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Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Oct 10, 2015; 7(14): 1114-1128
Published online Oct 10, 2015. doi: 10.4253/wjge.v7.i14.1114
Colorectal endoscopic submucosal dissection: Recent technical advances for safe and successful procedures
Katsumi Yamamoto, Tomoki Michida, Tsutomu Nishida, Shiro Hayashi, Masafumi Naito, Toshifumi Ito
Katsumi Yamamoto, Masafumi Naito, Toshifumi Ito, Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka 553-0003, Japan
Tomoki Michida, Third Department of Internal Medicine, Teikyo University Medical Center, Chiba 299-0111, Japan
Tsutomu Nishida, Shiro Hayashi, Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka 560-8565, Japan
Author contributions: Yamamoto K designed the clip-flap method and planned and wrote the manuscript; Michida T, Nishida T, Hayashi S, Naito M and Ito T reviewed this article and contributed valuable comments.
Conflict-of-interest statement: Authors have no conflict of interests to declare for this article.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Katsumi Yamamoto, MD, PhD, Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, 4-2-78 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan. yamamoto-kts@umin.ac.jp
Telephone: +81-6-64415451 Fax: +81-6-64458900
Received: May 27, 2015
Peer-review started: May 29, 2015
First decision: July 6, 2015
Revised: August 27, 2015
Accepted: September 7, 2015
Article in press: September 8, 2015
Published online: October 10, 2015
Processing time: 144 Days and 10.3 Hours
Abstract

Endoscopic submucosal dissection (ESD) is very useful in en bloc resection of large superficial colorectal tumors but is a technically difficult procedure because the colonic wall is thin and endoscopic maneuverability is poor because of colonic flexure and extensibility. A high risk of perforation has been reported in colorectal ESD. To prevent complications such as perforation and unexpected bleeding, it is crucial to ensure good visualization of the submucosal layer by creating a mucosal flap, which is an exfoliated mucosa for inserting the tip of the endoscope under it. The creation of a mucosal flap is often technically difficult; however, various types of equipment, appropriate strategy, and novel procedures including our clip-flap method, appear to facilitate mucosal flap creation, improving the safety and success rate of ESD. Favorable treatment outcomes with colorectal ESD have already been reported in many advanced institutions, and appropriate understanding of techniques and development of training systems are required for world-wide standardization of colorectal ESD. Here, we describe recent technical advances for safe and successful colorectal ESD.

Keywords: Endoscopic submucosal dissection; Colorectal tumors; Mucosal flap; Clip-flap method

Core tip: Endoscopic submucosal dissection (ESD) is useful for en bloc resection of large colorectal tumors but is a technically difficult procedure. Good visualization of the submucosal layer is crucial for safely and successfully performing colorectal ESD because poor visualization of the operative field may result in perforation or unexpected bleeding. Creating a mucosal flap solves these problems; however, it is the process that requires the most skill in this procedure. To facilitate the mucosal flap creation, we developed the clip-flap method, which is simple and very effective for colorectal ESD. We described recent advances in colorectal ESD techniques and devices.