The advent of endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) have changed the treatment scenario for recurrent polyps, which represented one of the bigger challenges for endoscopists when endoscopic mucosal resection (EMR) was the only available technique. However, these two techniques have some limits: high grade fibrosis may reduce the possibility of performing ESD and increase the risk of perforation [1]
[2], while the size, thickness, and rigidity of the lesion, the mobility of the wall, and the location and grade of fibrosis may limit EFTR [3]
[4]. Our aim was to evaluate the feasibility, efficacy, and safety of a single-session combined technique performing ESD and EFTR for adenomatous recurrence in the rectum.
In 2014, a 65-year-old man underwent EMR of a tubulovillous adenoma with low grade dysplasia (LGD) with a diameter of 40 mm in the rectum. The 3-year follow-up colonoscopy showed an adenomatous recurrence of 25 mm, characterized by a sessile part and a flat part, positioned on the back of the second Huston’s valve. ESD appeared difficult to perform alone because of the high grade fibrosis of the sessile portion, while an approach with EFTR was unfeasible because of the size, rigidity, and back-fold position of the flat part. Therefore, we decided to perform a partial ESD of the back-fold flat portion, thereby obtaining lesion mobility to allow performance of EFTR of the whole lesion ([Video 1]).
Video 1 A recurrent rectal polyp is successfully treated in a same-session combined approach using first endoscopic submucosal dissection (ESD) and then endoscopic full-thickness resection (EFTR).
Histologic examination of the resected lesion showed an en bloc specimen of tubulovillous adenoma with LGD and free resection margins ([Fig. 1]). After 12 months of follow-up, there is no evidence of endoscopic or histologic recurrence ([Fig. 2]).
Fig. 1 Histology of the resected en bloc specimen showing a tubulovillous adenoma with low grade dysplasia.
Fig. 2 Endoscopic views showing no evidence of recurrence at the 12-month follow-up.
In conclusion, this one-session combined endoscopic technique could represent a valid option for the resection of “hard-to-treat” recurrent rectal polyps, thereby reducing the need for surgical treatment.
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Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online.
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