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DOI: 10.1055/a-1918-1639
Complete resection of residual rectal dysplasia in a patient with ulcerative colitis using the pocket-creation method
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Formerly, when ulcerative colitis-associated neoplasia (UCAN) was identified, total colectomy was required to prevent future colorectal cancers. Since the introduction of the SCENIC guideline (2015) [1], endoscopic resection of UCAN is gradually being accepted. UCANs are however obscurely demarcated and have severe submucosal fibrosis, which makes endoscopic R0 resection challenging. Although multiple biopsies can be helpful to demarcate UCAN, they make the resection more challenging. The pocket-creation method (PCM) of endoscopic submucosal dissection (ESD) is good for resecting fibrotic submucosa, such as that under nongranular laterally spreading tumors [2] or after endoscopic interventions including biopsies. We illustrate the complete endoscopic resection of an area of rectal dysplasia in a patient with UC using the PCM.
The patient was a 67-year-old man who had an 18-year history of UC. Although he had undergone endoscopic mucosal resection (EMR) of an adenoma in the distal rectum 3 years previously, the resection margin was pathologically positive, and a surveillance colonoscopy 2 years after the resection revealed residual dysplasia. He was referred to our hospital because he wanted to undergo endoscopic local resection instead of total colectomy. After he had received 3 months of concurrent treatment with 5-aminosalicylic acid enemas for the still inflamed rectum, along with oral 5-aminosalicylic acid and vedolizumab, a slightly red elevated lesion was identified ([Fig. 1]). Multiple biopsies were taken from this elevated area and also from the surrounding mucosa to determine the extent of the dysplasia, with the outermost biopsies being found to be negative for dysplasia.
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The PCM was performed after the area of dysplasia had been demarcated by reference to the surrounding negative biopsies ([Video 1]). Despite severe submucosal fibrosis caused by chronic inflammation, the previous EMR, and the multiple biopsies ([Fig. 2]), en bloc resection was achieved, without any adverse events. Pathologic evaluation revealed a low grade dysplastic lesion, with a negative margin ([Fig. 3]).
Video 1 Complete resection of residual rectal dysplasia after endoscopic mucosal resection in a patient with ulcerative colitis using the pocket-creation method of endoscopic submucosal dissection.
Quality:
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This patient demonstrates that rectal dysplasia with severe submucosal fibrosis due to UC and previous multiple endoscopic interventions can be safely and completely resected using the PCM.
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Publication History
Article published online:
01 September 2022
© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
- 1 Laine L, Kaltenbach T, Barkun A. et al. SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. Gastroenterology 2015; 148: 639-651 e628
- 2 Sakamoto H, Hayashi Y, Miura Y. et al. Pocket-creation method facilitates endoscopic submucosal dissection of colorectal laterally spreading tumors, non-granular type. Endosc Int Open 2017; 5: E123-E129