Understanding Hybrid ESD

In the mid-90s, Japanese endoscopists developed the technique for performing mucosal incisions around lesions, now known as complex Endoscopic Mucosal Resections (EMRs).¹ In the early 2000s, the concept of mucosal incisions associated with Endoscopic Submucosal Dissection (ESD) was created.² Both procedures have grown in popularity due to the ability to use R0 resection for early gastrointestinal cancer. 

Since the early 2000s, the ESD strategy has gone through a wide range of developments and refinements. These resections have developed from superficial gastric cancers to the removal of esophageal and colonic lesions.^3,4

Because ESD is a challenging and demanding procedure, newer hybrid approaches are starting to make their way into the operating room.

The goal of any ESD is to achieve en bloc resection, which isn’t always the case with EMR. The technical aspects of colorectal ESD are especially challenging, as endoscopic maneuverability may be poor, imposing a longer procedure time with a higher risk of adverse events.⁵ An effective and safe alternative for overcoming some of these barriers is combined snare resection after partial submucosal dissection, known as hybrid ESD (H-ESD). However, limited data on H-ESD renders its comparison with conventional ESD (C-ESD) difficult.⁶

There are various techniques to ESD. A full dissection of the submucosal layer and en bloc resection of the lesion is considered a Conventional ESD. A Rescue Hybrid ESD is a planned conventional ESD where the submucosal layer was not dissected enough for proper snaring due to being faced with difficult situations, such as severe fibrosis, prolonged procedure time, large perforations, massive bleeding, and unstable vital signs. When the submucosal layer is consistently dissected and snared after the partial ESD procedure, this is known as the Hybrid ESD.⁷

In their study of 137 lesions, Okamoto et al.⁸ identified a pool of 27 for which planned ESD was switched to a hybrid technique owing to procedural challenges, with the approach classified as rescue treatment. Although the procedures were shorter in the rescue group, the en bloc resection rate dropped significantly from 94.2% to 66.7%.⁸

In consideration of this, Yamaguchi et al.⁹ thoroughly investigated the significance of rescue H-ESD (RH-ESD), standard H-ESD, and C-ESD in their recent article.

Their findings show that en bloc resection rate is of the utmost importance because removing the entire lesion confirms that any suspicious tissue is also removed. Among the total of 364 colorectal ESD procedures, the en bloc resection rate increased significantly with a hybrid approach:

• Rescue Hybrid ESD approach: 48.6% en bloc resection
• Hybrid ESD approach: 78.3% en bloc resection
• Conventional ESD approach: 97.7% en bloc resection

This data shows that when removing any attempt at a rescue approach, a planned Hybrid ESD has a higher en bloc resection percentage than previously thought. 

The Hybrid ESD approach is faster and less technically demanding than the conventional approach. It’s an optimal strategy for endoscopists who are still on the learning curve of submucosal dissection and offers a relatively low incidence of local recurrence. 

When opting for the Hybrid ESD approach, it is important to trim and dissect the submucosal layer as much as possible, allowing proper snaring. 

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_{¹Pontual JPS, Bestetti AM, de Moura DTH. Understanding hybrid endoscopic submucosal dissection subtleties. Clin Endosc. 2023 Nov;56(6):738-740. doi: 10.5946/ce.2023.195. Epub 2023 Nov 1. PMID: 37915190; PMCID: PMC10665629.
²Yahagi N. Development of colorectal endoscopic submucosal dissection. Dig Endosc 2022;34 Suppl 2:95–98.
³Ko BM. History and development of accessories for endoscopic submucosal dissection. Clin Endosc 2017;50:219–223.
⁴Sagae VM, Ribeiro IB, de Moura DT, et al. Endoscopic submucosal dissection versus transanal endoscopic surgery for the treatment of early rectal tumor: a systematic review and meta-analysis. Surg Endosc 2020;34:1025–1034.
⁵Turiani Hourneaux de Moura D, Aihara H, Jirapinyo P, et al. Robot-assisted endoscopic submucosal dissection versus conventional ESD for colorectal lesions: outcomes of a randomized pilot study in endoscopists without prior ESD experience (with video). Gastrointest Endosc 2019;90:290–298.
⁶Wang XY, Chai NL, Zhai YQ, et al. Hybrid endoscopic submucosal dissection: an alternative resection modality for large laterally spreading tumors in the cecum? BMC Gastroenterol 2021;21:203.
⁷Tanaka S, Kashida H, Saito Y, et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015;27:417–434.
⁸Okamoto K, Muguruma N, Kagemoto K, 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.
⁹Yamaguchi H, Fukuzawa M, Kawai T, et al. Significance of rescue hybrid endoscopic submucosal dissection in difficult colorectal cases. Clin Endosc 2023;56:778–789.}