A 71 year old woman was investigated for weight loss. A CT scan revealed a lesion in the rectum. Hence a flexible sigmoidoscopy was done which showed a 2.5cm sessile polyp in the rectum. The patient did not wish the polyp to be removed at the index procedure. She now attends for an elective colonoscopy to remove the polyp (see video…)
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Hybrid ESD or Knife Assisted Snare Resection combines ESD with snaring and thus simplifies the process of submucosal dissection. This video demonstrates a variation of hybrid ESD. Instead of using an ESD knife, a snare tip was used [1]. The procedure involves using an ESD knife, or snare tip as in this case, to make a circumferential mucosal incision around the lesion, and then the targeted subepithelial lesion is grasped, retracted toward the lumen, followed by snare resection. Resection is aimed for en-bloc removal. Because the lateral margins are clean, we do not need to treat the edges of the defect with SoftCoag or APC.
Retrospective data was collected from a study in Japan conducted in patients with large colorectal polyps with size greater than 20 mm who underwent either ESD (for 137 lesions in 134 patients) or hybrid ESD (27 lesions in 26 patients) [2]. Results showed a shorter procedure time with hybrid ESD (108 ± 59.5 vs. 122 ± 72.2 min) but lower en-bloc resection than the ESD group (66.7 vs. 94.2%). However, there were no significant differences in procedure time, in rates of en bloc resection or complication rates between the two groups [2].
In a meta-analysis, 97 studies evaluated standard technique, and 12 studies evaluated hybrid technique for colorectal lesions suspicious of superficial malignancy showed that R0 and en-bloc resection rate of 60.6 and 68.4%, respectively, for hybrid technique. It was significantly lower than the standard ESD technique with similar adverse event rates [3].
Another recent meta-analysis of 16 studies with 751 patients who underwent hybrid ESD for large colorectal lesions showed an en-bloc resection rate and complication rate of 81.63% (95% Cl: 72.07–88.44) and 7.74% (95% Cl 4.78–12.31), respectively. Subgroup analysis of conventional (N = 1,703) with hybrid ESD (N = 497), procedure time was found to significantly shorter with hybrid ESD (mean difference 18.45 min; p = 0.003), lower complication rate (p = 0.04), but it has lower en bloc resection rate (p less than 0.001) [4].
REFERENCES
1.Frost J, Kurup A, Dawson R, et al, AODTH-001 Snare tip assisted resection (star) of colorectal lesions – a novel technique, Gut 2017;66:A199.
https://gut.bmj.com/content/66/Suppl_2/A199.1
2. Okamoto K, Muguruma N, Kagemoto K, Mitsui Y, Fujimoto D, Kitamura S, et al. Efficacy of hybrid endoscopic submucosal dissection (ESD) as a rescue treatment in difficult colorectal ESD cases. Dig Endosc. (2017) 29 (Suppl. 2):45–52.
https://pubmed.ncbi.nlm.nih.gov/28425649/
3. Fuccio L, Hassan C, Ponchon T, Mandolesi D, Farioli A, Cucchetti A, et al. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc. (2017) 86:74–86.
https://pubmed.ncbi.nlm.nih.gov/28254526/
4. McCarty TR, Bazarbashi AN, Thompson CC, Aihara H. Hybrid endoscopic submucosal dissection (ESD) compared with conventional ESD for colorectal lesions: a systematic review and meta-analysis. Endoscopy. 2021 Oct;53(10):1048-1058.
https://pubmed.ncbi.nlm.nih.gov/32947624/
