Endoscopic transmural hydro-dissection as a rescue therapy for rectal fibrotic adenoma

The rectum is considered a feasible and safe area in which to perform endoscopic submucosal dissection (ESD) [1] [2]. Therefore, ESD is a suitable approach for the treatment of high risk rectal adenomas. However, scarred and fibrotic polyps have recently been described as the only preoperative predictor of failed ESD in the rectum [2] [3]. Transanal endoscopic microsurgery (TEM) has been shown to be an effective treatment for lower rectal carcinomas staged as T1 or T2 [4], owing to the depth of the resection.

We present the case of a 25 mm 0-Is type adenoma with wide scarred areas caused by two previous failed TEMs, located 3 cm away from the dentate line ([Fig. 1]), in a 75-year-old man without any relevant medical history.

Fig. 1 Intensely scarred adenoma located 3 cm away from the dentate line.

The pocket creation method was adopted because of the expected submucosal fibrotic tissue [5]. The first stage of the tunnel was created without any drawbacks using an Erbejet-2-HybridKnife (Erbe Elektromedizin GmbH, Tübingen, Germany). However, when the area below the lesion was reached, dramatic fibrotic tissue became visible. This finding made it extremely difficult to identify a feasible cutting line between the submucosal and muscular layers. At this point (stage 2), we decided to carry out a transmural dissection between the transverse and longitudinal muscular layers, in order to reach a feasible cutting line inside the submucosal layer ([Fig. 2], [Fig. 3], [Video 1]). Consequently, we successfully achieved en bloc resection of the lesion (stage 3). Subsequently, the muscular defect was closed using endoclips (Resolution; Boston Scientific, Marlborough, Massachusetts, USA). The patient was discharged 72 hours after the procedure.

Fig. 2 Transmural dissection planning diagram. a Different layers exposed during the procedure. b Final result. Red line indicates the previous location of the adenoma. SM, submucosal layer; ML, muscular layer.

Fig. 3 Detailed endoscopic transmural hydro-dissection procedure. a – c Initial step: tunnel creation across the submucosal layer. d Submucosal and muscular layer fusion without a feasible traditional cutting line. e Cutting of transverse and longitudinal muscular layer. f Dissection phase between transverse and longitudinal layer. g Remaining longitudinal muscular layer and perirectal fatty tissue exposed inside the tunnel. h Endoscopic submucosal dissection in retroflex position across the submucosal layer. i – k Final dissection steps. l Specimen mounted onto cork.

Video 1 Endoscopic transmural hydro-dissection by pocket creation method of a sessile scarred polyp located in the lower rectum.

The histopathological analysis revealed a transmural specimen with high grade dysplasia (R0 resection), intense fibrotic submucosal tissue, and superficial muscular propria layer ([Fig. 4]).

Fig. 4 Microscopic analysis of the dissected specimen, focusing on the different stages of the procedure. SML, submucosal layer; ML, muscular layer.

In conclusion, the pocket creation method performed in fibrotic and scarred lesions located in the lower rectum, allowed a safe and deep dissection across muscular layers. This approach might support ESD as a rescue therapy following failed TEM.

Endoscopy_UCTN_Code_TTT_1AO_2AG

• References

• 1 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2015; 47: 829-854
• 2 Iacopini F, Saito Y, Bella A. et al. Colorectal endoscopic submucosal dissection: predictors and neoplasm-related gradients of difficulty. Endosc Int Open 2017; 5: E839-E846
• 3 Hong SN, Byeon JS, Lee BI. et al. Prediction model and risk score for perforation in patients undergoing colorectal endoscopic submucosal dissection. Gastrointest Endosc 2016; 84: 98-108
• 4 Sajid MS, Farag S, Leung P. et al. Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer. Colorectal Dis 2014; 16: 2-14
• 5 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