Is a second ligation necessary in endoscopic submucosal resection of rectal carcinoid tumors?

With great interest, we have read the article of Moon et al. on endoscopic submucosal resection with a double ligation technique for treatment of rectal carcinoid tumors [1]. They have modified our technique of endoscopic submucosal resection with a ligation device (ESMR-L) [2]; that is, they have applied a second detachable snare to ligate the stalk below the elastic band and performed snare resection above the elastic band. They have employed this modified technique for complete removal of 11 rectal carcinoid tumors, without immediate or late complication such as bleeding or perforation. They concluded that it is a useful and safe method for the treatment of small rectal carcinoid tumors.

In our opinion, the second application of a detachable snare is not necessary for carcinoid tumors located within the lower part of the rectum. Generally, most rectal carcinoid tumors are detected in the lower rectum, where the wall is significantly thicker and supported by surrounding connective tissue. Therefore ESMR-L, providing a deeper margin at the cut end to remove these tumors completely, can be performed safely without perforation. In our first reported study, we encountered no immediate or late perforation associated with this procedure [2]. As the number of cases in that study was limited we have conducted a further investigation including removal of 63 rectal carcinoid tumors by ESMR-L, and there was still no procedure-related perforation [3]. With regard to bleeding, four lesions developed minor bleeding during the procedure and one lesion at 4 hours after the endoscopic resection. However, hemostasis was successfully achieved in all cases using hemoclips; thus no blood transfusion or surgery was necessary. We fear that using a second detachable snare for removal of carcinoid tumors, according to the suggestion of Moon et al., would result in a waste of time and resources.

In addition, they have cited our paper wrongly in their reference 15, giving the authors’ names incorrectly.

In conclusion, to save time and resources, we recommend the ESMR-L rather than the ESMR-DL technique, for carcinoid tumors that are 10 mm or smaller in size and located within the lower rectum.

Competing interests: None.

References

• 1 Moon J H, Kim J H, Park C H. et al . Endoscopic submucosal resection with double ligation technique for treatment of small rectal carcinoid tumors.  Endoscopy. 2006;  38 511-514
• 2 Ono A, Fujii T, Saito Y, Matsuda T. et al . Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device.  Gastrointest Endosc. 2003;  57 583-587
• 3 Mashimo Y, Matsuda T, Uraoka T. et al . Endoscopic submucosal resection with a ligation device is an effective and safe treatment for carcinoid tumors in the lower rectum.  J Gastroenterol Hepatol,. in submission;