Clinical course after endoscopic submucosal dissection in the rectum leaving a circumferential mucosal defect of 26 cm in length

A 70-year-old woman underwent a computed tomography (CT) scan for follow-up of a suspected intraductal papillary mucinous neoplasm, which showed thickening of the rectal wall. She subsequently underwent a colonoscopy, which showed a long circumferential lateral spreading tumor that was occupying nearly the entire rectum ([Fig. 1]). Endoscopic findings in a region with a small nodule indicated the possibility of submucosal tumor invasion; however, the CT scan showed no evidence of tumor metastasis.

Fig. 1 A long circumferential laterally-spreading granular-type tumor that was occupying nearly the entire rectum seen on: a standard endoscopic view; b chromoendoscopic view with indigo carmine dye.

Endoscopic submucosal dissection (ESD) was performed with the aim of reducing the invasiveness of her treatment. A Flush knife-BT (FUJIFILM) was used [1] and en bloc resection was achieved ([Fig. 2]), with the total procedure taking 275 minutes. Histopathologic examination showed well-differentiated adenocarcinoma in an adenoma, 250 × 135 mm in size, with 3000-μm submucosal invasion in a 4-mm nodular area without lymphovascular invasion ([Fig. 3]).

Fig. 2 The artificial ulcer left after endoscopic submucosal dissection (ESD), a circumferential mucosal defect of 26 cm in length that covered the whole rectum and part of distal sigmoid colon.

Fig. 3 Macroscopic view of the resected specimen, which measured 260 × 135 mm.

The patient did not wish to undergo additional surgery. Betamethasone suppositories (2 mg/day) were administered to prevent postoperative stricture and were tapered off over 4 months. There were no major symptomatic complaints from the patient after she underwent ESD. Follow-up colonoscopies showed slow epithelialization with no evidence 1 month later, approximately 20 % progress 2 months later, and 50 % coverage 3 months later. After 4 months, a membranous stricture was identified ([Fig. 4 a]) and successfully treated with one-time endoscopic balloon dilation (EBD). At the last follow-up 9 months later, healing was progressing with near complete epithelialization seen ([Fig. 4 b]).

Fig. 4 Endoscopic views during follow-up showing: a the stricture that occurred 4 months after the endoscopic submucosal dissection (ESD); b almost complete epithelialization of the treatment area 9 months later.

Previous articles have reported on the usefulness of ESD in large early colorectal tumors [2] [3] [4]. We demonstrated that a more than 90 % circumferential mucosal resection in the rectum carries the risk of postoperative stricture, which has been reported to occur on average 1 month after ESD [5]. In the present case, the emergence of a stricture and the development of epithelialization were slow, which may have been due to the extreme size of the resected area and to the steroid treatment.

Although the present case, to the best of our knowledge, had the longest circumferential mucosal defect after ESD in the rectum that has so far been reported, this long circumferential mucosal resection resulted in only a membranous stricture, which was easily treated by EBD.

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• References

• 1 Toyonaga T, Man-I M, Fujita T et al. The performance of a novel ball-tipped Flush knife for endoscopic submucosal dissection: a case-control study. Aliment Pharmacol Ther 2010; 32: 908-915
• 2 Toyonaga T, Man-i M, Fujita T et al. Retrospective study of technical aspects and complications of endoscopic submucosal dissection for laterally spreading tumors of the colorectum. Endoscopy 2010; 42: 714-722
• 3 Tang X, Jiang B, Gong W. Successful en bloc endoscopic submucosal dissection of a giant rectal laterally spreading adenoma. Endoscopy 2014; 46 (Suppl. 01) E615-E616
• 4 Tanaka S, Toyonaga T, Morita Y et al. Feasibility and safety of endoscopic submucosal dissection for large colorectal tumors. Surg Laparosc Endosc Percutan Tech 2015; 25: 223-228
• 5 Ohara Y, Toyonaga T, Tanaka S. Risk of stricture after endoscopic submucosal dissection for large rectal neoplasms. Endoscopy Epub ahead of print 2015; Jul 28.