Perforation: part and parcel of endoscopic resection?

The prepurse-string suture technique for gastric defect after endoscopic full-thickness resection (with video)

Endoscopic full-thickness resection (EFTR) is the main treatment for gastric tumors originating from the muscularis propria or gastric extra-luminal growth tumors. Successful closure of the gastric wall defect is a critical step during EFTR.The aim of this retrospective study was to evaluate the feasibility and safety of the endoscopic prepurse-string suture (p-EPSS) technique using an endoloop and several metallic clips during EFTR to close the perforation.Twenty-five patients with gastric tumors originated from the muscularis propria or with gastric extra-luminal growth tumors who received EFTR were analyzed at the Renmin Hospital of Wuhan University from June 2016 to May 2017. Patient characteristics, tumor characteristics, operation time length, and postoperative complications were evaluated in all patients.All the 25 patients underwent a successful EFTR. Complete closure of gastric defects was also achieved. The mean operation time length was 31 ± 14 minutes. The mean maximum size of tumor of was 1.7 ± 1.0 cm (range 0.5-4.5 cm). No severe postoperative complications occurred, such as massive bleeding, gastric leak, peritonitis, or abdominal abscess. No patient needed surgical intervention. Wounds were well healed 1 month after EFTR. No tumor metastasis and recurrence were observed during the follow-up period (median, 7 months).The p-EPSS technique using endoloop and several sterile repositionable hemostasis clips is safe and feasible for closing gastric perforation during EFTR.

Management of complex polyps of the colon and rectum

PUPRPOSE

Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options.

METHODS

A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum.

RESULTS

Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery.

CONCLUSION

Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.

Peritoneal Seeding after Gastric Perforation during Endoscopic Submucosal Dissection for Gastric Cancer

BACKGROUND/AIMS

Since the risk of cancer cells seeding the peritoneum after perforation during endoscopic submucosal dissection (ESD) is unclear, we retrospectively examined peritoneal relapse after gastric perforation during ESD for gastric cancer at a single institution.

METHODS

Of 876 patients who underwent ESD for early gastric cancer between January 2002 and December 2015, 22 patients (2.5%) experienced gastric perforation during ESD at the Osaka National Hospital in Osaka, Japan. Clinical data from these 22 patients were reviewed for information on pathology, clinical course, and evidence of peritoneal dissemination.

RESULTS

Patients were followed for a median of 55 (range 2-108) months. Two patients had peritoneal seeding following perforation during ESD. Multivariate analysis to explore the influence of clinical factors on the peritoneal seeding revealed that an intra-abdominal fluid collection on the CT imaging just after ESD, tumor location at the upper lesion of stomach, and pathologically marginal invasion were independently associated with an incidence of peritoneal relapse.

CONCLUSION

Although rare, we should recognize the possibility of cancer cells seeding the peritoneum after perforation during gastric ESD.

Outcome and risk of recurrence for endoscopic resection of colonic superficial neoplastic lesions over 2 cm in diameter

BACKGROUND

Large colorectal superficial neoplastic lesions are challenging to remove. This study aimed to assess the outcomes of routine endoscopic resection of large (≥2 cm and <3 cm) and giant (≥3 cm) lesions.

METHODS

From 4587 endoscopic resections, 265 (5.7%) large and giant lesions were removed in 249 patients. We retrospectively analyzed 125 patients (141 endoscopic mucosal resection, 73 large and 68 giant lesions) with a follow-up of 6-12 months. Rate of en bloc and piecemeal resection, recurrence and risk factors were analyzed.

RESULTS

En bloc was performed in 92 cases (65.2%) and piecemeal resection in 49 (34.8%). A complete endoscopic resection was achieved in 139 cases (98.5%) with radical resection in 84/139 cases (60.4%). Argon plasma coagulation was applied in 18/141 lesions (12.8%). A recurrence occurred in 16/139 lesions (11.5%). The risk of recurrence at one year was significantly higher for giant than large lesions (p=0.03). The recurrence risk was higher in treated than in non-argon plasma coagulation treated lesions (p=0.01).

CONCLUSIONS

endoscopic mucosal resection is a safe and effective routine treatment for large superficial neoplastic lesions. The risk factors for recurrence include giant size, non-protruding morphology, piecemeal technique and argon plasma coagulation.

Use of a double-channel gastroscope reduces procedural time in large left-sided colonic endoscopic mucosal resections

Background/Aims

Endoscopic mucosal resection (EMR) of large colorectal lesions is associated with increased procedural time. The objective of this study was to evaluate the effect of double-channel gastroscope (DCG) use on the procedural time of EMRs in the rectosigmoid area.

Methods

All EMRs for sessile or flat rectosigmoid lesions ≥2 cm performed between July 2011 and September 2012 were retrospectively analyzed.

Results

There were 55 lesions ≥2 cm in the rectosigmoid area in 55 patients, of which 26 were removed by EMR using a DCG (DC group) and 29 by using an ordinary colonoscope or gastroscope (OS group). The mean size of the removed polyps, morphology, adverse effects, and other parameters were similar between the two groups. The mean procedural time was significantly lower in the DC group than in the OS group (24.4±18.3 minutes vs. 36.3±24.4 minutes, p=0.015). Moreover, in a subgroup of patients with polyps >40 mm, the statistical difference in the mean procedural time between the DC and OS groups was even more pronounced (33±21 minutes vs. 58.7±20.6 minutes, p=0.004).

Conclusions

Our data suggest that the use of a DCG in the resection of large nonpedunculated rectosigmoid lesions significantly reduces the procedural time.

Pilot study of 'Scissorhands' technique for gastric endoscopic submucosal dissection using novel gel and endoscopic scissors in a porcine model (with video)

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is a complex procedure and is associated with significant risks. The aims of this pilot study were to study feasibility and procedural times of gastric ESD using a novel gel and endoscopic scissors in a porcine model.

METHODS

Simulated 3-cm gastric submucosal lesions were created in a porcine model. Subsequently, viscous gel was injected into the created bleb. A needle knife was used to create an initial incision when needed. Endoscopic scissors were then used for circumferential incision around the simulated submucosal lesions. The inserted coil (i.e. submucosal lesion) was then removed. The submucosal surface was carefully examined for signs of injury. Procedural times were recorded.

RESULTS

ESD was carried out in four consecutive pigs using the 'Scissorhands' technique. A small submucosal incision was created a using needle knife in the first pig and electrocautery was not used in the remaining three pigs. Circumferential incision using the scissors was done successfully in all pigs. Submucosal dissection was not required in any case. 'Auto-dissection' of created lesions by the gel was noted to be complete in all cases. Inserted coils were noted in the submucosal space during all experiments and were removed. All lesions were successfully resected en bloc. The mean procedure time was 19 min (range 13-22 min).

CONCLUSION

The combined technique of endoscopic scissors for circumferential incision and viscous gel for submucosal dissection permitted easy, safe and efficient gastric ESD. Electrocautery may be avoided and its consequent adverse events (e.g. perforation).

Colorectal endoscopic submucosal dissection: is it suitable in western countries?

Endoscopic submucosal dissection (ESD) represents a significant advance in therapeutic endoscopy with the major advantage being the ability to achieve a higher en bloc resection rate for early stage lesions. Western endoscopists infrequently perform colorectal ESD (CR-ESD) because of the greater technical difficulty involved, longer procedure times, and increased risk of perforation. Specialized training and sufficient clinical experience are necessary to successfully perform ESDs, but a systematic education and training program has still not been established in Japan or elsewhere in the world. Experts generally acknowledge that the stomach is the first organ in which endoscopists should begin performing ESDs. The incidence and detection rates for early stage gastric cancer are significantly higher in Japan than in western countries, so Japanese endoscopists have a greater opportunity to perform gastric ESDs than their western counterparts. It is logical to ask, therefore, whether CR-ESD can be effectively applied in western countries. Based on a review of the relevant literature and our practical perspective, we have focused on the progress made in performing CR-ESD, its indications, training methods, and learning curve. Use of animal gastric and colon models is strongly recommended along with accumulating the necessary experience from the rectum to the colon on a step-by-step basis. It is reasonable to assume that an increasing number of CR-ESDs will be performed by western endoscopists in the foreseeable future given the continuing development of new techniques, and the refinement of instruments and other technologically advanced devices together with the creation of even more effective submucosal injection agents.

Performance of the OTSC System in the endoscopic closure of iatrogenic gastrointestinal perforations: a systematic review

BACKGROUND

Reliable closure is a prerequisite for conventional and innovative endoscopic procedures, such as NOTES. The purpose of this study is the systematic evaluation of the procedural and clinical success rates in closure of iatrogenic gastrointestinal perforations and acute anastomotic leaks by means of the over-the-scope-clip system (OTSC(®)).

DESIGN

PubMed and other sources were searched systematically for clinical and preclinical research on the evaluation of the OTSC System for closure of gastrointestinal perforations and leaks. Appraisal of studies for inclusion and data extraction was performed independently by two reviewers using an a priori determined data extraction grid. Major endpoints to be extracted were data on procedural success (successful clip application) and clinical access (durable closure of defect without secondary adjunct therapy).

RESULTS

A total of 17 clinical research articles/abstracts and 22 preclinical research articles/abstracts were identified. The examined clinical studies comprised case series and clinical single-arm studies. The reviewed studies revealed a consistently high mean rate of procedural success of 80-100 % and durable clinical success of 57-100 %. An identified major drawback preventing successful clip application was occurrence of fibrotic or inflamed lesion edges. Usage of the OTSC System was accompanied by neither major clip-related nor application-related complication. In experimental settings, closure of larger perforations and gastric access sites of NOTES or endoscopic full-thickness resection were achieved with high rates of success.

CONCLUSIONS

Because randomized, clinical trials are not available in this field of indication, the evaluation is based on small case series. Nevertheless, by pooling all experience gained, we conclude that endoscopic closure of iatrogenic gastrointestinal perforations and acute anastomotic leaks by means of the OTSC System is a safe and effective method.

Management of Complications during Gastric Endoscopic Submucosal Dissection

Popularity of endoscopic submucosal dissection (ESD) has shown an increase during the last decade, and may, for the time being, be the most important technique in treatment of early gastrointestinal cancer or a premalignant lesion. This technique has advantages in the aspect of en bloc resection, which enables evaluation of the completeness of resection and other pathologic characteristics; however, it has limitation in terms of complications, compared to endoscopic mucosal resection (EMR). Bleeding and perforation are the most common complications encountered during the procedure. These complications can cause embarrassment for the endoscopist and hamper performance of the procedure, which can result in an incomplete resection. To overcome these obstacles during performance of the procedure, we should be familiar with management of complications. In particular, beginners who start performing ESD should have full knowledge of and be in good handling of the method of hemostasis using hemoclips or electrocoagulation for management of complications. Various methods, procedures, and equipment are under development, which will provide us with powerful tools for achievement of successful ESD without complications in the near future.

Risk factors for incomplete resection and complications in endoscopic mucosal resection for lateral spreading tumors

AIM

Lateral spreading tumors (LST) are relatively large flat lesions with diameters exceeding 10 mm in length. Endoscopic mucosal resection (EMR) is a commonly used technique for removing LST. We aimed to evaluate the risk factors for incomplete resection and complications of EMR for LST.

METHOD

Between January 2004 and December 2010, 497 patients who underwent EMR for LST were retrospectively reviewed. Risk factors for endoscopic and histopathological complete resection, complications, and clinical outcomes were investigated.

RESULTS

Risks for incomplete resection by piecemeal resection and en bloc resection of a lesion ≥ 30 mm were higher than for en bloc resection of a lesion <30 mm (OR=2.688, CI 1.036-6.993; OR=4.982, CI 1.894-13.101). Risks of post-EMR bleeding for piecemeal resection and en bloc resection for a lesion ≥ 40 mm were higher than for en bloc resection of a lesion <40 mm (OR=15.231, CI 1.816-127.744; OR=43.043, CI 4.306-430.314).

CONCLUSION

We found risk factors of EMR for LST and tentatively suggest a protocol for EMR adapted to the size of LST and resection methods. (i) Following piecemeal resection and en bloc resection for LST ≥ 40 mm, hospitalize patients for 36 h and note risk for incomplete resection and delayed bleeding. (ii) After en bloc resection for 40 mm>LST ≥ 30 mm, hospitalize patients for 12 h and note risk for incomplete resection. (iii) Following en bloc resection for LST<30 mm, hospitalize the patient for 12 h and expect complete resection.

Beyond the snare: technically accessible large en bloc colonic resection in the West: an animal study

BACKGROUND

Endoscopic submucosal dissection (ESD) and circumferential submucosal incision endoscopic mucosal resection (CSI-EMR) are techniques for en bloc excision of large sessile colonic lesions. Our aims were to compare the efficacy, safety and learning curve of colonic hybrid knife (HK) ESD versus CSI-EMR for en bloc excision of 50 mm diameter hemi-circumferential artificial lesions in a porcine model.

PATIENTS AND METHODS

Two separate 50 mm diameter areas of normal recto-sigmoid mucosa were marked out in each of ten pigs. One was excised with HK-ESD using succinylated gelatin (SG) submucosal injection. The other was isolated with CSI with the Insulated Tip Knife 2 followed by SG submucosal injection then EMR with a large snare. Euthanasia and colectomy was performed at 72 h followed by blinded histopathology assessment.

RESULTS

En bloc excision rates were: HK-ESD 100% versus CSI-EMR 20% (P = 0.008). The mean number of resections per lesion was HK-ESD 1 versus CSI-EMR 3 (P = 0.001). The mean dimensions of the largest specimen per technique were HK-ESD 63 × 54 mm versus CSI-EMR 49 × 41 mm (P = 0.005). Procedure duration mean was HK-ESD 54 min versus CSI-EMR 22 min (P < 0.001). When procedure duration was adjusted for the size of the resected en bloc specimen, a statistically significant and accelerated learning effect was noted for HK-ESD (r = -0.83, P = 0.003). There were no perforations and no significant bleeding.

CONCLUSIONS

HK-ESD with SG submucosal injection is superior to CSI-EMR for en bloc excision of 50 mm diameter lesions in a porcine model. The technique is rapidly learnt. This novel approach may lower the barrier to colonic ESD for Western endoscopists.

Polyp recurrence after endoscopic mucosal resection of sessile and flat colonic adenomas

BACKGROUND

Endoscopic mucosal resection (EMR) is used for treatment of sessile and flat colonic adenomas. There is limited data comparing polyp recurrence between piecemeal and en-bloc resections.

AIM

The purpose of this study was to evaluate the incidence density and predictive factors for polyp recurrence after piecemeal and en-bloc resections.

METHODS

Patients undergoing EMR of flat or sessile adenomas≥10 mm were included. Incidence density (ID) and incidence rate ratio (IRR) of polyp recurrence were calculated. Predictive factors for recurrence were assessed by multivariate analysis using logistic regression.

RESULTS

A total of 105 patients (males 54, mean age 68) with 121 polyps were included. Sixty-seven polyps (mean size±SD, 23.3±9.2 mm) were resected piecemeal and 54 polyps (mean size 14.7±5.1 mm) were resected en-bloc. There were 12 recurrences in the piecemeal group and two in the en-bloc group. The ID of polyp recurrence in the piecemeal group was 13.1 (95% CI 7.43-23.03) and in the en-bloc group was 2.7 (95% CI 0.67-10.78) per 100 person-years of follow-up. Piecemeal resections were 5.5 (95% CI 1.1-30.48, P=0.045) times and flat polyps were 6.6 (95% CI 1.22-35.53, P=0.028) times more likely to result in recurrence compared to en-bloc resections and sessile polyps, respectively. In the piecemeal group, additional use of argon plasma coagulation (APC) did not affect the recurrence (OR 0.46, P=0.29).

CONCLUSIONS

Piecemeal resections and flat polyps are associated with higher recurrence following EMR. Additional use of APC did not affect the recurrence rates after piecemeal resection.

Feasibility of endoscopic closure of an iatrogenic colon perforation occurring during colonoscopy

BACKGROUND

Colon perforation is one of the most dreaded complications of colonoscopy. Traditionally, patients with a colon perforation have been treated surgically. Although there are several case reports documenting the usefulness of endoscopic closure of colon perforations, there are few current data evaluating the feasibility of endoscopic closure for an iatrogenic perforation on consecutive patients undergoing colonoscopy.

OBJECTIVE

To assess the incidence of colon perforations and the utility of immediate endoscopic closure during colonoscopy.

DESIGN

Retrospective, observational study.

SETTING

Tertiary-care academic medical center.

PATIENTS

All patients who underwent colonoscopy at 1 institution from June 2002 to December 2008 were identified.

INTERVENTION

An attempt at immediate colon perforation closure by endoscopic means.

MAIN OUTCOME MEASUREMENTS

Successful endoscopic closure of colon perforation.

RESULTS

During the study period, a total of 8601 colonoscopies were performed (2472 therapeutic interventions, 28.7%). A total of 12 iatrogenic colon perforations occurred, yielding a rate of 1.4/1000. Five (41.7%) occurred during a diagnostic colonoscopy (0.8/1000), and 7 perforations (58.3%) occurred as the result of a therapeutic intervention (2.8/1000). Endoscopic closure of the perforation site was possible in 5 patients (42%). Seven patients were treated surgically (large defects [n = 3], including 1 failed endoscopic closure, difficult endoscope position [n = 2], stool contamination [n = 1], and endoscopist's inexperience with closure of mucosal defects [n = 1]).

LIMITATION

Retrospective design.

CONCLUSIONS

In this study, the incidence of colon perforations was 1.4/1000. Endoscopic closure of iatrogenic colon perforations was attempted in 50% of patients and was successful in 83%. All patients with successful endoscopic closure had lesions smaller than 10 mm.

A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon

OBJECTIVES

Succinylated gelatin (SG) is an inexpensive, safe, colloidal solution. It was superior to normal saline (NS) in a porcine colon endoscopic resection (ER) model. Our aim was to compare the efficacy, efficiency, and safety of ER with SG vs. NS.

METHODS

A randomized double-blind trial of submucosal injection with SG vs. NS was conducted for patients undergoing colonoscopy and ER for sessile lesions ≥20 mm in size at an Australian academic hospital endoscopy unit. The primary end point was the "Sydney Resection Quotient" (SRQ), defined as "lesion size in mm divided by the number of pieces to resect." This allows a comparison of technical outcomes for lesions of various sizes. A large lesion removed in fewer pieces gives a greater value.

RESULTS

Eighty patients (45 men, mean age 69) with lesions sized 20-100 mm were randomized. A total of 41 SG subjects were well matched to 39 NS subjects, with median (interquartile range) lesion size 40 mm (25-45) vs. 35 mm (30-50), respectively (P=0.382). Complete single-session lesion excision was 90% in both groups. There were no adverse events attributable to SG. The SRQ (median (interquartile range)) was SG 10.0 (7.5-20.0) vs. NS 5.9 (4.4-11.7), P=0.004. Other end points (median (interquartile range)) included fewer resections per lesion in the SG group: 3.0 (1.0-6.0) vs. NS 5.5 (3.0-10.0), P=0.028; fewer injections per lesion with SG: 2.0 (1.0-3.0) vs. NS 3.0 (2.0-11.0), P=0.002; lower injection volume: 14.5 ml (8.5-23.0) vs. NS 20.0 ml (16.0-46.0), P=0.009; and shorter procedure duration with SG: 12.0 min (8.0-28.0) vs. NS 24.5 min (15.0-36.0), P=0.006.

CONCLUSIONS

SG significantly improves SRQ by almost halving the number of resections for piecemeal ER. SG also safely halves procedure duration.

Succinylated gelatin substantially increases en bloc resection size in colonic EMR: a randomized, blinded trial in a porcine model

BACKGROUND

Succinylated gelatin (SG) is an inexpensive colloid that may combine ease of use with the advantages of a colloid to potentially increase EMR specimen size, leading to a higher rate of en bloc resection.

OBJECTIVE

To evaluate the safety, efficacy, and impact on EMR specimen size of SG as a submucosal (s.m.) injectant in comparison with normal saline solution (NS).

DESIGN

Randomized, blinded, controlled trial conducted with Animal Ethics Committee approval.

SETTING

Academic hospital.

SUBJECTS

Ten swine.

INTERVENTIONS

Sixty EMRs (30 using SG vs 30 using NS as 3 paired experiments per animal) of the largest possible en bloc snare resection of normal colonic mucosa after s.m. injection of a fixed volume of either SG or NS.

MAIN OUTCOME MEASUREMENTS

EMR specimen size, duration of s.m. cushion, duration of procedure, ratio of vertical elevation to lateral spread of injectant, ease of resection, adverse effects, perforation, histopathology of EMR sites in colectomy specimens at necropsy (for inflammatory cell content, depth of ulceration, and vascular or ischemic changes).

RESULTS

The mean subject weight was 53 kg. The mean EMR specimen dimensions and surface area were significantly larger with SG (length 37 vs 31 mm, P = .031; width 32 vs 26 mm, P = .022; surface area 9.5 cm(2) vs 6.7 cm(2), P = .044, respectively). The median s.m. cushion duration was 60 minutes with SG versus 15 minutes with NS (P = .005). The median procedure duration with SG was 2.6 minutes vs 2.5 minutes with NS (P = .515). The ratio of vertical elevation to lateral spread of injectant (mean score on a 3-point scale) was 3 with SG versus 2 with NS (P = .228). Ease of resection score (mean score on a 10-point scale) was 8 with SG versus 7 with NS (P = .216). There were no systemic adverse effects, hypersensitivity reactions, or bleeding episodes. There were 2 perforations (treated with clips) with SG and 1 with NS (P = 1.0). Blinded histopathologist assessment of necropsy colectomy specimens did not identify any significant differences between SG and NS EMR sites.

LIMITATIONS

Animal study.

CONCLUSIONS

SG is safe and results in a 42% increased surface area for en bloc EMR. Given its other favorable properties, it represents a significant step toward defining the ideal EMR solution.

Meta-analysis and systematic review of colorectal endoscopic mucosal resection

AIM: To evaluate the proportion of successful complete cure en-bloc resections of large colorectal polyps achieved by endoscopic mucosal resection (EMR).

METHODS: Studies using the EMR technique to resect large colorectal polyps were selected. Successful complete cure en-bloc resection was defined as one piece margin-free polyp resection. Articles were searched for in Medline, Pubmed, and the Cochrane Control Trial Registry, among other sources.

RESULTS: An initial search identified 2620 reference articles, from which 429 relevant articles were selected and reviewed. Data was extracted from 25 studies (n = 5221) which met the inclusion criteria. All the studies used snares to perform EMR. Pooled proportion of en-bloc resections using a random effect model was 62.85% (95% CI: 51.50-73.52). The pooled proportion for complete cure en-bloc resections using a random effect model was 58.66% (95% CI: 47.14-69.71). With higher patient load (> 200 patients), this complete cure en-bloc resection rate improves from 44.19% (95% CI: 24.31-65.09) to 69.17% (95% CI: 51.11-84.61).

CONCLUSION: EMR is an effective technique for the resection of large colorectal polyps and offers an alternative to surgery.

Endoclipping for gastric perforation secondary to second session of EMRC in locally residual early gastric cancer: a case report

A 72-year-old woman underwent gastric endoscopic mucosal resection with a cap-fitted endoscope for an adenocarcinoma in situ. She was scheduled for endoscopic follow-up at 1 and 3 months after the procedure. By the third month of follow up, biopsies of a slightly depressed scar area showed an high grade epithelial dysplasia. For this reason a second endoscopic resection (ER) was performed using the oblique soft cap. A perforation in the site of endoscopic resection was immediately observed. The complication was treated successfully by the application of seven clips.

Esophageal perforation as a complication of esophagogastroduodenoscopy

Fifty years ago, esophageal perforation was common after rigid upper endoscopy. The arrival of flexible endoscopic instruments and refinement in technique have decreased its incidence; however, esophageal perforation remains an important cause of morbidity and mortality. This complication merits a high index of clinical suspicion to prevent sequelae of mediastinitis and fulminant sepsis. Although the risk of perforation with esophagogastroduodenoscopy alone is only 0.03%, this risk can increase to 17% with therapeutic interventions in the setting of underlying esophageal and systemic diseases. A wide spectrum of management options exist, ranging from conservative treatment to surgical intervention. Prompt recognition and management, within 24 hours of perforation, is critical for favorable outcomes.

En bloc endoscopic submucosal dissection of a 14-cm laterally spreading adenoma of the rectum with involvement to the anal canal: expanding the frontiers of endoscopic surgery (with video)

BACKGROUND

Endoscopic submucosal dissection (ESD) was recently developed in Japan for en bloc removal of laterally spreading tumors (LSTs). Although initially used for gastric tumors, ESD has now been applied to lesions elsewhere in the gut. Recent reports from Japan included removal of colorectal lesions up to 10 cm.

OBJECTIVE

To show the feasibility of ESD to remove en bloc, very large LSTs of the rectum, even when there is involvement to the dentate line.

DESIGN

Case report.

SETTING

The procedure was performed at an American GI unit. The patient was admitted to the hospital after the procedure for observation.

PATIENTS

A 53-year-old patient, with a 14-cm tubulovillous adenoma of the rectum, which, at its maximal extent, involved two thirds of the circumference of the rectum. The tumor extended distally to the dentate line.

INTERVENTIONS

En bloc submucosal dissection with a conventional needle-knife to remove the neoplasm.

MAIN OUTCOME MEASUREMENTS

Completeness of en bloc removal of the tumor and subsequent follow-up endoscopy that showed no residual neoplasm.

RESULTS

The tumor was able to be removed en bloc by ESD. The distal margin included squamous mucosa. At a 2.5-week endoscopic follow-up, a 3-mm focus of residual polyp was seen and removed. At the time of the last follow-up, there was complete healing of the wound and no residual neoplasm.

LIMITATIONS

Single case.

CONCLUSIONS

This case demonstrated the feasibility of using ESD to remove large laterally spreading rectal tumors, including when there was involvement to the dentate line (and the dissection line must include squamous mucosa of the anal canal). ESD is a promising alternative to conventional surgical techniques; however, additional published experience is needed.