Strategies to successfully complete complex ESD in the colon

Introduction

Endoscopic submucosal dissection (ESD) is challenging in the colon. Lesions with fibrosis and located in diverticular areas add extra technical difficulty [1] [2] [3].

We describe the case of a 71-year-old woman with a sigma 20-mm nongranular, laterally spreading tumor (LST NG) with a type Vi pit pattern and NICE 2, surrounded by diverticula and in contact with a tattoo ([Fig. 1] and [Fig. 2]). A tattoo close to a lesion can make its resection even harder [4].

Fig. 1 Lesion.

Fig. 2 Lesion i-Scan.

Endoscopy

The procedure was performed with a Pentax gastroscope (EPI-i 7010 processor) with a straight cap and a Type-T HybridKnife connected to the ERBEJET system and combined with VIO3 electrosurgery equipment (endoCUT Q and preciseSECT).

Due to the anatomical difficulty and the presence of fibrosis secondary to the tattoo, an immersion dissection with bottled water was performed with creation of a pocket for greater stability and safety. Fibrosis was managed with the knife in “probe mode,” which consists of using the knife in a closed position that offers a cutting diameter of 1.5 mm and a cutting depth of 0.5 mm, offering security and precision [5] ([Fig. 3]). The dissection was largely performed in preciseSECT mode, which offers a perfect balance between cutting ability and hemostasis ([Video 1]).

Fig. 3 The "probe mode". Courtesy of MD, PhD F. Ramos-Zabala.

Complex ESD in colon.Video 1

The ESD was performed and an en-bloc specimen measuring 30 × 28 mm was obtained. Histologic examination revealed an adenoma with high-grade dysplasia and extensive areas of intramucosal adenocarcinoma. The lateral and deep margins were disease-free (> 1 mm).

Review 6 months later showed a clean scar with normal biopsies ([Fig. 4]).

Fig. 4 Scar at 6 months.

Conclusions

Immersion dissection with pocket creation may be useful when treating challenging lesions. Using the HybridKnife in “probe mode” and preciseSECT is effective and safe in fibrotic areas.

We recommend evaluating the need for tattooing prior to dissection due to the risk of extension into the submucosa with consequent secondary fibrosis.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Ikezawa N, Toyonaga T, Tanaka S. et al. Feasibility and safety of endoscopic submucosa dissection for lesions in proximity to a colonic diverticulum. Clinc Endosc 2022; 55: 417-425
• 2 Muramoto T, Ohata K, Sakai E. et al. Endoscopic submucosal dissection for colorectal neoplasms in proximity or extending to a diverticulum. Surg Endosc 2021; 35: 3479-3487 DOI: 10.1007/s00464-020-07795-y. (PMID: 32671524)
• 3 Jimenez-García VA, Yamada M, Ikematsu H. et al. Endoscopic submucosal dissection in management of colorectal tumors near or involving a diverticulum: a retrospective case series. Endosc Int Open 2019; 7: E664-E671 DOI: 10.1055/a-0848-8048. (PMID: 31061878)
• 4 Barquero D, González V, García O. et al. Ways to perform an endoscopic tattoo. Prospective and randomized study in patients with colorectal neoplasm. Rev Esp Enferm Dig 2021; 113: 519-523
• 5 Ramos Zabala F, García M, Domínguez A. et al. Combination of immersion in saline solution, pocket-creation method, water-jet hydrodissection, and hybrid knife “probe mode” simplifies endoscopic submucosa dissection in giant rectal polyp. VideoGIE 2019; 4: 478-480

Publication History

Received: 06 January 2024

Accepted after revision: 14 March 2024

Article published online:
25 July 2024