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.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
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