ESD is widely accepted as a minimally invasive treatment option for early gastrointestinal cancer without risk of nodal metastasis. The concept of ESD, mucosal incision and submucosal dissection for en bloc resection, is common among the esophagus, stomach, and colon. However, the ESD approaches are different among the organ.
The esophagus is a thin, narrow, and straight tube. Although scope access is easy and anatomical variation is small, the scope manipulation is limited, and gravity-assisted traction is less effective in the esophagus than other organs. Also, the risk of perforation is higher than the stomach. Less air condition will make submucosal space thicker and softer, which allows us to facilitate esophageal ESD. Clip line traction is beneficial to reduce the ESD procedure time and the risk of intraoperative perforation because of better exposure of the submucosal dissection plane.
The scope operability of gastric ESD is good owing to the wide operation field. Nevertheless, intraoperative bleeding is one of the major concerns of gastric ESD. Also, it is difficult to obtain a close and tangential approach for the target lesion in the stomach in some areas. Experts recommend submucosal dissection just above the muscle layer as the optimal dissection level to solve the issues. It is essential to select an appropriate endoscope. A randomized controlled trial demonstrated that clip line traction-assisted ESD is beneficial to reduce the ESD procedure time in the greater curvature of the middle and upper gastric body.
In colorectal ESD, a pediatric colonoscope is highly recommended to perform careful scope manipulation in narrow and curved operation fields. Patient position is a key point to obtain satisfactory traction and facilitate the procedure. It is recommended to position the target lesion in the opposite direction of gravity. The multidirectional traction devices independently provide traction by being anchored to the other side of the colorectal wall.
It is essential to perform safe and successful ESD considering the anatomical differences.