Endoscopic submucosal dissection for premalignant lesions and noninvasive early gastrointestinal cancers

Figure 1 Endoscopic submucosal dissection procedure for adenoma with high grade dysplasia at antrum. A: Endoscopic view flat adenoma at antrum; B: Cutting of the first piece of the lesion which was decided to be extracted in two pieces; C: Submucosal dissection of the first piece; D: Cutting of the second piece of the lesion; E: Submucosal dissection of the second piece; F: Endoscopic view after the lesion is being extracted; G: Microscopic view of the lesion; H: Histology; Adenoma including fields of marked glandular atypia and distortion (HE × 20); I: Endoscopic view ten weeks after the procedure.

Figure 2 Endoscopic submucosal dissection procedure for adenoma with high grade dysplasia at cardia. A: Adenoma at cardia; B: View of the lesion from esophageal aspect; C: Endosonographic image of the lesion; D, E: Marking the borders of the lesion with needle knife and lifting it; F, G: Cutting the lesion circumferentially with endo-cut above Z line, in retroflexion; H: Dissection of the submucosal area; I: Appearance of the mucosa after the lesion being extracted; K: Microscopic view of the lesion; L: Histology: mucosa, muscularis mucosa and superficial submucosa of stomach (HE × 20). Adenoma structure including adenomatous epithelium formed by irregular glands at mucosa; M: Endoscopic view six months after the procedure.

Figure 3 Endoscopic submucosal dissection procedure for tubulovillous adenoma with high grade dysplasia at sigmoid colon. A: Adenoma at sigmoid colon; B: Endosonographic image of tubulovillous adenoma; C-D: Lifting the lesion; E: Cutting with endo-cut; F: Coagulation of submucosal vein with hemostatic forceps; G: Mini perforation during the procedure; H: Fixing perforation with hemoclip; I: Hemoclip application to control bleeding that occured after cutting the lesion circumferentially with endo-cut; K: Appearance of the mucosa after the lesion being extracted; L: Microscopic view of the lesion; M: Histology; tubulovillous adenoma with high grade dysplasia (HE × 40).

Figure 4 Endoscopic submucosal dissection procedure for pseudo-depressed type lateral spreading tumor with high grade dysplasia at rectum. A: Pseudo-depressed type lateral spreading tumor at rectum; B: Cutting the lesion circumferentially with endo-cut; C, D: Submucosal dissection with semipermeable cap; E: Endoscopic view just before completing submucosal dissection; F: Appearance of the mucosa after the lesion being extracted; G: Microscopic view of the lesion; H: Histology; tubulovillous adenoma including fields of focal pattern loss and dysplasia (HE × 20); I: Endoscopic view ten weeks after the procedure.