Endoscopic submucosal dissection of high-grade dysplasia recurrence in ulcerative colitis using a multitraction technique

Endoscopic submucosal dissection (ESD) is the gold standard for removing superficial tumor in the digestive tract [1]. Dyplasia in inflammatory bowel disease (IBD) patient is a major concern due to the risk of neoplastic progression. ESD for dysplasia in IBD is feasible, but long-term follow-up data are lacking especially for the management of dysplasia recurrence in an area previously treated by ESD [2] [3] [4] [5].

We report the case of a 71-year-old man with a history of long-standing ulcerative colitis who underwent ESD for high-grade dysplasia and focal intramucosal carcinoma in the left colon. The resection was incomplete with dysplasia in the lateral margin. Three years later, recurrence of high-grade dysplasia was detected in the area previously treated ([Fig. 1]). Another ESD was decided upon ([Video 1]). After marking of the lesion and circumferential incision, a new multitraction technique was employed using a device made of three intertwined loops ([Fig. 2]). Each of the loops was attached to an edge of the lesion, then the entire device was attached to the opposite wall, facilitating the exposure of the submucosal area and enabling en bloc resection despite intense fibrosis ([Fig. 3]). We wanted to extend the dissection to the upper pole of the lesion because of the suspicion of a serrated lesion. However, a small perforation was made so we stopped the procedure as the diagnosis was not certain. The defect was closed and the patient discharged the day after without any adverse event. The pathology report confirmed complete en bloc resection of a high-grade dysplasia, with chronic inflammatory changes with focal low-grade dysplasia on the area not removed. Our multidisciplinary team decided on endoscopic surveillance.

Fig. 1 In a 71-year-old man who 3 years ago had undergone ESD for high-grade dysplasia and focal intramucosal carcinoma in the left colon, high-grade dysplasia recurrence was detected in the area previously treated.

Video 1 Endoscopic submucosal dissection of high-grade dysplasia in a 71-year-old patient with long-standing ulcerative colitis, using a multitraction technique.

Fig. 2 A new multitraction technique was employed using a device made of three intertwined loops.

Fig. 3 Each loop was attached to an edge of the lesion, then the entire device was attached to the opposite wall, thus facilitating the exposure of the submucosal area.

ESD is feasible in patients with IBD, even in a fibrotic area that has previously been resected, and can be facilitated by a multitraction technique. Patients with dysplasia should always be referred to a center of endoscopic expertise before colectomy is considered.

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Publication History

Article published online:
08 September 2021

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