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EID precision teaching - demonstrates the core philosophy of EID: it is all about precision and about knowing you are doing what you are doing and the reason why you are doing it
"I would switch here to EID and call this a muscle retraction sign."
Overview
The PRIME algorithm represents a paradigm shift in how we approach early rectal cancer endoscopically. Standing for deeP-maRgin optIcal diagnosis and endoscopic resection algorithM for Early rectal cancer, this systematic approach ensures we make the right resection plane decision based on real-time tissue assessment rather than predetermined strategies.
"So deep margin optical assessment. What we're doing here, you can clearly see the lesion, you can clearly see the muscle."
Key Learning Points
- Pocket Detection Method (PDM): Creating a submucosal pocket allows direct visualization of the tissue planes and assessment of invasion depth before committing to a resection strategy
- Muscle Retraction Sign (MRS): Recognition of this critical sign indicates muscle involvement and signals the need to change from standard ESD to intermuscular dissection
- Deep Margin Optical Diagnosis: Real-time assessment of the relationship between lesion, submucosa, and muscle layer guides plane selection
- Endoscopic Intermuscular Dissection (EID): When MRS is detected, EID allows dissection between circular and longitudinal muscle layers for adequate margins
- R0 as the Goal: The algorithm emphasizes achieving clear margins rather than accepting the excisional biopsy mindset
"R zero is, should be the goal. It's probably the goal of surgeons anyway."
The PRIME Algorithm in Practice
The procedure begins with careful lesion assessment. In this case, the lesion displays BLINK positivity, central depression, and converging folds - features concerning for deep invasion. Rather than proceeding directly with standard ESD, the operator creates a pocket to assess the submucosal plane.
Upon identifying the muscle retraction sign during pocket creation, deep margin optical diagnosis confirms the need to change planes. The decision to switch to EID is made in real-time, demonstrating the adaptive nature of the PRIME algorithm.
"We will encounter muscle retraction sign. So the question is will we need to get R zero?"
REACT Tool Integration
This case demonstrates integration of the REACT tool for procedural support, highlighting how digital resources can enhance complex endoscopic procedures.
Who Should Watch
This video is essential viewing for interventional endoscopists managing rectal lesions, particularly those looking to expand beyond standard ESD into intermuscular dissection techniques. The surgical-endoscopic collaboration also provides valuable anatomical perspectives for understanding safe dissection zones.
Watch the full 75-minute procedure to master the PRIME algorithm and see how real-time decision-making leads to optimal oncological outcomes.
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