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CLASSIFICATION
Classification
ESD submucosal fibrosis classification (F0–F2)
Intraoperative grading of submucosal fibrosis during colorectal ESD after indigo carmine submucosal injection (F0 / F1 / F2). Separate from pit pattern, NICE, and JNET.
Classification overview
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F0 · No fibrosis
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F1 · Mild fibrosis
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F2 · Severe fibrosis
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Assessment
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Assessment · When and how to grade
F0
No fibrosis
Definition
No fibrosis, which manifests as a transparent submucosal layer after indigo carmine submucosal injection
Appearance
Blue transparent submucosal layer (when indigo carmine is mixed into the injection solution)
Dissection
Submucosal dissection is usually straightforward
F1
Mild fibrosis
Definition
Mild fibrosis, which appears as a white web-like structure in the transparent submucosal layer
Appearance
White web-like strands within the blue transparent submucosal layer
Dissection
En bloc resection is usually achievable with standard technique
F2
Severe fibrosis
Definition
Severe fibrosis, which appears as a white muscular-like structure without a transparent submucosal layer
Appearance
White muscular-like structure; no blue transparent submucosal layer. Difficult to separate from the muscular layer
Outcomes
Associated with lower complete resection rates, longer procedure time, and higher perforation risk in colorectal ESD
Predictors (colorectal)
Submucosal invasion and carcinoma are independent predictors of F2 fibrosis in multivariate analysis (Kim 2016)
Note: Hook knife and ST hood are often useful. Consider an experienced endoscopist or surgical resection given incomplete resection and additional-surgery risk.
Assessment
Assessment
When and how to grade
Timing
Graded during colorectal ESD at the time of submucosal injection and dissection, not as a standalone preoperative diagnosis
Injection
Indigo carmine is added to the submucosal injection solution (e.g., glycerin, hyaluronic acid) to visualize the submucosal layer
Not EUS-F
Preoperative EUS-based EUS-F0/F1/F2 (submucosal layer brightness and thickness on EUS) is a separate classification used to predict fibrosis before ESD
Gastric ESD
The same F0–F2 definitions are used during gastric ESD and correlate with Masson trichrome staining (Higashimaya 2012, Gastric Cancer)
Kim 2016, Fig. 1, Not original
Inada 2013, Fig. 1, Not original, CC BY
Reference
Original article
Matsumoto A, Tanaka S, Oka S, et al. Scand J Gastroenterol 2010;45:1329-1337
Review
Kim EK, Han DS, et al. Intest Res 2016;14:358-364
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Sydney DMI
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Decision support only. Follow current guidelines and local protocols. Classification definitions and terminology follow the original publication language.