Circumferential rectal laterally spreading tumor resected by endoscopic submucosal dissection in a Western center

A 78-year-old patient without relevant past medical history underwent colonoscopy for chronic diarrhea. Examination identified a laterally spreading tumor (LST), mixed-granular-type (nodules up to 1 cm) in the rectum, from the pectin line to the rectosigmoid transition. The LST covered 100 % of the circumference of this segment ([Fig. 1]). Endoscopic evaluation was compatible with an adenomatous lesion with preserved pit pattern (Kudo IIIL/IV classification), without unequivocal endoscopic suspicion of invasive lesion (NICE 2; JNET 2B). After multidisciplinary evaluation, endoscopic resection by endoscopic submucosal dissection (ESD) was decided.

Fig. 1 A 15 cm circumferential rectal laterally spreading tumor, mixed granular type.

The procedure was performed with the patient under general anesthesia. A gastroscope (GIF-HQ190; Olympus, Tokyo, Japan) and carbon dioxide insufflation were used. The lesion was gradually elevated with a colloid solution (Voluven [Fresenius Kabi Norge AS, Halden, Norway] + indigo carmine + adrenaline), and the excision was performed by ESD using the FlushKnife (Fujifilm Corp., Tokyo, Japan) and the IT Knife nano (Olympus) ([Fig. 2]). En bloc resection was achieved, obtaining a circumferential specimen with a length of 15 cm, corresponding to the entire rectal mucosa ([Fig. 3], [Video 1]). The procedure time was 420 minutes. Antimicrobial prophylaxis with a single dose of ceftriaxone (2 g) was given. There were no immediate complications and the patient was discharged 24 hours after the procedure. Histological examination revealed a tubulovillous adenoma with high grade dysplasia.

Fig. 2 Endoscopic submucosal dissection of the rectal laterally spreading tumor.

Fig. 3 Resected tumor, corresponding to the entire circumferential rectal mucosa.

Video 1 Endoscopic submucosal dissection for the treatment of a 15 cm circumferential rectal laterally spreading tumor.

Although the patient remained asymptomatic, endoscopic evaluation after 2 months revealed stenosis at the ESD site. Balloon dilation up to 15 mm (diameter) was performed in a single session ([Fig. 4]).

Fig. 4 Endoscopic balloon dilation at the endoscopic submucosal dissection site.

ESD is an organ-sparing endoscopic technique that allows en bloc resection of superficial gastrointestinal lesions regardless of their size, optimizing the histological evaluation [1]. This is particularly important in the rectum because of the high morbidity associated with the alternative surgical approaches [2]. Although described in Asian case reports [3] [4], to our knowledge this is the first report showing endoscopic treatment by ESD of a giant circumferential colorectal LST in a Western center.

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• References

• 1 Kantsevoy SV, Adler DG, Conway JD. et al. Endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc 2008; 68: 11-18
• 2 Gruen RL, Pitt V, Green S. et al. The effect of provider case volume on cancer mortality: systematic review and meta-analysis. CA Cancer J Clin 2009; 59: 192-211
• 3 Takahashi H, Hayashi Y, Sunada K. et al. Complete resection of a 225-mm circumferential rectosigmoid intramucosal carcinoma by endoscopic submucosal dissection. Endoscopy 2016; 48 : E161-E162
• 4 Kure K, Kawai M, Ishiyama S. et al. Complete endoscopic submucosal dissection of a giant rectal villous adenocarcinoma with electrolyte depletion syndrome. Case Rep Gastroenterol 2015; 9: 126-131