliability, and simplicity in ESD, we decided to use a 2-point fixed ESD with a transparent hood fitted with a mucosal forceps channel in a case of a rectal tumor and report its usefulness. Objective: To evaluate the safety, simplicity, and usefulness of 2-point fixed ESD performed on a rectal tumor. Design: Case series. Setting: Kanagawa Cancer Center Hospital. Main Outcome Measurements: Safety, simplicity, and usefulness of 2-point fixed ESD performed on a rectal tumor. Results: The mean duration of the procedure was 45 minutes (range 30-110 minutes). Hemostasis and manipulation of the vessels were easy in all patients who did not have postoperative bleeding, perforation, or retroperitoneal emphysema as complications. Limitations: Uncontrolled study. Conclusion: This study of 2-point ESD performed in 12 patients with rectal lesions revealed that the 2-point ESD with a transparent hood fitted with a mucosal forceps channel is a useful auxiliary device, enabling safe and reliable ESD on a rectal lesion.
Polypectomy, EMR, transanal endoscopic microsurgery,1,2 and surgery have been performed as treatments of rectal intramucosal tumors. Endoscopic procedures are the least invasive to patients among the local procedures. In
recent years, endoscopic submucosal dissection (ESD)3,4 has begun to be performed in cases in which necessary and sufficient thorough resection cannot be performed by polypectomy or EMR. Although transanal endoscopic
Abbreviation: ESD, endoscopic submucosal dissection.
Received April 21, 2011. Accepted July 18, 2011.
DISCLOSURE: The author disclosed no financial relationships relevant to this publication.
Current affiliation: Department of Gastroenterology (1), Kanagawa Cancer Center, Kanagawa, Japan.
Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.07.035
Reprint requests: Osamu Motohashi, MD, PhD, Department of Gastroenterology, Kanagawa Cancer Center, 1-1-2, Nakao, Asahi-ku, Yokohama City, Kanagawa, 241-0815 Japan.
1132 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 5 : 2011
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Motohashi
Two-point fixed ESD in rectal tumor
Take-home Message ●
Figure 1. Two-point fixed endoscopic submucosal dissection using a transparent hood fitted with a mucosal forceps channel (Impact Shooter). When dissecting the mucosa, in parallel with elevation of the mucosa held to apply countertraction, the hood is compressed to the intestinal wall to fix the dissected site to keep it under direct vision, and dissection is continuously carried out manipulating bleeding points and the vessels.
Figure 2. Two-point fixed endoscopic submucosal dissection using a transparent hood fitted with a mucosal forceps channel (Impact Shooter). When the mucosal dissection proceeds and no traction is applied only by elevating the held and dissected mucosa, the mucosa-holding forceps are pushed out to apply continuous countertraction for dissection.
microsurgery or laparotomy may also be performed for thorough resection, ESD seems less invasive and the most useful procedure when considering invasiveness to patients. For the goal of a safe and reliable thorough resection of early stomach and esophageal cancers, we performed basic experiments on 2-point fixed ESD to confirm its safety and usefulness, and then we used it in clinical cases and reported its safety and usefulness.5-9 We confirmed the safety, simplicity, and usefulness of 2-point fixed ESD performed for rectal tumors.
METHODS We performed ESD for 12 rectal tumors. Consent to implement 2-point fixed ESD was obtained from patients after sufficiently explaining the procedure’s safety, usefulwww.giejournal.org
Two-point endoscopic submucosal dissection (ESD) with a transparent hood fitted with a mucosal forceps channel, a useful auxiliary device, enables safe and reliable ESD of a rectal lesion.
ness, and possible complications, after obtaining the approval of our institutional review board. The depth of tumor was measured by EUS in all cases. The endoscope used was GIFQ240 (Olympus Optical Co, Tokyo, Japan). A solution of 0.4% sodium hyaluronate (MucoUp; Seikagaku, Tokyo, Japan) with indigo carmine was used for local submucosal injection. In mucosal incision, a short transparent hood (Top Co, Tokyo, Japan) was fitted to the endoscope and a needle-shaped knife (Olympus Optical Co) was used. A high-frequency generator with an automatically controlled system (VIO300D; ERBE Elektromedizin, Tübingen, Germany) was used for incision, dissection, and coagulation. It was set at the autocut mode 80 W/effect 3 during incisions. In dissection of the submucosa by the 2-point fixed procedure, a transparent hood fitted with a mucosal forceps channel, which has been commercialized under the trade name of Impact Shooter (TOP Co), was fixed on the fiber with tape, so that the forceps channel of Impact Shooter was located in the 10 to 11 o’clock direction to the forceps channel of GIFQ240 endoscope in the 8 o’clock direction. A Hot Crow (Olympus Optical Co), which was grasped and released by an assistant, was used as mucosal forceps. To secure the gripping of the mucosa, the muscularis mucosae should be dissected sufficiently. VIO300D was set at forced mode 40 W/effect 3 during the dissection. Bleeding and blood vessels to be manipulated were observed under direct vision, and the needle-shaped knife was stopped near the vessels, which were coagulated by VIO300D set at forced 40 W/effect 3. The larger vessels with a diameter of 1 mm or more and vessels with massive bleeding were manipulated with hemostatic forceps (Olympus Optical Co) setting VIO300D at soft coagulation 60 W.
RESULTS Countertraction was easy to apply to the submucosal dissection site by elevating and turning the dissected mucosa, as shown in Figures 1 and 2. Adequate visual fields were ensured from the beginning to the completion of the dissection without occurrence of perforation. The dissection procedure was safely carried out by using the needleshaped knife. In a 2-point fixed ESD, the grasp is changed several times to ensure effective traction and a good visual field. We reported that 2 cm of the submucosal layer can be Volume 74, No. 5 : 2011 GASTROINTESTINAL ENDOSCOPY 1133
Two-point fixed ESD in rectal tumor
Motohashi
Figure 3. A, Rectal mucosal lesion sprayed with indigo carmine. B, The perimeter of the lesion was incised after locally injecting submucosal hyaluronic acid. C, The mucosa was dissected from the anal side. Applying countertraction by grasping the mucosa with the holding forceps, the mucosa was dissected with a manipulation of vessels ensuring a sufficient visual field. D, The vessels were coagulated by using hemostatic forceps. E, The mucosa was dissected by applying countertraction by holding the adjacent mucosa with the holding forceps and pushing it backward. F, After dissecting the submucosa.
TABLE 1. The data for the 12 cases
Case
Site of tumor
Size, mm
Gross type
Histology
Duration of ESD, min
Result
1
Rb
22
LST-G
Well, m, ly0, v0, HM(⫺), VM(⫺)
60
En bloc
2
Rb
36
LST-G
Adenoma, HM(⫺), VM(⫺)
110
En bloc
3
Rb-Ra
25
LST-G
Well, m, ly0, v0, HM(⫺), VM(⫺)
42
En bloc
4
Rb
40
LST-G
Well, m, ly0, v0, HM(⫺), VM(⫺)
43
En bloc
5
Rb
43
LST-G
Well, m, ly0, v0, HM(⫺), VM(⫺)
40
En bloc
6
Rb
32
LST-NG
Well, sm 300 m, ly0, v0, HM(⫺), VM(⫺)
30
En bloc
7
Rb
25
LST-G
Adenoma, HM(⫺), VM(⫺)
35
En bloc
8
Rb
30
LST-NG
Adenoma, HM(⫺), VM(⫺)
30
En bloc
9
Rb
32
SMT (carcinoid)
Carcinoid, sm, ly0, v0, HM(⫺), VM(⫺)
35
En bloc
10
Ra
40
LST-NG
Well, sm 400 m, ly0, v0, HM(⫺), VM(⫺)
30
En bloc
11
Rs
35
LST-G
Well, m, ly0, v0, HM(⫺), VM(⫺)
40
En bloc
12
Rs
30
LST-G
Adenoma, HM(⫺), VM(⫺)
45
En bloc
ESD, Endoscopic submucosal dissection; Rb, rectum bellow the peritoneal reflection; LST-G, laterally spreading tumor granular type; Well, well-differentiated adenocarcinoma; m, mucosa; ly0, there is no lymphatic invasion; v0, there is not the venous invasion; HM(⫺), horizontal margin negative; VM(⫺), vertical margin negative; en bloc, en bloc resection; Ra, rectum above the peritoneal reflection; LST-NG, laterally spreading tumor nongranular type; SMT, submucosal tumor; sm, submucosa; Rs, rectosigmoid.
1134 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 5 : 2011
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manipulated in both the right and left directions per single grasp.9 Pushing out the forceps as shown in Figure 2 allows 2 cm of ablation of the submucosal layer. Figure 3 shows a 2-point ESD performed in a 40-mm diameter early rectal adenocarcinoma adjacent to the anal verge with abundant vessels, where manipulation of the vessels was also easy. Video 1 (available online at www.giejournal.org) shows a 2-point fixed ESD performed in a 10-mm diameter rectal carcinoid tumor without muscle invasion, where the muscle layer was confirmed and the submucosa immediately above the muscle layer was dissected safely. Table 1 shows the data for the 12 cases, site of tumor, size, gross type, histology, duration of ESD, and result. The mean duration of the procedure was 45 minutes (range 30-110 minutes), and resected specimens were 22 to 42 mm. Margins, both horizontal and vertical, were clear in the 12 cases. Hemostasis and manipulation of vessels were easy in all cases without postoperative bleeding, perforation, or retroperitoneal emphysema.
DISCUSSION ESD is a very useful procedure, although its disadvantages have been pointed out, such as longer procedure time and a higher incidence of complications than those with polypectomy or EMR. Various devices, auxiliary devices, and resection procedures have been developed for ESD.10-17 In ESD of the large intestine with narrow lumen and the thin intestinal wall, however, the procedure by Sakamoto et al18 using spring clips and our 2-point fixed procedure allows simple and easy application of traction. Our 2-point fixed ESD allows expansion of the mucosal dissection surface with the holding forceps to ensure a sufficient visual field throughout the dissection manipulation, facilitating observation/manipulation of the bleeding points and the vessels in the lower rectum with abundant hemorrhoidal veins and vessels. This procedure also has a great advantage in that the 2-point fixing by the holding forceps and the hood can apply countertraction to the submucosa between the 2 points in addition to ordinary countertraction applied by direct compression of the hood. Furthermore, by changing the point of the mucosa held with the forceps and pushing the mucosa being dissected backward with the holding forceps as the dissection proceeds, a sufficient visual field and the distance from the dissection site is constantly ensured to apply constant and sufficient countertraction to the submucosal tissue being dissected, enabling safe and easy dissection of the submucosa. When the lesion extended across the Houston valve, the mucosa adjacent to the valve was dissected easily by pushing out the holding forceps. The 2-point fixed procedure has the additional advantage of keeping a constant distance between the dissection www.giejournal.org
Two-point fixed ESD in rectal tumor
device and the dissection site to suppress the movement of the rectal wall. When the endoscope is swung with the holding point in the mucosa serving as a fulcrum (a manipulation of swinging the needle-shaped knife with rightleft angle of the endoscope), the knife goes out at the 8 o’clock position between the forceps-held point (10-11 o’clock position) and the hood applied to the mucosa (6 o’clock position). As a result, the knife is applied to the submucosa alone. Furthermore, the movement of the knife in the right or left direction was restricted by means of holding the mucosa with the forceps, which prevents the knife from dissecting too much or perforating because of an accidental slip. The clinical uses in this study revealed that the 2-point fixed ESD enabling performance of the ESD procedure with safety and reliability is a useful auxiliary device for ESD of a rectal tumor. Two-point fixed ESD in the inversion is useful in the stomach and will become useful in the colon. We have begun to perform the 2-point fixed ESD in cases with the intramucosal tumor located between the sigmoid colon and the transverse colon. We will gain more experience with additional cases to establish a safe and reliable ESD procedure not only in the rectum but also in other colonic areas. REFERENCES 1. Darwood RJ, Wheeler JMD, Borlry NR. Transanal endoscopic microsurgery is a safe and reliable technique even for complex rectal lesions. Br J Surg 2009;52:1107-13. 2. De Graaf, EJ, Doornebosch PG, Tetteroo GW, et al. Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: a prospective study. Dis Colon Rectum 2009;52:1107-13. 3. Kobayashi N, Saito Y, Uraoka T, et al. Treatment strategy for laterally spreading tumors in Japan: before and after the introduction of endoscopic submucosal dissection. J Gastroenterol Hepatol 2009;24: 1387-92. 4. Tanaka S, Tamegai Y, Tsuda S, et al. Multicenter questionnaire survey on the current situation of colorectal endoscopic submucosal dissection in Japan. Dig Endosc 2010;22:52-8. 5. Motohashi O, Takagi S, Yonemitsu K, et al. Test production and utility of an ESD assistive device (transparent hood with mucosa gripping channel attached) (for animal studies and clinical use) [Japanese with English abstract]. Gastroenterol Endosc 2006;48:2518-25. 6. Motohashi O, Takagi S, Nakayama N, et al. Safety and utility of new ESD technique using transparent hood with mucosa gripping channel attached [Japanese with English abstract]. Prog Dig Endosc 2006;68:24-6. 7. Motohashi O, Nishimura K, Nakayama N, et al. An ESD procedure using transparent hood with mucosa gripping channel attached [Japanese with English abstract]. Prog Dig Endosc 2007;71:25-7. 8. Motohashi O, Takagi S, Nakayama N, et al. Utility of an ESD procedure of esophagus using assistive device (transparent hood with mucosa gripping channel attached) (an examination of animal studies) [Japanese with English abstract]. Gastroenterol Endosc 2007;49:2819-24. 9. Motohashi O, Nishimura K, Nakayama N, et al. Endoscopic submucosal dissection (two-point fixed ESD) for early esophageal cancer. Dig Endosc 2009;21:176-9. 10. Oyama T, Kikuchi Y. Aggressive endoscopic mucosal resection in the upper GI tract– hook knife EMR method. Minim Invasive Ther Allied Technol 2002;11:291-5.
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11. Yamamoto H, Kawata H, Sunada K, et al. Successful en bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy 2003;35: 690-4. 12. Yahagi N, Fujishiro M, Kakushima N, et al. Endoscopic submucosal dissection for early gastric cancer using the tip of an electrosurgical snare (thin type). Dig Endosc 2004;16:34-8. 13. Saito Y, Emura F, Matsuda T, et al. A new sinker assisted endoscopic submucosal dissection for colorectal tumors. Gastrointest Endosc 2005; 62:297-301. 14. Kobayashi T, Gotohda T, Tamakawa K, et al. Magnetic anchor for more effective endoscopic mucosal resection. Jpn J Clin Onchol 2004;34: 118-23.
Motohashi
15. Imaeda H, Iwao Y, Ogata H, et al. A new technique for endoscopic submucosal dissection for early gastric cancer using an external grasping forceps. Endoscopy 2006;38:1007-10. 16. Yonezawa J, Kaise M, Sumiyama K, et al. A novel double-channel therapeutic endoscope (“R-scope”) facilitates endoscopic submucosal dissection of superficial gastric neoplasms. Endoscopy 2006;38: 1011-5. 17. Uraoka T, Kato J, Ishikawa S, et al. Thin endoscope-assisted endoscopic submucosal dissection for large colorectal tumors (with videos). Gastrointest Endosc 2007;66:836-9. 18. Sakamoto N, Osada T, Shibuya T, et al. Endoscopic submucosal dissection of large colorectal tumors by using a novel spring-action S-O clip for traction (with video) Gastrointest Endosc 2009;69:1370-4.
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1136 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 5 : 2011
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13. Verdonk RC, de Ruiter AJ, Weersma RK. Treatment of complex biliary stones by cholangioscopy laser lithotripsy in 10 patients [In German with English abstract]. Ned Tijdschr Geneeskd 2010;154:A2085. 14. Neuhaus H, Hoffmann W, Gottlieb K, et al. Endoscopic lithotripsy of bile duct stones using a new laser with automatic stone recognition. Gastrointest Endosc 1994;40:708-15. 15. Hochberger J, Hahn EG, Ell C. Laser lithotripsy in the treatment of bile duct calculi. Ther Umsch 1993;50:596-601. 16. Cho YD, Cheon YK, Moon JH, et al. Clinical role of frequency-doubled double-pulsed yttrium aluminum garnet laser technology for removing difficult bile duct stones (with videos). Gastrointestinal Endosc 2009;70:684-9. 17. Chan KF, Vassar GJ, Pfefer TJ, et al. Holmium:YAG laser lithotripsy: a dominant photothermal ablative mechanism with chemical decomposition of urinary calculi. Lasers Surg Med 1999;25:22-37.
Motohashi
18. Vassar GJ, Chan KF, Teichman JM, et al. Holmium: YAG lithotripsy: photothermal mechanism. J Endourol 1999;13:181-90. 19. Draganov PV, Lin T, Chauhan S, et al. Prospective evaluation of the clinical utility of ERCP-guided cholangiopancreatoscopy with a new direct visualization system. Gastrointest Endosc 2011;73: 971-9. 20. Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video). Gastrointest Endosc 2007; 65:832-41. 21. Waxman I, Dillon T, Chmura K, et al. Feasibility of a novel system for intraductal balloon-anchored direct peroral cholangioscopy and endotherapy with an ultraslim endoscope (with videos). Gastrointest Endosc 2010;72:1052-6.
Two-point fixed endoscopic submucosal dissection in rectal tumor (with video) Osamu Motohashi, MD, PhD1 Kanagawa, Japan
Background: Polypectomy, EMR, transanal endoscopic microsurgery, and surgery have been performed as treatments of rectal tumors. Endoscopic procedures are the least-invasive treatments for patients. Complete resection of the lesion is required to prevent its recurrence, and endoscopic submucosal dissection (ESD) has begun to be performed. With increasing requirements for safety, reliability, and simplicity in ESD, we decided to use a 2-point fixed ESD with a transparent hood fitted with a mucosal forceps channel in a case of a rectal tumor and report its usefulness. Objective: To evaluate the safety, simplicity, and usefulness of 2-point fixed ESD performed on a rectal tumor. Design: Case series. Setting: Kanagawa Cancer Center Hospital. Main Outcome Measurements: Safety, simplicity, and usefulness of 2-point fixed ESD performed on a rectal tumor. Results: The mean duration of the procedure was 45 minutes (range 30-110 minutes). Hemostasis and manipulation of the vessels were easy in all patients who did not have postoperative bleeding, perforation, or retroperitoneal emphysema as complications. Limitations: Uncontrolled study. Conclusion: This study of 2-point ESD performed in 12 patients with rectal lesions revealed that the 2-point ESD with a transparent hood fitted with a mucosal forceps channel is a useful auxiliary device, enabling safe and reliable ESD on a rectal lesion.
Polypectomy, EMR, transanal endoscopic microsurgery,1,2 and surgery have been performed as treatments of rectal intramucosal tumors. Endoscopic procedures are the least invasive to patients among the local procedures. In
recent years, endoscopic submucosal dissection (ESD)3,4 has begun to be performed in cases in which necessary and sufficient thorough resection cannot be performed by polypectomy or EMR. Although transanal endoscopic
Abbreviation: ESD, endoscopic submucosal dissection.
Received April 21, 2011. Accepted July 18, 2011.
DISCLOSURE: The author disclosed no financial relationships relevant to this publication.
Current affiliation: Department of Gastroenterology (1), Kanagawa Cancer Center, Kanagawa, Japan.
Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.07.035
Reprint requests: Osamu Motohashi, MD, PhD, Department of Gastroenterology, Kanagawa Cancer Center, 1-1-2, Nakao, Asahi-ku, Yokohama City, Kanagawa, 241-0815 Japan.
1132 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 5 : 2011
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Motohashi
Two-point fixed ESD in rectal tumor
Take-home Message ●
Figure 1. Two-point fixed endoscopic submucosal dissection using a transparent hood fitted with a mucosal forceps channel (Impact Shooter). When dissecting the mucosa, in parallel with elevation of the mucosa held to apply countertraction, the hood is compressed to the intestinal wall to fix the dissected site to keep it under direct vision, and dissection is continuously carried out manipulating bleeding points and the vessels.
Figure 2. Two-point fixed endoscopic submucosal dissection using a transparent hood fitted with a mucosal forceps channel (Impact Shooter). When the mucosal dissection proceeds and no traction is applied only by elevating the held and dissected mucosa, the mucosa-holding forceps are pushed out to apply continuous countertraction for dissection.
microsurgery or laparotomy may also be performed for thorough resection, ESD seems less invasive and the most useful procedure when considering invasiveness to patients. For the goal of a safe and reliable thorough resection of early stomach and esophageal cancers, we performed basic experiments on 2-point fixed ESD to confirm its safety and usefulness, and then we used it in clinical cases and reported its safety and usefulness.5-9 We confirmed the safety, simplicity, and usefulness of 2-point fixed ESD performed for rectal tumors.
METHODS We performed ESD for 12 rectal tumors. Consent to implement 2-point fixed ESD was obtained from patients after sufficiently explaining the procedure’s safety, usefulwww.giejournal.org
Two-point endoscopic submucosal dissection (ESD) with a transparent hood fitted with a mucosal forceps channel, a useful auxiliary device, enables safe and reliable ESD of a rectal lesion.
ness, and possible complications, after obtaining the approval of our institutional review board. The depth of tumor was measured by EUS in all cases. The endoscope used was GIFQ240 (Olympus Optical Co, Tokyo, Japan). A solution of 0.4% sodium hyaluronate (MucoUp; Seikagaku, Tokyo, Japan) with indigo carmine was used for local submucosal injection. In mucosal incision, a short transparent hood (Top Co, Tokyo, Japan) was fitted to the endoscope and a needle-shaped knife (Olympus Optical Co) was used. A high-frequency generator with an automatically controlled system (VIO300D; ERBE Elektromedizin, Tübingen, Germany) was used for incision, dissection, and coagulation. It was set at the autocut mode 80 W/effect 3 during incisions. In dissection of the submucosa by the 2-point fixed procedure, a transparent hood fitted with a mucosal forceps channel, which has been commercialized under the trade name of Impact Shooter (TOP Co), was fixed on the fiber with tape, so that the forceps channel of Impact Shooter was located in the 10 to 11 o’clock direction to the forceps channel of GIFQ240 endoscope in the 8 o’clock direction. A Hot Crow (Olympus Optical Co), which was grasped and released by an assistant, was used as mucosal forceps. To secure the gripping of the mucosa, the muscularis mucosae should be dissected sufficiently. VIO300D was set at forced mode 40 W/effect 3 during the dissection. Bleeding and blood vessels to be manipulated were observed under direct vision, and the needle-shaped knife was stopped near the vessels, which were coagulated by VIO300D set at forced 40 W/effect 3. The larger vessels with a diameter of 1 mm or more and vessels with massive bleeding were manipulated with hemostatic forceps (Olympus Optical Co) setting VIO300D at soft coagulation 60 W.
RESULTS Countertraction was easy to apply to the submucosal dissection site by elevating and turning the dissected mucosa, as shown in Figures 1 and 2. Adequate visual fields were ensured from the beginning to the completion of the dissection without occurrence of perforation. The dissection procedure was safely carried out by using the needleshaped knife. In a 2-point fixed ESD, the grasp is changed several times to ensure effective traction and a good visual field. We reported that 2 cm of the submucosal layer can be Volume 74, No. 5 : 2011 GASTROINTESTINAL ENDOSCOPY 1133
Two-point fixed ESD in rectal tumor
Motohashi
Figure 3. A, Rectal mucosal lesion sprayed with indigo carmine. B, The perimeter of the lesion was incised after locally injecting submucosal hyaluronic acid. C, The mucosa was dissected from the anal side. Applying countertraction by grasping the mucosa with the holding forceps, the mucosa was dissected with a manipulation of vessels ensuring a sufficient visual field. D, The vessels were coagulated by using hemostatic forceps. E, The mucosa was dissected by applying countertraction by holding the adjacent mucosa with the holding forceps and pushing it backward. F, After dissecting the submucosa.
TABLE 1. The data for the 12 cases
Case
Site of tumor
Size, mm
Gross type
Histology
Duration of ESD, min
Result
1
Rb
22
LST-G
Well, m, ly0, v0, HM(⫺), VM(⫺)
60
En bloc
2
Rb
36
LST-G
Adenoma, HM(⫺), VM(⫺)
110
En bloc
3
Rb-Ra
25
LST-G
Well, m, ly0, v0, HM(⫺), VM(⫺)
42
En bloc
4
Rb
40
LST-G
Well, m, ly0, v0, HM(⫺), VM(⫺)
43
En bloc
5
Rb
43
LST-G
Well, m, ly0, v0, HM(⫺), VM(⫺)
40
En bloc
6
Rb
32
LST-NG
Well, sm 300 m, ly0, v0, HM(⫺), VM(⫺)
30
En bloc
7
Rb
25
LST-G
Adenoma, HM(⫺), VM(⫺)
35
En bloc
8
Rb
30
LST-NG
Adenoma, HM(⫺), VM(⫺)
30
En bloc
9
Rb
32
SMT (carcinoid)
Carcinoid, sm, ly0, v0, HM(⫺), VM(⫺)
35
En bloc
10
Ra
40
LST-NG
Well, sm 400 m, ly0, v0, HM(⫺), VM(⫺)
30
En bloc
11
Rs
35
LST-G
Well, m, ly0, v0, HM(⫺), VM(⫺)
40
En bloc
12
Rs
30
LST-G
Adenoma, HM(⫺), VM(⫺)
45
En bloc
ESD, Endoscopic submucosal dissection; Rb, rectum bellow the peritoneal reflection; LST-G, laterally spreading tumor granular type; Well, well-differentiated adenocarcinoma; m, mucosa; ly0, there is no lymphatic invasion; v0, there is not the venous invasion; HM(⫺), horizontal margin negative; VM(⫺), vertical margin negative; en bloc, en bloc resection; Ra, rectum above the peritoneal reflection; LST-NG, laterally spreading tumor nongranular type; SMT, submucosal tumor; sm, submucosa; Rs, rectosigmoid.
1134 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 5 : 2011
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manipulated in both the right and left directions per single grasp.9 Pushing out the forceps as shown in Figure 2 allows 2 cm of ablation of the submucosal layer. Figure 3 shows a 2-point ESD performed in a 40-mm diameter early rectal adenocarcinoma adjacent to the anal verge with abundant vessels, where manipulation of the vessels was also easy. Video 1 (available online at www.giejournal.org) shows a 2-point fixed ESD performed in a 10-mm diameter rectal carcinoid tumor without muscle invasion, where the muscle layer was confirmed and the submucosa immediately above the muscle layer was dissected safely. Table 1 shows the data for the 12 cases, site of tumor, size, gross type, histology, duration of ESD, and result. The mean duration of the procedure was 45 minutes (range 30-110 minutes), and resected specimens were 22 to 42 mm. Margins, both horizontal and vertical, were clear in the 12 cases. Hemostasis and manipulation of vessels were easy in all cases without postoperative bleeding, perforation, or retroperitoneal emphysema.
DISCUSSION ESD is a very useful procedure, although its disadvantages have been pointed out, such as longer procedure time and a higher incidence of complications than those with polypectomy or EMR. Various devices, auxiliary devices, and resection procedures have been developed for ESD.10-17 In ESD of the large intestine with narrow lumen and the thin intestinal wall, however, the procedure by Sakamoto et al18 using spring clips and our 2-point fixed procedure allows simple and easy application of traction. Our 2-point fixed ESD allows expansion of the mucosal dissection surface with the holding forceps to ensure a sufficient visual field throughout the dissection manipulation, facilitating observation/manipulation of the bleeding points and the vessels in the lower rectum with abundant hemorrhoidal veins and vessels. This procedure also has a great advantage in that the 2-point fixing by the holding forceps and the hood can apply countertraction to the submucosa between the 2 points in addition to ordinary countertraction applied by direct compression of the hood. Furthermore, by changing the point of the mucosa held with the forceps and pushing the mucosa being dissected backward with the holding forceps as the dissection proceeds, a sufficient visual field and the distance from the dissection site is constantly ensured to apply constant and sufficient countertraction to the submucosal tissue being dissected, enabling safe and easy dissection of the submucosa. When the lesion extended across the Houston valve, the mucosa adjacent to the valve was dissected easily by pushing out the holding forceps. The 2-point fixed procedure has the additional advantage of keeping a constant distance between the dissection www.giejournal.org
Two-point fixed ESD in rectal tumor
device and the dissection site to suppress the movement of the rectal wall. When the endoscope is swung with the holding point in the mucosa serving as a fulcrum (a manipulation of swinging the needle-shaped knife with rightleft angle of the endoscope), the knife goes out at the 8 o’clock position between the forceps-held point (10-11 o’clock position) and the hood applied to the mucosa (6 o’clock position). As a result, the knife is applied to the submucosa alone. Furthermore, the movement of the knife in the right or left direction was restricted by means of holding the mucosa with the forceps, which prevents the knife from dissecting too much or perforating because of an accidental slip. The clinical uses in this study revealed that the 2-point fixed ESD enabling performance of the ESD procedure with safety and reliability is a useful auxiliary device for ESD of a rectal tumor. Two-point fixed ESD in the inversion is useful in the stomach and will become useful in the colon. We have begun to perform the 2-point fixed ESD in cases with the intramucosal tumor located between the sigmoid colon and the transverse colon. We will gain more experience with additional cases to establish a safe and reliable ESD procedure not only in the rectum but also in other colonic areas. REFERENCES 1. Darwood RJ, Wheeler JMD, Borlry NR. Transanal endoscopic microsurgery is a safe and reliable technique even for complex rectal lesions. Br J Surg 2009;52:1107-13. 2. De Graaf, EJ, Doornebosch PG, Tetteroo GW, et al. Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: a prospective study. Dis Colon Rectum 2009;52:1107-13. 3. Kobayashi N, Saito Y, Uraoka T, et al. Treatment strategy for laterally spreading tumors in Japan: before and after the introduction of endoscopic submucosal dissection. J Gastroenterol Hepatol 2009;24: 1387-92. 4. Tanaka S, Tamegai Y, Tsuda S, et al. Multicenter questionnaire survey on the current situation of colorectal endoscopic submucosal dissection in Japan. Dig Endosc 2010;22:52-8. 5. Motohashi O, Takagi S, Yonemitsu K, et al. Test production and utility of an ESD assistive device (transparent hood with mucosa gripping channel attached) (for animal studies and clinical use) [Japanese with English abstract]. Gastroenterol Endosc 2006;48:2518-25. 6. Motohashi O, Takagi S, Nakayama N, et al. Safety and utility of new ESD technique using transparent hood with mucosa gripping channel attached [Japanese with English abstract]. Prog Dig Endosc 2006;68:24-6. 7. Motohashi O, Nishimura K, Nakayama N, et al. An ESD procedure using transparent hood with mucosa gripping channel attached [Japanese with English abstract]. Prog Dig Endosc 2007;71:25-7. 8. Motohashi O, Takagi S, Nakayama N, et al. Utility of an ESD procedure of esophagus using assistive device (transparent hood with mucosa gripping channel attached) (an examination of animal studies) [Japanese with English abstract]. Gastroenterol Endosc 2007;49:2819-24. 9. Motohashi O, Nishimura K, Nakayama N, et al. Endoscopic submucosal dissection (two-point fixed ESD) for early esophageal cancer. Dig Endosc 2009;21:176-9. 10. Oyama T, Kikuchi Y. Aggressive endoscopic mucosal resection in the upper GI tract– hook knife EMR method. Minim Invasive Ther Allied Technol 2002;11:291-5.
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11. Yamamoto H, Kawata H, Sunada K, et al. Successful en bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy 2003;35: 690-4. 12. Yahagi N, Fujishiro M, Kakushima N, et al. Endoscopic submucosal dissection for early gastric cancer using the tip of an electrosurgical snare (thin type). Dig Endosc 2004;16:34-8. 13. Saito Y, Emura F, Matsuda T, et al. A new sinker assisted endoscopic submucosal dissection for colorectal tumors. Gastrointest Endosc 2005; 62:297-301. 14. Kobayashi T, Gotohda T, Tamakawa K, et al. Magnetic anchor for more effective endoscopic mucosal resection. Jpn J Clin Onchol 2004;34: 118-23.
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15. Imaeda H, Iwao Y, Ogata H, et al. A new technique for endoscopic submucosal dissection for early gastric cancer using an external grasping forceps. Endoscopy 2006;38:1007-10. 16. Yonezawa J, Kaise M, Sumiyama K, et al. A novel double-channel therapeutic endoscope (“R-scope”) facilitates endoscopic submucosal dissection of superficial gastric neoplasms. Endoscopy 2006;38: 1011-5. 17. Uraoka T, Kato J, Ishikawa S, et al. Thin endoscope-assisted endoscopic submucosal dissection for large colorectal tumors (with videos). Gastrointest Endosc 2007;66:836-9. 18. Sakamoto N, Osada T, Shibuya T, et al. Endoscopic submucosal dissection of large colorectal tumors by using a novel spring-action S-O clip for traction (with video) Gastrointest Endosc 2009;69:1370-4.
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