Endoscopic submucosal dissection for early cancer using the water pressure method in the remnant rectum after Hartmann’s procedure

Endoscopic submucosal dissection (ESD) for colorectal neoplasms, including laterally spreading tumors, has been widely performed [1]. However, ESD has rarely been reported for neoplasms located in the remnant rectum after Hartmann’s procedure. Herein, we report a successful ESD for early rectal cancer using the water pressure method.

A 74-year-old man was referred to our department due to high uptake of 18F-fluorodeoxyglucose in the rectum. He had undergone Hartmann’s procedure for rectosigmoid colon cancer nine years earlier. Colonoscopy revealed a 40-mm, 0–Is + IIa villous lesion located in the Rb, 2 cm from the anal verge ([Fig. 1]). Narrow-band imaging partially revealed atypical vascular structures consistent with JNET classification type 2B, suggesting the presence of carcinoma in villous adenoma ([Fig. 2]).

Fig. 1 Colonoscopy revealed a 40-mm, 0–Is + IIa villous lesion located in the Rb, 2 cm from the anal verge.

Fig. 2 Narrow-band imaging partially revealed an atypical vessel structure consistent with JNET 2B.

When performing ESD ([Video 1]), even slight CO₂ insufflation caused abdominal pain and oozing from the fragile mucosa. After mucosal incision and trimming, submucosal dissection was performed using the water pressure method with a short ST hood (DH-28GR; Fujifilm, Tokyo, Japan) without CO₂ insufflation ([Fig. 3]). The water pressure method relieved abdominal pain and allowed safe dissection by inflating the atrophic submucosal layer with water. CO₂ insufflation was used in combination with the water pressure method when the dissection reached a stage where traction by gravity was utilized. En bloc resection was accomplished without any complications ([Fig. 4]). Pathological examination confirmed carcinoma in a villous adenoma with negative margins.

The water pressure method was utilized for endoscopic submucosal dissection in the remnant rectum, relieving abdominal pain and mucosal damage.Video 1

Fig. 3 Submucosal dissection was performed using the water pressure method.

Fig. 4 Curative resection was accomplished.

A standardized technique of ESD in the remnant rectum has not yet been established. Insufflation of gas in such a closed cavity readily increases the internal pressure, inducing abdominal pain and mucosal damage. The water pressure method, which is often used in duodenal and colorectal ESD [2], ensures visibility at low pressure [3]. This method can be a useful technique for safe ESD in closed, narrow spaces, such as the remnant rectum.

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• References

• 1 Tanaka S, Terasaki M, Kanao H. et al. Current status and future perspectives of endoscopic submucosal dissection for colorectal tumors. Digestive Endoscopy 2012; 24: 73-79
• 2 Noguchi M, Yano T, Kato T. et al. Risk factors for intraoperative perforation during endoscopic submucosal dissection of superficial esophageal squamous cell carcinoma. World J Gastroenterol 2017; 23: 478-485
• 3 Kirita K, Akimoto T, Niikawa M. et al. Efficacy of water pressure method for colorectal endoscopic submucosal dissection: Propensity-score matching analysis. Endosc Int Open 2025; 13: a25442654