COMBINATION OF POCKET-ESD WITH COUNTERTRACTION AND PARTIAL FULL THICKNESS EXCISION FOR AN ADVANCED COLONIC ADENOMA IN THE SETTING OF SEVERE FIBROSIS

A 68-year-old female patient with history of surgery and radiotherapy for rectal cancer, was referred for ESD of a flat non-granular polyp (Paris IIa+IIc) located in a sub-stenotic segment of the sigmoid colon. A small incision was made at the anal side and the endoscope was gently pushed in the submucosal space. A submucosal pocket was created following the external markers. Dissection of the right side of the lesion was challenging due to thick fibrosis. A snare was loaded over the extremity of the scope, a clip was placed at the edge of the mucosal flap and then the snare was released and grasped the clip. Back and forward movements of the snare changed the direction of the countertraction as desired. After copious dissection of about 90% of the lesion, the specimen was now hanging from a band of scar tissue fused with the muscle layer. It was hard to recognize the dissection plane; therefore, we proceed to blind dissection taking into account the risk of perforation. Finally, en bloc resection was achieved, leaving a circumferential mucosal defect. A 2 cm long transmural defect was recognized leading into a small blind cavity that was completely closed with clips. The next day the patient developed diffuse abdominal pain and we proceeded to laparoscopy that showed generalized peritonitis. The site of perforation was firmly closed with the endoscopic clips. The abdomen was washed and one surgical drain was placed. The patient was discharged home on day 2 and had an uneventful recovery. Histology showed R0 resection of a tubulo-villous adenoma with high grade dysplasia. The muscular layer was identified in a small portion of the specimen, corresponding to the area with severe fibrosis. At 6 months of follow up, the patient remains asymptomatic.