The scarring in the submucosa means that there is difficulty in finding the submucosal plane, a failure to lift, a ‘diffuse’ lift in which fluid tracks laterally rather than resulting in focal elevation, and a rapid loss of any lift achieved. Techniques to counter these problem include the use of the dynamic injection technique,17 the use of thinner-bore injection needles (25 G rather than 21 G or 23 G), and the use of more viscous and longer-lasting injection solutions including colloids, eg, gelofusine,18 or sodium hyaluronate.19 Other viscous solutions, eg, hypromellose or glycerol,

click here might also be considered.19 Nevertheless, even with these advantages, lift in colitic lesions is often suboptimal. En bloc resection of the lesion is preferable to allow precise pathologic assessment and minimize residual dysplasia or recurrence. ESD offers this possibility and is technically possible in colitis. However, the comprehensive submucosal fibrosis increases the procedural risks and reduces R0 resection rates even for superspecialist experts in ESD (Figs. 3 and 4). Use of small-caliber-tip transparent

hoods can help in severe fibrosis, and there is often a need to use sharp-tipped needle knives to cut fibrotic bands, albeit at the risk of a loss of hemostatic capacity (Video 1).20 The adaptation BAY 73-4506 ic50 of ESD concepts may offer some advantages to less-experienced Western endoscopists. Two concepts may be helpful.21 The first is the so-called Endoscopic Mucosal Resection with snaretip incision (SI) that can be

possible for smaller lesions up to 20 mm in which submucosal scarring is not so severe and some lift is possible. Here, after lifting, the snare tip is used to make a small incision on the oral side of the lesion. This small hole is used to anchor the snare tip to allow definite edge capture and additional downward pressure with the snare in a situation of limited lift, increasing the chances on an en bloc snare resection. The second is the use of mucosal incision, the first Sitaxentan step in full ESD.21 Here the use of an endoknife to carefully incise a groove around the lesion is performed before an attempt at conventional en bloc or piecemeal EMR. The edge of the snare is then placed in this marginal groove for resection. Both these concepts improve grip on the lesion edge by the snare and allow a clean resection margin at the edge of the lesion. In colitis, once resection starts, the lesion margin can be difficult to see, so marginal incision can assist here as well. This procedure is sometimes described as simplified or hybrid ESD and in some situations represents a good compromise between the time, risk, and difficulty of full ESD, yet fulfills the need for resection with a clear margin. Standard snares can be used for EMR in colitis; however, as alluded to above, scarred, flat lesions with poor lift can be difficult to engage into the snare.