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)

Published:March 25, 2019DOI:

      Background and Aims

      Endoscopic submucosal dissection (ESD) is becoming the preferred method for certain early GI malignancies; however, very few U.S. physicians have adopted this technique. This is in part because of the technically challenging nature of the procedure and the long learning curve. Several endoscopic robots are under development to address these complexities.


      This is a randomized, controlled, pilot study comparing conventional ESD versus robotic-assisted ESD (RESD) in an ex vivo bovine colon model. Five endoscopists without prior ESD or RESD experience were randomized into 2 groups (group 1, RESD after ESD; group 2, RESD before ESD). A standard template was used to create colonic lesions. The primary outcome was completeness of en bloc resection. Secondary outcomes included differences in procedure time, perforation rate, muscle injury rate, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) to assess physical and mental workload.


      Five endoscopists each performed 4 tissue resections (2 RESD and 2 ESD), for a total of 20 procedures. Complete en bloc resection was achieved in all RESD and in 50% of ESD (P < .0001). The perforation rate was higher in the ESD group (60% vs 30%, P = .18). Total procedure time (34.1 vs 88.6 min, P = .001) and dissection time (27.8 vs 79.4 minutes, P = .002) were lower for RESD. The NASA-TLX also revealed better results for RESD (28.4 vs 47.4, P = .01).


      RESD appears to be more effective in obtaining en bloc resection with shorter procedure times and a lower perforation rate compared with conventional ESD as performed by ESD novices. RESD is also associated with lower physical and mental workloads.

      Graphical abstract


      ESD (endoscopic submucosal dissection), NASA-TLX (National Aeronautical and Space Administration Task Load Index), RESD (robotic-assisted endoscopic submucosal dissection)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gotoda T.
        • Kondo H.
        • Ono H.
        • et al.
        A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases.
        Gastrointest Endosc. 1999; 50: 560-563
        • Daoud D.C.
        • Suter N.
        • Durand M.
        • et al.
        Comparing outcomes for endoscopic submucosal dissection between Eastern and Western countries: a systematic review and meta-analysis.
        World J Gastroenterol. 2018; 24: 2518-2536
        • Fuccio L.
        • Repici A.
        • Hassan C.
        • et al.
        Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection.
        Gut. 2018; 67: 1464-1474
        • Patel N.
        • Patel K.
        • Ashrafian H.
        • et al.
        Colorectal endoscopic submucosal dissection: systematic review of mid-term clinical outcomes.
        Dig Endosc. 2016; 28: 405-416
        • Kondo A.
        • de Moura E.G.
        • Bernardo W.M.
        • et al.
        Endoscopy vs surgery in the treatment of early gastric cancer: systematic review.
        World J Gastroenterol. 2015; 21: 13177-13187
        • Fukami N.
        What we want for ESD is a second hand! Traction method.
        Gastrointest Endosc. 2013; 78: 274-276
        • Fujishiro M.
        • Yahagi N.
        • Kakushima N.
        • et al.
        Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases.
        Clin Gastroenterol Hepatol. 2007; 5 (quiz 645): 678-683
        • Saito Y.
        • Fukuzawa M.
        • Matsuda T.
        • et al.
        Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection.
        Surg Endosc. 2010; 24: 343-352
        • Tanaka S.
        • Oka S.
        • Kaneko I.
        • et al.
        Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization.
        Gastrointest Endosc. 2007; 66: 100-107
        • Yoon J.Y.
        • Kim J.H.
        • Lee J.Y.
        • et al.
        Clinical outcomes for patients with perforations during endoscopic submucosal dissection of laterally spreading tumors of the colorectum.
        Surg Endosc. 2013; 27: 487-493
        • Wong J.Y.Y.
        • Ho K.Y.
        Robotics for advanced therapeutic colonoscopy.
        Clin Endosc. 2018; 51: 552-557
        • Boškoski I.
        • Costamagna G.
        Endoscopy robotics: current and future applications.
        Dig Endosc. 2019; 31: 119-124
        • Yeung B.P.
        • Chiu P.W.
        Application of robotics in gastrointestinal endoscopy: a review.
        World J Gastroenterol. 2016; 22: 1811-1825
        • Zizer E.
        • Roppenecker D.
        • Helmes F.
        • et al.
        A new 3D-printed overtube system for endoscopic submucosal dissection: first results of a randomized study in a porcine model.
        Endoscopy. 2016; 48: 762-765
        • Lang S.
        • Mattheis S.
        • Hasskamp P.
        • et al.
        A European multicenter study evaluating the flex robotic system in transoral robotic surgery.
        Laryngoscope. 2017; 127: 391-395
        • Peters B.S.
        • Armijo P.R.
        • Krause C.
        • et al.
        Review of emerging surgical robotic technology.
        Surg Endosc. 2018; 32: 1636-1655
        • Korkischko N.
        • Wanderley M.B.
        • Lordello M.
        • et al.
        Comparison between carbon dioxide and air insufflation in colonoscopy: a systematic review and meta-analysis based on randomized control trials.
        Gastroenterol Pancreatol Liver Disord. 2017; 4: 1-11
        • Persky M.J.
        • Issa M.
        • Bonfili J.R.
        • et al.
        Transoral surgery using the Flex Robotic System: initial experience in the United States.
        Head Neck. 2018; 40: 2482-2486
        • Paull J.O.
        • Pudalov N.
        • Obias V.
        Medrobotics flex transanal excision of a rectal gastrointestinal stromal tumour: first video of the transanal flex robot used in a human—a video vignette.
        Colorectal Dis. 2018; 20: 1048-1049
        • Atallah S.
        • Hodges A.
        • Larach S.W.
        Direct target NOTES: prospective applications for next generation robotic platforms.
        Tech Coloproctol. 2018; 22: 363-371
        • Hart S.G.
        • Staveland L.E.
        Development of NASA-TLX (Task Load Index): results of empirical and theoretical research.
        Adv Psychol. 1988; 52: 139-183
        • Guimarães de Moura E.
        • Ottoboni Brunaldi V.
        • Hiroshi Ananias Morita F.
        • et al.
        Videoscopy. 2017; 27: 6
        • Pimentel-Nunes P.
        • Dinis-Ribeiro M.
        • Ponchon T.
        • et al.
        Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) guideline.
        Endoscopy. 2015; 47: 829-854
        • Mani M.
        • Morita Y.
        • Fujita T.
        • et al.
        Endoscopic submucosal dissection for gastric neoplasm in patients with co-morbidities categorized according to the ASA Physical Status Classification.
        Gastric Cancer. 2013; 16: 56-66
        • Ribeiro I.B.
        • Bernardo W.M.
        • Martins B.D.C.
        • et al.
        Colonic stent versus emergency surgery as treatment of malignant colonic obstruction in the palliative setting: a systematic review and meta-analysis.
        Endosc Int Open. 2018; 6: E558-E567
        • Takizawa K.
        • Knipschield M.A.
        • Gostout C.J.
        Randomized controlled trial comparing submucosal endoscopy with mucosal resection and endoscopic submucosal dissection in the esophagus and stomach: animal study.
        Dig Endosc. 2018; 30: 65-70
        • Aihara H.
        • Kumar N.
        • Ryou M.
        • et al.
        Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video).
        Gastrointest Endosc. 2014; 80: 495-502
        • de Moura D.T.
        • Guedes H.
        • Tortoretto V.
        • et al.
        [Comparison of colon-cleansing methods in preparation for colonoscopy-comparative of solutions of mannitol and sodium picosulfate].
        Rev Gastroenterol Peru. 2016; 36: 293-297
        • Kume K.
        Endoscopic therapy for early gastric cancer: standard techniques and recent advances in ESD.
        World J Gastroenterol. 2014; 20: 6425-6432
        • Imaeda H.
        • Hosoe N.
        • Ida Y.
        • et al.
        Novel technique of endoscopic submucosal dissection by using external forceps for early rectal cancer (with videos).
        Gastrointest Endosc. 2012; 75: 1253-1257
        • Ahn J.Y.
        • Choi K.D.
        • Choi J.Y.
        • et al.
        Transnasal endoscope-assisted endoscopic submucosal dissection for gastric adenoma and early gastric cancer in the pyloric area: a case series.
        Endoscopy. 2011; 43: 233-235
        • Neuhaus H.
        • Costamagna G.
        • Devière J.
        • et al.
        • ARCADE Group
        Endoscopic submucosal dissection (ESD) of early neoplastic gastric lesions using a new double-channel endoscope (the "R-scope").
        Endoscopy. 2006; 38: 1016-1023
        • von Delius S.
        • Karagianni A.
        • von Weyhern C.H.
        • et al.
        Percutaneously assisted endoscopic surgery using a new PEG-minitrocar for advanced endoscopic submucosal dissection (with videos).
        Gastrointest Endosc. 2008; 68: 365-369
        • Li C.H.
        • Chen P.J.
        • Chu H.C.
        • et al.
        Endoscopic submucosal dissection with the pulley method for early-stage gastric cancer (with video).
        Gastrointest Endosc. 2011; 73: 163-167
        • Saito Y.
        • Emura F.
        • Matsuda T.
        • et al.
        A new sinker-assisted endoscopic submucosal dissection for colorectal cancer.
        Gastrointest Endosc. 2005; 62: 297-301
        • Chen P.J.
        • Chu H.C.
        • Chang W.K.
        • et al.
        Endoscopic submucosal dissection with internal traction for early gastric cancer (with video).
        Gastrointest Endosc. 2008; 67: 128-132
        • Parra-Blanco A.
        • Nicolas D.
        • Arnau M.R.
        • et al.
        Gastric endoscopic submucosal dissection assisted by a new traction method: the clip-band technique. A feasibility study in a porcine model (with video).
        Gastrointest Endosc. 2011; 74: 1137-1141
        • Fernández-Esparrach G.
        • Shaikh S.N.
        • Cohen A.
        • et al.
        Efficacy of a reverse-phase polymer as a submucosal injection solution for EMR: a comparative study (with video).
        Gastrointest Endosc. 2009; 69: 1135-1139
        • Ritsuno H.
        • Sakamoto N.
        • Osada T.
        • et al.
        Prospective clinical trial of traction device-assisted endoscopic submucosal dissection of large superficial colorectal tumors using the S-O clip.
        Surg Endosc. 2014; 28: 3143-3149
        • He Y.
        • Fu K.
        • Leung J.
        • et al.
        Traction with dental floss and endoscopic clip improves trainee success in performing gastric endoscopic submucosal dissection (ESD): a live porcine study (with video).
        Surg Endosc. 2016; 30: 3138-3144
        • Ge P.S.
        • Thompson C.C.
        • Jirapinyo P.
        • et al.
        Suture pulley countertraction method reduces procedure time and technical demand of endoscopic submucosal dissection among novice endoscopists learning endoscopic submucosal dissection: a prospective randomized ex vivo study.
        Gastrointest Endosc. 2019; 89: 177-184
        • Arezzo A.
        • Passera R.
        • Saito Y.
        • et al.
        Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions.
        Surg Endosc. 2014; 28: 427-438

      Linked Article

      • Colorectal endoscopic submucosal dissection: a robotic system is coming
        Gastrointestinal EndoscopyVol. 90Issue 2
        • Preview
          Endoscopic submucosal dissection (ESD) is now widely accepted as a major therapeutic option for large and superficial colorectal neoplasias in Asian countries because it provides a greater chance of en bloc and curative resection of such lesions than conventional EMR.1 Because of the high technical difficulty, prolonged procedure time, and high risk of perforation, intensive and stepwise training is required before an endoscopist can practice colorectal ESD.1,2 However, the lack of teaching experts in local areas and less chance of gastric ESD have limited the propagation of ESD in Western countries.
        • Full-Text
        • PDF