ESD operations are more taboo to be done randomly or arbitrarily.
Different strategies are used for different parts. The main parts are esophagus, stomach, and colorectum. The stomach is divided into antrum, prepyloric area, gastric angle, gastric fundus, and greater curvature of gastric body. The colorectum is divided into colon and rectum. Among them, ESD of antrum greater curvature lesions is an entry-level part, while ESD of gastric angle, cardia, and right colon lesions is more difficult.
The general principle is to consider the low gravity factor and start with the difficult part and then the easy part. Start the incision and stripping from the low gravity position. During the stripping, the stripping should also start from the most difficult part. Esophageal ESD can be performed by push-type incision. The direction of incision and stripping of gastric lesions should be designed in advance. Lesions in the gastric angle, lesser curvature of the gastric body, and prepyloric area can be exposed by traction. Tunnel technology and pocket method are both part of the ESD strategy. ESD-derived technologies include ESTD, EFTR, ESE, POEM, etc. These technologies are also technologies that naturally emerge after the ESD skills are mastered. So ESD is the foundation.
2. ESD operation details
ESD operation details are details under the guidance of the big strategy.
Operational Details
The operation details include marking, injection, peeling, etc.
There are two tricks: one is the controllable knife picking under direct vision (use blind knife picking as little as possible), and the other is the controlled processing of boundaries and small organizations.
Labeling and injection
Electrocoagulation marking is used for marking. Generally, the lesion boundary (2-5 mm outside) is used as the mark. The marking can be done point by point or from large to small. In the end, the interval between the two marking points should be within 5 mm, and it should be visible when the endoscope is close to the field of vision.
To the next marked point. Injection is based on personal habits. After injecting into the submucosal layer, the needle should be slightly withdrawn and then injected again to ensure that the lesion is raised to a sufficient height for subsequent incision and peeling.
Cut
Incision, some parts are cut from far to near or from near to far (push cutting), according to personal habits and the specific parts, it is also necessary to cut from the lowest point of gravity first. The cutting includes shallow pre-cutting and deep pre-cutting. The pre-cutting must be “accurate” and “enough”. The depth of the cutting must be sufficient before the subsequent peeling operation can be carried out. Such as picking up the knife and establishing the angel window. Once entering the angel window,
ESD means to achieve an efficient way. But in reality, not every ESD can enter the Angel’s Window. Many small-area lesions and special lesions ESD basically cannot enter the Angel’s Window. At this time, it mainly depends on the refined knife operation.
Peel off: Peel off the difficult-to-handle part first. When peeling off the submucosal part, it should be done from both sides to the center, forming a V-shaped “key”. The depth of the peripheral pre-cut should be sufficient, otherwise it is easy to peel off beyond the boundary. The less the remaining tissue, the greater the degree of freedom. It is necessary to control the knife to cut the tissue directly, especially the last tissue. If the control is not good, it is easy to cut too much or too little.
How to hold the mirror
There are two ways to hold the ESD scope, both of which control the scope body, knobs, and in-and-out accessories. There are two methods: “left-hand direction + accessories” and “two hands to four hands”. The key principle of holding the scope is to keep the operating field stable and controllable. At present, the two-hand to four-hand method has better scope control stability and is more widely used. Only when the scope is stable can the exposure operation of small tissues + flaps be better handled.
Only with a good mirror holding method can the knife be better controlled. The knife picking technique can better control the direction, the purpose is to stay away from the muscle layer and cut the target tissue. When making an ESD submucosal incision, it is necessary to cut close to the muscle layer, the depth of tissue incision is sufficient, and it is easier to stop bleeding. The most important thing is to ensure that the incision is not too deep or through, and the knife picking technique is the key skill at this time.
Control of vision
Direction control is also reflected in the exposure and control of the field of view. In addition to rotating the knob and the lens body, transparent caps and accessories are also used to reveal the field of view or target tissue, especially the tiny force used to reveal and lift small tissues, which is a very small tissue deformation.
Control the distance of the field of vision. Only when the field of vision is kept at an appropriate distance can it be operated and controlled. If it is too far or too close, it will be difficult to control the knife stably. The subtle movements may seem like no movement, but the tissue already has an inherent deformation force. This is why ESD must use the appropriate distance and appropriate deformation.
The above details, lens holding, and field of view control are the main contents of ESD “lens control”.
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Post time: Jul-14-2025