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ESD operation in Large Flat Colonic Polyps Treatment
Different from EMR operation, ESD operation could treat more complicated polyps cases. It contains 5 standard steps including mark, mucosa lifting, margin incision, dissection and trauma management. In Japan, ESD operation has been regarded as the standard for endoscopic dissection of upper GI malignant tumor.For tumors atlower GI, as colon has the features of pathological and specific organs, ESD is still not listed as the standard treatment though it is mostly adopted. Another reason is the difficulties in controlling devices through colonoscopy.
To assess the clinical efficacy and safety of ESD for large flat colonic polyps, between August 2006 and March 2007, 18 patients with large flat colonic polyps were treated by ESD with needle knife after chromoscopy, magnification and endoscopic ultrasonography examination. Among 18 large flat colonic polyps, 11 cases were located in rectum, 3 cases in sigmoid colon, 1 case in descending colon, 1 case in hepatic flexure of colon, 1 case in ascending colon and 1 in caecum. Polyps ranged from 2.0 to 5.2cm and a mean resected size was 3.1cm.
Operation Device Introduction
Olympus CF-Q260 electronic Colonoscope. NM-4L-1 injection needle, FD-1U-1 hot biopsy forceps, HX-610-135 hemoclip, ERBE ICC-200 high frequency needle and APC 300 Argon ion coagulator. Olympus KD-1L-1 needle knife (the front 1mm tip of the knife is bent like Hook knife).
The polyps, proved by dying, magnifying endoscope and microprobe, are confirmed to grow from mucosa layer. Transparent cap is added on the tip of the endoscope.
1. Mark: mark on the margin of the lesion by needle knife tip every 0.5~1 cm around the margin.
2. Sub-mucosa injection: inject sodium chloride fluid into the sub mucosa to elevate the lesion from the muscle layer.
3. Margin incision: pre-cut the surrounding mucosa of the lesion margin. Use needle knife under EndoCut Mode. Cut the mucosa in the oral direction firstly and then cut the mucosa in the rectum direction.
4. Polyps dissection: use needle knife with bended tip to dissect the connective tissue of the submucosa beneath the lesion under the EndoCut Mode.
5. Trauma management: check the trauma. Use argon plasma coagulation (APC) on the vessels which appear after dissection. Close the trauma with clip if necessary. Use compound carraghenates suppositories to protect the trauma.
Operation advantages and cautions:
Comparing with EMR, ESD treatment has these advantages.
1. It is able to dissect large polyps, that is more than 2.5cm, in complete body for psychological test.
2. It could also reduce the rate of re-occurrence of the polyps. In our study, 12 cases went back to hospital for endoscopic examination 2 months after operation. Trauma was healed without polyps residue. The patients were visited after 4.2 months in average, and there was no case reoccurrence.
3. It is in the real sense minimally invasive therapy for GI polyps.
Bleeding and perforation are the main complications of ESD. Once there is bleeding in the operation, it takes long time to stop bleeding and this process is easy to lead to perforation. Therefore, consciously stop bleeding in ESD is very crucial for operation success.
There are various methods to stop bleeding in ESD operation:
1. During the process on mucosa injection, try not to inject on the vessels under mucosa.
2. When the vessel around the lesion margin is incised, prepare hot biopsy forceps for coagulation. Or use the needle knife to stop bleeding.
3. If bleeding happens during mucosa dissection procedure, use frozen saline to wash the trauma. When the bleeding point is seen clearly, use needle knife or hot biopsy forceps to stop bleeding.
4. If the above methods fail, use hemoclip to close the trauma and stop bleeding.
The worry and fear towards perforation is one reason that limits the development of ESD. If endoscopic inspection is made before ESD, the perforation is small and the peritonitis is not serious. For small perforation that is detected during operation, it could be closed by hemoclip. After operation, food inhibition and antibiotic in vein could be taken. In this way, the patient does not need to take open surgery.
For lesions at lower rectum, perforation would allow the gas in the enteric cavity to enter peritoneal spaces, then peritoneal emphysema, mediastinal emphysema, pneumothorax, scrotal emphysema, subcutaneous emphysema may happen.
Keep your vision clear during the dissection process is the most important in operation to prevent perforation happening. Clinically, the physician should watch whenever there is bleeding point, repeatedly make under mucosa injection and keep the dissection under mucosa. There are all useful methods to prevent perforation.
With the proper procedures, the mean ESD procedure time of the above 18 cases was 75 min (range from 55 to 115 min). None of patients had massive hemorrhage during ESD which couldn’t be controlled under colonoscope and had delayed bleeding after ESD. One patient had subcutaneous emphysema due to deep tearing of mucosa layer and recovered after several days’ conservative treatment. Perforation occurred in 1 case during the dissection of the lesions which was typically closed by metallic endoclip without surgical treatment. Twelve cases were followed up after ESD with confirmed healing of the artificial ulcer. No residue or re-occurrence was found.
(From China Practical Surgical Magazine, 8th Issue, August, 2007)