Endoscopic submucosal dissection of large sessile colorectal adenomas

Introduction: Endoscopic submucosal dissection (ESD) is a useful method to accomplish en-block resection of large, laterally spreading, sessile adenomas and intramucosal cancers. Colorectal ESD is technically more difficult, however, and there is an increased risk of complications such as perforation and bleeding compared with gastric ESD. The aim of the present study were to compare the available ESD accessories with different dissection techniques and to improve the outcome.

Patients and Methods: ESD has been performed in 15 consecutive patients (pts) up till now due to laterally spreading tumors in the sigmoid and the rectum, in which histology proved dysplastic adenomas or intramucosal carcinomas. Before ESD, all pts had multiple biopsy and endoscopic ultrasound (EUS) of the lesion. Different type of hyaluronic acid solutions and available Olympus and Fujinon knifes were applied and compared.

Results: No submucosal invasion was predicted by EUS. Successful ESD was completed in all but one patient, en-block resection was possible in 8 out of 14 patients. Mean procedural time was 195+50min. Mean diameter of the lesions were 3.5+2cm. Bleeding could be always controlled by coagulation forceps and hemoclipp application. No late complication was observed. To ensure a long lasting (over 60 minutes) tissue elevation after submucosal injection the application of polymerised hyaluronic acid proved to be the best. Trinagular knife was the optimal choice for incision and circumferencial cut, and hook knife or flush knife were the most suitable devices for submucosal preparation and dissection. Preventive coagulation of large submucosal vessels could be safely performed with coagulation forceps at 60 W to reduce the risk of immediate bleeding.

Conclusions: This limited case series demonstrated that large laterally spreading tumors in the rectum and rectosigmoid colon could be safely resected en bloc with ESD.