A 58-year-old man presented with a fully circumferential, granular-type, laterally
spreading tumor in the rectosigmoid ([Fig. 1 a], [Fig. 1 b]), which was diagnosed as an intramucosal cancer using magnifying endoscopy. En bloc
resection was accomplished by endoscopic submucosal dissection (ESD) using the pocket-creation
method [1].
Fig. 1 Endoscopic submucosal dissection (ESD) of a circumferential rectosigmoid intramucosal
carcinoma. a, b Endoscopic view of a large circumferential laterally spreading tumor (granular, mixed-nodular
type) extending from the upper rectum to the rectosigmoid. c The en bloc resected cylindrical specimen. The dissection time was 662 minutes. A
total of 225 mL of 0.4 % sodium hyaluronate was injected during the ESD procedure.
d The opened specimen measured 220 × 140 mm (longest specimen axis 247 mm), with the
tumor occupying 210 × 140 mm (longest tumor axis 225 mm). e Endoscopic view during the first endoscopic balloon dilation session 2 months after
ESD. f The ESD site 4 months after ESD and after three dilation sessions.
Three submucosal pockets were created, leaving submucosal tissue between the pockets
to maintain traction until the end of the ESD procedure. Circumferential mucosal incision
at the proximal border of the cylindrical tumor was performed before completion of
submucosal dissection in order to avoid visual interference of a flap from the resected
distal portion. The resected tumor was extracted by defecation ([Fig. 1 c], [Fig. 1 d]) [2].
Pathological examination showed an intramucosal, well-differentiated, adenocarcinoma
in an adenoma, with negative resection margins and no lymphovascular invasion. The
patient was discharged without complications. Betamethasone suppositories (1.0 mg/day)
were given for 8 weeks to prevent stricture formation.
Although the patient remained free of obstructive symptoms, follow-up colonoscopy
at 2 months revealed stenosis at the ESD site. This was dilated using endoscopic balloon
dilation up to 16.5 mm in diameter in a stepwise manner over three sessions ([Fig. 1 e], [Fig. 1 f]) [3]. At the 7-month follow-up, the patient was asymptomatic.
Endoscopic submucosal dissection of a 210-mm-long (longest tumor axis 225 mm) circumferential
rectosigmoid intramucosal carcinoma.
In this patient, a 210-mm-long circumferential tumor was completely resected. To the
best of our knowledge, this is the first description of curative ESD for a circumferential
rectosigmoid intramucosal cancer > 200 mm long. Although obstructive symptoms are
almost inevitable following ESD of a long circumferential esophageal lesion, this
patient experienced no obstructive symptoms. The risk of obstruction after circumferential
ESD may be lower in the colon and rectum [4] than in the esophagus, owing to a larger lumen and possible self-dilation by stool.
Colorectal circumferential ESD is feasible and may have a low risk of post-ESD obstruction.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
