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Endoscopic submucosal dissection (ESD) is an innovative endoscopic technique used for excision of superficial gastrointestinal neoplasms. Compared to endoscopic mucosal resection (EMR), ESD has the potential to achieve a high rate of en bloc resection, regardless of tumor size, leading to precise histological evaluation of specimen margins and a lower recurrence rate observed at long-term follow-up. Although ESD was first utilized for resection of superficial gastric neoplasms, it is popularly being used as a standard treatment modality for management of superficial colorectal neoplasms 20 mm in diameter for lesions where en bloc resection using standard EMR is difficult. However, limitations to its use in routine clinical practice include technical difficulties, significant time required to learn the technique, long procedure time, and increased risks of associated complications, such as postoperative bleeding and perforation. Reportedly, the colorectal ESD-induced perforation rate is as high as 1.4% to 20.4% owing to the anatomy of the large intestine with its narrow lumen, thin walls, tortuous structure, and redundancy. Standard EMR is considered a more reliable, easier, safer, and quicker technique compared to a full ESD. Colorectal ESD is not very popular and is rarely performed in countries other than Korea and Japan due to lack of universal acceptance. Given that the primary goal of endoscopic resection for colorectal neoplasms is to prevent spread of colorectal cancer and reduce cancer-related mortality, en bloc resection is preferred, when feasible, to maximize the accuracy of histological assessment and to reduce the risk of local recurrence ensuing from incomplete excision that might occur with use of piecemeal methods. Therefore, simplification of the ESD technique or improvements in EMR through use of modified techniques and development of newer devices is warranted because curative en bloc resection is often the best management for large superficial colorectal tumors and early invasive colorectal cancers. Several modified EMR and simplified ESD techniques have been proposed to fill the gap between standard EMR and full ESD techniques. The scratch-stick-method proposed by Nomura et al. is one of the first advanced EMR techniques to be introduced. Using the tip of the snare, the electrocautery makes a scratch in the normal mucosa oral to the lesion. After the tip of the snare is fixed into the scratch to stabilize the polypectomy snare, an EMR is performed. The complete resection rate achieved using this scratch-stick-method for colorectal tumors ≥20 mm was observed to be higher than that of standard EMR (65% vs. 35%). No severe complications and no recurrence at Received: July 4, 2017 Accepted: July 10, 2017 Correspondence: Sung Noh Hong Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82-2-3410-3409, Fax: +82-2-3410-6983, E-mail: gisnhong@gmail.com

clinical endoscopy

Filling the Technical Gap between Standard Endoscopic Mucosal Resection and Full Endoscopic Submucosal Dissection for 20–35 mm Sized Colorectal Neoplasms