Endoscopic submucosal dissection (ESD): indication and technique. a case report

Introduction: The complet removal of flat, sessile polyps is usually impossible with conventional snare. Lesions larger than 2cm cannot be removed en bloc with endoscopic mucosal resection due to the technical limitation of this method. A new therapeutic procedure called endoscopic submucosal dissection allows large, flat lesions to be resected radically.

Case report: A 64-years old woman with a 3,5cm in diameter, flat, sessile polyp of the rectum has been undergone piecemeal polypectomy in 2004. The histological investigation proved tubular adenoma with high grade dysplasia. One year later a recurrent polyp was removed by mucosectomy, but the control colonoscopy detected a recurrent lesion again in 2007.

Method: As the first step of the procedure the mucosa was painted with methylene-blue, and the lesion was marked around with an electrocoagulator. The mucosal layer was elevated by methylen blue-epinephrine-salin solution (1:1:20), which was injected into the submucosal layer. In the beginning of the polyp removal a needle knife was used, later -to prevent perforation- it has been changed for IT-knife. To elevate the lesion, which is necessary to perform circumferential mucosal incision, an endo-cap was used.

Result: The procedure took 55 minutes, no complication occured. The histological investigation proved tubular adenoma, the resection surface was tumor-free. The control colonoscopy performed 3 month later was negative.

Conclusion: Endoscopic submucosal dissection is a suitable method for removal of large sessile lesions. Owning to en bloc resection it decreases the recurrence rate and it could be applied for high risk patients with malignant deseases as a new alternative minimal invasive treatment. Because of the application of new accesories for endoscopic submucosal dissection and the difficult technique, compared to polypectomy, more preparation and practice required for the endoscopic assistants in the everyday practice.