【技术篇】食管、胃、结直肠高质量ESD操作技巧
How to Perform a High-Quality Endoscopic Submucosal Dissection
如何进行高质量内镜黏膜下剥离术
Gastric polypectomy was developed by Niwa and Tsuneoka et al in 1968, followed by Wolff and Shinya in 1969, who first reported colon polypectomy. In 1971, Karita et al and Dyehle et al reported endoscopic mucosal resection (EMR), and Inoue et al developed EMR using a cap for the treatment of early esophageal cancer.
Niwa和Tsuneoka等人于1968年提出胃息肉切除术，随后Wolff和Shinya于1969年首先报告了结肠息肉切除术。1971年，Karita等人和Dyehle等人报告了内镜下黏膜切除术（EMR），Inoue等人开发了用于治疗早期食管癌的透明帽辅助下EMR。
During EMR, lesions of ≤2 cm in diameter can be resected en bloc; for lesions that are >2 cm, the only options were piecemeal resection or surgery. Endoscopic submucosal dissection (ESD) is a minimally invasive and effective technique for the en bloc resection of early-stage cancers or precancerous lesions in the gastrointestinal tract that are >2 cm in size.
EMR期间，直径≤2 cm的病变可以整块切除；对于> 2 cm的病变，唯一的选择是分片切除或外科手术。内镜黏膜下剥离术（ESD）是一种微创且有效的技术，用于整块切除胃肠道中大于2 cm的早期癌症或癌前病变。
In the 1980s, Hirao et al developed a technique called endoscopic resection with a local injection of hypertonic saline-epinephrine solution. In this procedure, a circumferential incision is made with a needle knife and the submucosa is dissected. Later, in the 1990s, Ono et al at National Cancer Center Hospital developed an insulated tipped knife and started gastric ESD. At about the same time, Oyama started gastric ESD using the prototype of the hook knife, which they created by bending a needle knife, and Yahagi et al. used the snare tip (then the dual knife) for ESD.
20世纪80年代，Hirao等人开发了一种称为内镜切除术的技术，先局部注射高渗盐水-肾上腺素溶液，然后用针刀做一个圆周切口并剥离黏膜下层。20世纪90年代，国立癌症中心医院的Ono等人开发了一种尖端绝缘的电刀，并开始了胃ESD。大约在同一时间，Oyama将针刀弯曲（hook刀原型）进行胃ESD，而Yahagi等人使用圈套器尖端（然后是双刀）进行ESD。
After >20 years, esophageal and colorectal ESD can now be safely performed by experts. However, ESD cannot be performed safely and reliably without appropriate indications, devices, and a well-thought-out strategy. Furthermore, the first step is to properly identify and diagnose lesions using image-enhanced endoscopy that are amenable to ESD. Obtaining adequate histological specimens for detailed pathologic evaluation with high-quality ESD is also a minimum requirement. The purpose of this article is to provide tips and strategies for performing high-quality ESD in the gastrointestinal tract in an easy-to-understand manner.
20多年后，食管和结直肠ESD已经可以由专家安全地进行。但是，如果没有适当的适应症、设备和深思熟虑的策略，无法安全可靠地进行ESD。此外，进行ESD的第一步是使用适合ESD的图像增强内镜正确识别和诊断病变。进行高质量ESD，获得足够的组织学样本，进行详细的病理学评估是最低要求。本文的目的是以一种易于理解的方式介绍在胃肠道中进行高质量ESD的技巧和策略。
Devices and Setting
设备和设置
A number of devices should be available for the conduct of ESD, including a water-jet scope, CO2 insufflation, distal attachments, submucosal injection solution, electrocautery generator, hemostat forceps, and clip device.
进行ESD需要各种设备，包括水射流装置、二氧化碳注入装置、远端附件、黏膜下溶液注射装置、电灼器、止血钳和钛夹。
Esophageal ESD
食管ESD
Esophageal ESD is technically challenging because the narrow lumen of the esophagus makes countertraction owing to gravity less effective, the resected specimen retracts distally, making it difficult to maintain good traction and orientation, and the thin wall of the esophagus increases the risk of perforation. To overcome these challenges, the following are technical tips and tricks to achieve high-quality esophageal ESD.
食管ESD在技术上具有挑战性，因为食管的管腔狭窄，使得受重力影响的反向牵引效果较差，从远端方向取出切除的样本时，难以保持良好的牵引和方向，此外，食管壁较薄增加了穿孔风险。为了克服这些挑战，介绍以下有助于进行高质量食管ESD的技术和技巧。
C-Shaped Incision and Dissection Strategy
C形切开和剥离策略
Because esophageal ESD is normally performed in the left lateral position, the left side is gravity dependent. A partial circumferential incision is preferred to prevent the escape of fluid from the submucosal layer. Therefore, a C-shaped mucosal incision is normally performed followed by submucosal dissection to maintain the lesion away from the water-pooling area, thereby enhancing visualization (Figure 1). In addition, suction of air thickens the submucosal cushion and facilitates a safe and effective mucosal incision.
由于食管ESD通常以左侧卧位进行，而左侧是依赖重力影响的。优选部分圆周切开，以防止液体从黏膜下层流出。因此，通常进行C形黏膜切开，然后进行黏膜下剥离，以使病变远离液体区，从而增强可视化（图 1）。此外，抽吸空气可使黏膜下液垫变厚，有利于安全有效的黏膜切开。
Figure 1 C-shaped mucosal incision and submucosal dissection. This procedure allows the lesion to be maintained away from the water-pooled area, thereby enhancing visualization
图1. C形黏膜切开和黏膜下剥离。该操作使病变远离液体区，使手术视野更清楚。
Clip Line Traction
钛夹挂线牵引
Tissue traction to expose the submucosal space plays a key role during high-quality esophageal ESD. Among several reported traction methods, clip-line traction is commonly used in the esophagus. An Endoclip with a thread is applied to the proximal edge of the lesion. The thread is then pulled through the mouth proximally and gentle pressure is applied to the string; this maneuver invariably optimizes visualization of the submucosal layer during dissection.
牵引组织以暴露黏膜下空间在高质量食管ESD中起着关键作用。在几种报告的牵引方法中，钛夹挂线牵引通常用于食管。将带线的钛夹放置在病变的近端边缘，然后从近端将线从口中拉出，轻微拉动该线，此操作可在剥离过程中保持黏膜下层的手术视野清晰。
A randomized controlled trial by Yoshida et al demonstrated that clip line traction-assisted ESD significantly decreased the procedure time compared with conventional ESD (44.5 minutes vs 60.5 minutes; P < .001). More important, no adverse events, such as intraoperative perforation, were noted using this technique. This traction technique is recommended by Japanese ESD/EMR guidelines. Thereafter, submucosal dissection can be performed by manipulating the knife from inside to outside (Figure 2). This technique facilitates visualization of the left edge of the submucosal plane and muscle direction, allowing for safe and efficient esophageal ESD.
Yoshida等人的一项随机对照试验表明，与常规ESD相比，钛夹挂线牵引辅助下ESD的操作时间显著更短（44.5分钟vs 60.5分钟；P<0 .001）。更重要的是，使用这种技术进行的ESD没有发现不良事件，例如术中穿孔。日本ESD/EMR指南推荐的就是这种牵引技术。之后，可以从内到外利用电刀进行黏膜下剥离（图2）。这种技术有助于观察黏膜下层的左边缘和肌层方向，从而实现安全有效的食管ESD。
Figure 2 Submucosal dissection using the insulated tip knife. Submucosal dissection can be performed by manipulating the knife from the inside to the outside. This technique facilitates the visualization of the edges of the submucosal plane and the muscle direction, and allows safe and efficient esophageal endoscopic submucosal dissection.
图2. 使用尖端绝缘的电刀进行黏膜下剥离。可以从内到外利用电刀进行黏膜下剥离。这种技术有利于观察黏膜下层边缘和肌层方向，进行安全有效的食管内镜黏膜下剥离。
Gastric ESD
胃ESD
With experience and improvement in endoscopists' skills and the availability of various ESD devices, gastric ESD has now become standard for early gastric cancer with a negligible risk of nodal metastasis. A recent multicenter prospective cohort study showed en bloc and R0 resection rates of 99.2% and 91.6%, respectively. However, the procedural time was >120 minutes in 25.9% of patients. The main factors associated with long procedure time were lesions located in the upper or middle one-third of the stomach, a large tumor, and ulcerated lesions. The following techniques are recommended to perform a safe and high-quality gastric ESD and to overcome technical difficulties.
随着经验的累积、内镜医师的技能提高以及越来越多的ESD设备可用，胃ESD现在已成为淋巴结转移风险忽略不计的早期胃癌的标准疗法。最近的一项多中心前瞻性队列研究显示，整块切除率和R0切除率分别为99.2%和91.6%。然而，25.9%的患者操作时间>120分钟。与操作时间较长相关的主要因素是病变位于胃上部或中部三分之一处、大型肿瘤以及溃疡病变。推荐以下技术来进行安全、高质量的胃ESD并克服技术难点。
Appropriate Submucosal Dissection Level
适当的黏膜下剥离
Gastric ESD is technically less demanding than esophageal and colorectal ESD and can be a starting point for nonexpert endoscopists. The relative ease can be attributed to the thick stomach wall and the ability to obtain a stable scope position. However, intraoperative bleeding commonly hinders the procedure owing to the presence of large vessels, particularly in the anterior and posterior walls of the middle and upper one-third of the stomach. These large vessels normally penetrate the muscle layer vertically and then inflow horizontally at the level of the middle submucosal layer, forming a ramified vascular network.
与食管和结直肠ESD相比，胃ESD对技术的要求较低，可以作为非专业内镜医师的起点。胃ESD相对容易是因为胃壁较厚以及内镜位置可保持稳定。然而，由于存在大血管，特别是位于胃中和胃上三分之一的前壁和后壁的大血管，术中出血通常会阻碍手术。这些大血管通常垂直穿透肌层，然后水平流入中间的黏膜下层，形成交错的血管网络。
A layer containing fewer vessels and fibrotic tissue exists just above the muscularis propria. Thus, the appropriate submucosal dissection depth is the avascular stratum immediately above the muscle layer. It is also important to maintain an appropriate dissection level and identify the left and right edges of the submucosa as well as the muscle direction (Figure 3). These techniques allow us to perform safe and efficient gastric ESD and to obtain a high-quality specimen containing the entire submucosal layer.
在固有肌层正上方存在含有较少血管和纤维组织的层。因此，合适的黏膜下剥离深度是肌层正上方的无血管层。确保适当的剥离深度并确定黏膜下层的左右边缘以及肌肉方向也很重要（图3）。这些技术有利于进行安全有效的胃ESD，并获得包含整个黏膜下层的高质量样本。
Figure 3 Appropriate submucosal dissection level. The appropriate submucosal dissection depth is the avascular stratum just above the muscle layer. It is very important to maintain the appropriate dissection level and to identify the left and right edges of the submucosa, as well as the muscle direction during submucosal dissection.
图3. 适当的黏膜下剥离。适当的黏膜下剥离深度是肌层正上方的无血管层。确保适当剥离并确定黏膜下层的左右边缘，以及黏膜下层剥离过程中的肌肉方向非常重要。
Near-Side Approach
从近侧剥离
As mentioned elsewhere in this article, gastric ESD is a battle against intraprocedure bleeding, particularly for lesions located in the middle and upper one-third of the stomach. It is challenging to identify the source of bleeding and subsequent hemostasis efforts if a circumferential mucosal incision is performed from the far to the near side in the retroflexed view.
如上文所述，胃ESD是与术中出血的斗争，特别是对于位于胃中部和上部三分之一的病变。如果在反转内镜时从远侧到近侧进行圆周黏膜切开，那么确定出血源以及进行后续止血是具有挑战性的。
To avoid this challenging situation, the near-side approach was developed. In this approach, a step-by-step incision is made followed by submucosal dissection from the near side to open the incision space quickly and to facilitate hemostasis (Figure 4). The near-side approach combines the use of an insulated and needle-type knife strategies to decrease the risk of making the bleeding points difficult to recognize and does not impair the advantages of the insulated knife as a safe and fast method.
为了避免这种具有挑战性的情况，开发了近侧方法，即先逐步切开，然后从近侧进行黏膜下剥离，以快速打开切口空间，促进止血（图 4）。使用该方法，并使用绝缘刀和针刀，可以降低出血点识别难度，并且不会削弱绝缘刀安全快速的优势。
Figure 4 Near-side approach in gastric endoscopic submucosal dissection. This strategy facilitates visualization of bleeding sources and securing hemostasis.
图4. 胃内镜黏膜下剥离术的从近侧剥离。该方法有利于识别出血源，方便止血。
Colorectal ESD
结直肠ESD
Colorectal ESD is an excellent minimally invasive treatment for early-stage colorectal cancer or precancerous lesions larger than 2 cm, which are usually difficult to resect en bloc by EMR. The main advantage of en bloc resection is that it can accurately assess submucosal and lymphovascular invasion and in case of submucosal invasion, en bloc specimens can reliably determine whether the resection is curative or noncurative. Second, because the risk of local recurrence is extremely low, frequent surveillance for recurrence may not be necessary.
早期结直肠癌或大于2 cm的结直肠癌前病变通常难以通过EMR整块切除，结直肠ESD是治疗这些病变极好的微创疗法。整块切除术的主要优点是它可以准确评估黏膜下浸润和淋巴血管浸润，在黏膜下浸润的情况下，整块样本可以可靠地确定切除是治愈性还是非治愈性。其次，由于局部复发的风险极低，可能没有必要频繁监测复发。
Basic Technique for Colorectal ESD
结直肠ESD的基本技术
1. For ESD, a basic skill involves using the left hand for all angle operations, and this is critical to gain expertise for this procedure. It is not recommended for endoscopists to use the right hand to handle the up-down and right-left knobs.
对于ESD，基本技能涉及使用左手进行所有角度操作，这对于掌握ESD至关重要。不建议内镜医师使用右手来操控上下左右旋钮。
2. Colorectal ESD does not involve a full circumferential incision, but a partial incision that is followed by immediate submucosal dissection (Figure 5, A-D). After the flap is created, it is important to use a short-type tapered hood to adequately penetrate the submucosal layer (Figure 5, D).
结直肠ESD不需要完全的圆周切开，而需要局部切开，然后立即进行黏膜下剥离（图 5，A-D）。在黏膜瓣形成后，重要的是使用短型锥形透明帽充分穿透黏膜下层（图 5，D）。
Figure 5 Basic technique for colorectal endoscopic submucosal dissection. (A, B) If a reversal position is possible, commence endoscopic submucosal dissection with the reverse position. (B) First, inject glycerol or saline to confirm good submucosal elevation, followed by the use of a viscous solution. (C) A partial incision followed by immediate submucosal dissection. (D) After the flap is created, use a short-type ST hood to adequately penetrate the submucosal layer. (E, F). Proceed with partial incision and submucosal dissection in the pocket creation method or tunneling method. (G, H) Once the dissection has progressed to some extent, commence marginal incision and dissection on the opposite side. (I-K) Repeat the process of partial incision and dissection of the submucosa in the same way. (L-O) Once the tunnel is opened in the middle, widen the tunnel to the right and to the left using the insulated tip knife.
图5. 结直肠内镜黏膜下剥离术的基本技术。（A, B）如果可以反转内镜，则在反转内镜下开始内镜黏膜下剥离。（B）首先，注入甘油或生理盐水以保证黏膜下层抬举良好，然后使用粘性溶液。（C）创建部分切口，然后立即进行黏膜下剥离。（D）形成黏膜瓣后，使用短型ST透明帽充分穿透黏膜下层。（E，F）继续进行部分切开，并使用创建口袋法或建立隧道法进行黏膜下层剥离。（G, H）剥离到一定程度时，开始切开边缘并进行对侧剥离。（I-K）以同样的方式重复部分切开和剥离黏膜下层。（L-O）在中间形成隧道后，使用尖端绝缘电刀向左右两侧扩张隧道。
3. If a retroflexed position is possible, it is advisable to commence ESD in this position as it stabilizes the colonoscope and allows for a horizontal approach to the submucosal layer.
如果可以反转内镜，建议在反转内镜下开始ESD，因为这可以稳定结肠镜，并允许从水平方向接近黏膜下层。
4. Proceed with a partial incision and submucosal dissection using either the pocket creation method or tunneling method (Figure 5, E, F), and continue with the dissection without making incisions on both lateral sides until the end of the ESD. In general, dissection of the lower one-third of the submucosal layer is recommended without exposing the muscularis propria. Leaving a thin submucosal layer is also necessary to avoid intraprocedural or delayed perforation.
继续部分切开，并使用创建口袋法或隧道法进行黏膜下剥离（图 5，E，F），在剥离过程中，不要切开两侧，直至ESD。一般来说，建议剥离至黏膜下层的下三分之一，不要暴露固有肌层。留下较薄的黏膜下层也是必要的，可以避免术中穿孔或迟发性穿孔。
5. Once the dissection has progressed to some extent, marginal incision and dissection are commenced at the opposite side (Figure 5, G, H). The process of partial incision and dissection of the submucosal is repeated in the same way (Figure 5, I-K).
剥离到一定程度时，开始切开边缘并进行对侧剥离（图5，G，H）。以同样的方式重复部分切开和剥离黏膜下层（图 5，I-K）。
6. Once the tunnel is open in the middle (Figure 5, L), the tunnel is then widened in either direction using an insulated knife (Figure 5, M-O).
在中间形成隧道（图 5，L）后，使用绝缘电刀向左右两侧扩张隧道（图 5，M-O）。
Technical Tips for Difficult Colorectal ESD
困难结直肠ESD的技术提示
The risk of perforation is estimated to be higher when submucosal fibrosis is severe. In such cases, it is necessary to use the appropriate traction method in addition to the basic strategy as described (Figure 5, M, N). Clips and nylon line traction can be used in the distal colon. In the proximal colon, SO clips or multitraction loops should be used, especially for cecal ESD owing to the thin muscle layer and vertical approach to the submucosal layer. Unlike simple gastric ESD, for colorectal ESD, it is important to repeat submucosal dissection through a partial incision instead of creating a full circumferential incision at the start.
当黏膜下纤维化严重时，穿孔风险可能会增加。在这种情况下，除了所描述的基本策略之外，还需要使用适当的牵引方法（图 5，M，N）。钛夹和尼龙绳牵引可用于远端结肠。对于近端结肠ESD，应使用SO夹或多个牵引环，特别是对于盲肠ESD，因为这里肌层较薄且垂直于黏膜下层。与简单的胃ESD不同，对于结直肠ESD，重要的是通过部分切口重复黏膜下剥离，而不是在开始时就创建完整的圆周切口。
Using the Insulated Tip Knife: Technical Tips
使用尖端绝缘电刀：技术提示
The basic principles of using the insulated knife along with the different steps are detailed in Figure 6. The key to safe and reliable ESD using the insulated knife is to perform submucosal dissection from both sides (left and right) while considering the effect of gravity, and to lift the dissected specimen using the sheath of the insulated knife after confirming the incision line before proceeding with the next dissection.
使用绝缘电刀的基本原理及各个步骤详述于图6。使用绝缘电刀进行安全可靠的ESD的关键是从两侧（左右）进行黏膜下剥离，同时考虑重力的影响，在确认切口线后使用绝缘电刀鞘提起剥离样本，然后进行下一次剥离。
Figure 6 Using the insulated tip. Technical tips. (A, B) The basic principle of insulated tip knife movement is the “out→in” submucosal dissection. Place the tip of the knife on the edge of the submucosa to be resected (A) and move the scope along the muscle layer (B). (C, D) Press the knife against the frontal submucosal layer to secure a safety margin (C), and then step on the coagulation mode or spray coagulation. The knife can then dive into the submucosal layer (D), (E, F) Proceed with the submucosal layer dissection to the right or to the left.
图6. 使用尖端绝缘电刀的技术提示。（A、B）尖端绝缘电刀移动的基本原理是“从外向内”黏膜下层剥离。将电刀的尖端放在要切除的黏膜下层边缘（A），并沿肌层移动内镜（B）。（C、D）将电刀压在黏膜下层前部以确保安全边缘（C），然后进行电凝或喷射电凝。据此，电刀可以进入黏膜下层（D），（E、F）继续向右或向左剥离黏膜下层。
Conclusions
结论
Herein, we have described tips for efficient and appropriate ESD of the esophagus, stomach, and colon. A high-quality ESD enables detailed pathologic diagnosis and reliable completion even in situations with severe fibrosis or those lesions in a difficult anatomic location. It is essential to apply this technique after detecting lesions that are amenable to ESD by image enhanced endoscopy and appropriately diagnose intramucosal neoplasia using magnification endoscopy. Finally, it is equally important to prevent complications but take appropriate measures in the event of a complication.
本文描述了对食管、胃和结肠进行有效适当ESD的技巧。即使在严重纤维化或病变位置难以剥离的情况下，高质量ESD也能进行详细的病理诊断，并可靠地完成。如果图像增强内镜发现病变适合ESD，且放大内镜正确诊断了黏膜内瘤变，那么进行高质量ESD至关重要。最后，预防并发症同样重要，在出现并发症时要采取适当措施。
Reference:
Saito Y, Abe S, Inoue H, Tajiri H. How to Perform a High-Quality Endoscopic Submucosal Dissection. Gastroenterology. 2021 Aug;161(2):405-410. doi: 10.1053/j.gastro.2021.05.051. Epub 2021 Jun 2. PMID: 34089735.
声明：
本文翻译为来自柳叶新潮团队编辑整理，仅供学习交流，欢迎个人转发至朋友圈。