Different endoscopic submucosal dissection techniques: a tailored approach.

Background and Aims: Endoscopic submucosal dissection (ESD) is an advanced, minimally invasive technique for the removal of GI lesions, offering several advantages over traditional methods, such as EMR. Although ESD facilitates en bloc resection and allows for precise pathologic assessment, its technical complexity underscores the need for tailored approaches. This video aims to provide a detailed explanation of the technical aspects of various ESD methods and to demonstrate the applicability of each technique in different clinical scenarios. Methods: This video provides a comprehensive, step-by-step technical review of classic ESD techniques as well as various ESD modifications. The most common modifications include pocket, modified pocket, bridge, multiple tunnels, hybrid, and traction-assisted ESD. Limitations of each method are discussed, and how to overcome these limitations using other methods is also addressed. Results: Pocket ESD is the most commonly used modification, creating a tunnel beneath the lesion. Modified pocket ESD follows a similar approach but combines the steps of dissection and making the circular incision simultaneously. Both methods are considered classic for esophageal lesions, although they also can be applied in colorectal ESD. Bridge ESD involves starting from the cecal side of the lesion, followed by the oral or anal side, and then connecting both sides. This approach provides effective countertraction and is particularly useful in rectal ESD, though it remains applicable in other locations. For circumferential lesions, the multiple tunnel technique is the optimal option for management. Hybrid ESD combines EMR and ESD techniques. Traction-assisted ESD, using simple tools such as a clip in line or band, can be applied in conjunction with all of the aforementioned methods. Conclusions: The adoption of a tailored ESD approach is crucial for improving procedural success rates, enhancing patient outcomes, and expanding the applicability of ESD to a broader range of complex lesions.