P Zormpas, K Dimopoulou, M Spinou, Y Komeda, A Papathanasis, E Nakou, E Voulgari, D Dimitriadis, G Tribonias
{"title":"有肌肉收缩征（MRS+）的巨大结肠肿物的解剖。ESD过程中重力牵引的战略管理可能是解决方案。","authors":"P Zormpas, K Dimopoulou, M Spinou, Y Komeda, A Papathanasis, E Nakou, E Voulgari, D Dimitriadis, G Tribonias","doi":"10.1007/s10151-025-03151-1","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Large polyps have a higher risk of muscle retracting sign (MRS) positivity and display higher incomplete resection rates by endoscopic submucosal dissection (ESD). Techniques used are pocket creation methods and circumferential excision with traction application. This is a pilot study aiming to explore the efficacy and safety of a new ESD technique for MRS+ lesions.</p><p><strong>Methods: </strong>First, a 5-cm-long tunnel is created distally from the lesion, stabilizing the scope and enabling a deeper, flatter dissection plane. As the resection nears the lesion's center with suspected MRS, a local pocket is made for circular access to the muscle retraction tip. Effective gravity management is key for procedure success. Initially working against gravity (or opposite to the direction of gravity) allows better submucosal exposure. Subsequently, patient position is adjusted to allow the specimen to be pulled by gravity towards the dissection line. As a result, the altered position loosens the muscle layer, thereby reducing the tension at the MRS site and ultimately the perforation risk. Finally, a circumferential \"360° dissection\" is performed, with prophylactic coagulation applied at the muscle retraction tip to minimize bleeding from large feeding vessels.</p><p><strong>Results: </strong>Our cases series consists of 18 patients who underwent ESD for MRS+ colonic (3/18) and rectal (15/18) giant (> 4 cm) lesions, with en bloc and R0 resection documented in 16/18(89%) cases. Two patients were referred to surgery because of massive MRS+ and high risk of severe intraprocedural bleeding.</p><p><strong>Conclusions: </strong>This case series demonstrates the efficacy of the aforementioned technique, yielding satisfactory results in the majority of cases-even those without curative resection. The application of this technique not only in giant rectal polyps but also in colonic protruding lesions amplifies the significance of the proposal.</p>","PeriodicalId":51192,"journal":{"name":"Techniques in Coloproctology","volume":"29 1","pages":"124"},"PeriodicalIF":2.9000,"publicationDate":"2025-05-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12116710/pdf/","citationCount":"0","resultStr":"{\"title\":\"Dissection of giant bulky colorectal lesions with muscle retracting sign (MRS+). Strategic management of gravitational traction during ESD might be the solution.\",\"authors\":\"P Zormpas, K Dimopoulou, M Spinou, Y Komeda, A Papathanasis, E Nakou, E Voulgari, D Dimitriadis, G Tribonias\",\"doi\":\"10.1007/s10151-025-03151-1\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Large polyps have a higher risk of muscle retracting sign (MRS) positivity and display higher incomplete resection rates by endoscopic submucosal dissection (ESD). Techniques used are pocket creation methods and circumferential excision with traction application. This is a pilot study aiming to explore the efficacy and safety of a new ESD technique for MRS+ lesions.</p><p><strong>Methods: </strong>First, a 5-cm-long tunnel is created distally from the lesion, stabilizing the scope and enabling a deeper, flatter dissection plane. As the resection nears the lesion's center with suspected MRS, a local pocket is made for circular access to the muscle retraction tip. Effective gravity management is key for procedure success. Initially working against gravity (or opposite to the direction of gravity) allows better submucosal exposure. Subsequently, patient position is adjusted to allow the specimen to be pulled by gravity towards the dissection line. As a result, the altered position loosens the muscle layer, thereby reducing the tension at the MRS site and ultimately the perforation risk. Finally, a circumferential \\\"360° dissection\\\" is performed, with prophylactic coagulation applied at the muscle retraction tip to minimize bleeding from large feeding vessels.</p><p><strong>Results: </strong>Our cases series consists of 18 patients who underwent ESD for MRS+ colonic (3/18) and rectal (15/18) giant (> 4 cm) lesions, with en bloc and R0 resection documented in 16/18(89%) cases. Two patients were referred to surgery because of massive MRS+ and high risk of severe intraprocedural bleeding.</p><p><strong>Conclusions: </strong>This case series demonstrates the efficacy of the aforementioned technique, yielding satisfactory results in the majority of cases-even those without curative resection. The application of this technique not only in giant rectal polyps but also in colonic protruding lesions amplifies the significance of the proposal.</p>\",\"PeriodicalId\":51192,\"journal\":{\"name\":\"Techniques in Coloproctology\",\"volume\":\"29 1\",\"pages\":\"124\"},\"PeriodicalIF\":2.9000,\"publicationDate\":\"2025-05-27\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12116710/pdf/\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Techniques in Coloproctology\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1007/s10151-025-03151-1\",\"RegionNum\":3,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q2\",\"JCRName\":\"GASTROENTEROLOGY & HEPATOLOGY\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Techniques in Coloproctology","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1007/s10151-025-03151-1","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"GASTROENTEROLOGY & HEPATOLOGY","Score":null,"Total":0}
Dissection of giant bulky colorectal lesions with muscle retracting sign (MRS+). Strategic management of gravitational traction during ESD might be the solution.
Background: Large polyps have a higher risk of muscle retracting sign (MRS) positivity and display higher incomplete resection rates by endoscopic submucosal dissection (ESD). Techniques used are pocket creation methods and circumferential excision with traction application. This is a pilot study aiming to explore the efficacy and safety of a new ESD technique for MRS+ lesions.
Methods: First, a 5-cm-long tunnel is created distally from the lesion, stabilizing the scope and enabling a deeper, flatter dissection plane. As the resection nears the lesion's center with suspected MRS, a local pocket is made for circular access to the muscle retraction tip. Effective gravity management is key for procedure success. Initially working against gravity (or opposite to the direction of gravity) allows better submucosal exposure. Subsequently, patient position is adjusted to allow the specimen to be pulled by gravity towards the dissection line. As a result, the altered position loosens the muscle layer, thereby reducing the tension at the MRS site and ultimately the perforation risk. Finally, a circumferential "360° dissection" is performed, with prophylactic coagulation applied at the muscle retraction tip to minimize bleeding from large feeding vessels.
Results: Our cases series consists of 18 patients who underwent ESD for MRS+ colonic (3/18) and rectal (15/18) giant (> 4 cm) lesions, with en bloc and R0 resection documented in 16/18(89%) cases. Two patients were referred to surgery because of massive MRS+ and high risk of severe intraprocedural bleeding.
Conclusions: This case series demonstrates the efficacy of the aforementioned technique, yielding satisfactory results in the majority of cases-even those without curative resection. The application of this technique not only in giant rectal polyps but also in colonic protruding lesions amplifies the significance of the proposal.
期刊介绍：
Techniques in Coloproctology is an international journal fully devoted to diagnostic and operative procedures carried out in the management of colorectal diseases. Imaging, clinical physiology, laparoscopy, open abdominal surgery and proctoperineology are the main topics covered by the journal. Reviews, original articles, technical notes and short communications with many detailed illustrations render this publication indispensable for coloproctologists and related specialists. Both surgeons and gastroenterologists are represented on the distinguished Editorial Board, together with pathologists, radiologists and basic scientists from all over the world. The journal is strongly recommended to those who wish to be updated on recent developments in the field, and improve the standards of their work.
Manuscripts submitted for publication must contain a statement to the effect that all human studies have been reviewed by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in an appropriate version of the 1965 Declaration of Helsinki. It should also be stated clearly in the text that all persons gave their informed consent prior to their inclusion in the study. Details that might disclose the identity of the subjects under study should be omitted. Reports of animal experiments must state that the Principles of Laboratory Animal Care (NIH publication no. 86-23 revised 1985) were followed as were applicable national laws (e.g. the current version of the German Law on the Protection of Animals). The Editor-in-Chief reserves the right to reject manuscripts that do not comply with the above-mentioned requirements. Authors will be held responsible for false statements or for failure to fulfill such requirements.
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