Colorectal endoscopic submucosal dissection up-to-date

Figure 1 Flowchart about Japan NBI Expert Team subtypes and the correlation with the histological findings and management. CT: Computed tomography; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; JNET: Japan NBI Expert Team; PET: Positron emission tomography.

Figure 2 Representative case of colorectal endoscopic submucosal dissection. A: Flat-elevated laterally spreading tumor in the rectum with a nodule in white-light imaging; B: Virtual chomoendoscopy assessment (Blue light imaging); C: Magnifying view assessing the nodule at the center of the lesion revealing enlarged crypts and slightly dilated and tortuous microvessels; D: Markings were placed with diathermic knife surrounding the lesion; E: Mucosal incision is performed in the anal side of the lesion; F: Pocket-creation method is initiated from anal side to oral side of the lesion; G: Pocket-creation method is advanced. Note that the dissection plane is at the deep submucosal layer, close to the muscularis propria layer; H: Perforating vessels should be identified, isolated and then coagulated with the knife or hemostatic forceps before transection; I: After endoscopic submucosal dissection is finished the defect should be closely inspected for blood vessel coagulation and closure of any muscularis propria layer damage with endoclips; J: The specimen should be fixed for histological assessment; K: The specimen measured 47.2 mm.

Figure 3 Histopathological evaluation. A: Histological assessment revealed lateral and deep free margins; B: Histology revealed an intramucosal adenocarcinoma without lymph-vascular invasion, findings consistent with a potentially curative resection. (Courtesy, Dr. Bernardo F P Ricardo, Department of Pathology of Hospital Mater Dei Contorno).

Figure 4 Criteria for a curative and non-curative procedure. CT: Computed tomography; ESD: Endoscopic submucosal dissection; PET: Positron emission tomography.

Figure 5 Laterally spreading subtypes and the corresponding risk of submucosal invasion. ESD: Endoscopic submucosal dissection; LST: Laterally spreading tumor; LST-G: Granular laterally spreading tumor; LST-NG: Non-granular laterally spreading tumor.