Welcome to the Gastroenterology and Endoscopy podcast. In this episode we'll be discussing an innovative hybrid technique that combines aspects of endoscopic submucosal dissection and endoscopic mucosal resection to improve resection of difficult gastrointestinal lesions. Endoscopic resection has become a mainstay for removing many GI tumors and lesions without surgery. Experts like ESD and EMR allow dissection and resection of superficial neoplastic tissue, but challenges exist fully resecting certain flat, slippery and large lesions. To overcome these limitations, experts pioneered an ESD-EMR hybrid approach, also called pre-cutting EMR. This strategy leverages the strengths of both ESD and EMR to optimize complete resection of tricky colorrectal, esophageal, gastric and duodenal growths. Esd involves first lifting the lesion off the deeper muscle layers using submucosal fluid injection to prevent perforation. An electrosurgical knife then dissects the submucosa and cuts around the lesion for end block removal. Esd enables histologic assessment of 100% of the specimen margins. Emr resects lesions piecemeal after elevating them off the muscle using submucosal lift. A snare placed around the raised lesion applies electrocautery to remove the tissue above the cushion. Larger growths are divided into sections for serial EMR. But ESD and EMR have limitations resecting certain flat, slippery lesions.

Laterally spreading colorrectal polyps often slip out of EMR snares, causing incomplete removal and recurrence. Serrated polyps also evade snares due to subtle mucosal surfaces preventing lift. This is where the hybrid ESD-EMR technique comes in. It involves four key steps. First, lift the lesion by injecting specialized fluid into the submucosa. Next, use the tip of a snare to pre-cut a shallow groove around the lesion through the upper mucosal layer. This exposes the margins. If needed, further dissect the submucosa under the lesion with the snare tip to minimize the resection base. Finally, position the opened snare into the pre-cut groove and resect the lesion on block with EMR.

Making a custom groove enables complete snare capture and resection of even challenging flat lesions. Lateral and deep margins can be thoroughly assessed to confirm complete removal. This hybrid approach is useful for laterally spreading colorrectal polyps where the pre-cut groove enables on block lateral margin resection, decreasing recurrence compared to piecemeal EMR. Large flat adenomas that cannot be resected fully with standard EMR, the pre-cutting facilitates, on block removal, slippery, serrated polyps that evade snare capture. The groove allows complete resection of these pre-malignant lesions and small subepithelial tumors like lipomas, where the combined ESD and EMR technique enables resection of larger growths While limitations exist. This innovative ESD-EMR hybrid strategy expands the range of lesions treatable by endoscopic resection while minimizing recurrence and perforation risks. I hope you enjoyed this podcast explaining the novel ESD-EMR hybrid technique for improving resection of challenging gastrointestinal lesions. Be sure to subscribe for more GI and endoscopy insights.