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DOI: 10.1055/a-2604-8189
An Y shaped tunnel to bypass a hemorrhoid band ligation scar during rectal endoscopic submucosal dissection
Authors
Endoscopic submucosal dissection (ESD) has advanced significantly in the past decade, incorporating numerous technical enhancements. For colorectal ESD, the European Society of Gastrointestinal Endoscopy (ESGE) recommends the pocket-creation method when traction devices are not employed [1]. Extending and opening the pocket at the opposite side of the lesion creates a tunnel, enabling resection of very large colorectal lesions through single, double, or multiple tunnels [2] [3] [4].
We present a 54-year-old woman referred for endoscopic resection of a large rectal laterally spreading tumor (LST). Notably, the anal side of the lesion exhibited a substantial fibrous scar from prior hemorrhoidal band ligation, extending near and beyond the dentate line ([Fig. 1]). Two years earlier, she had undergone hemorrhoidal band ligation without a preceding colonoscopy.
To navigate the fibrotic area and achieve en-bloc resection, we employed a Y-shaped tunnel ESD technique ([Video 1]). At the oral side, there was one opening (the base or the Y letter), while at the anal side, there were two openings (the oblique arms of the Y letter).
An Y-shaped tunnel seen from the oral side during rectal endoscopic submucosal dissection.Video 1Minimal delayed bleeding occurred one week after the procedure, for which thermal coagulation was performed. Histopathological examination confirmed an R0 resection of a low-grade traditional adenoma.
While ESD of distal rectal LSTs overlying stapled mechanical hemorrhoidectomy sites has been documented, to our knowledge, this is the first reported case utilizing a Y-shaped tunnel to bypass a hemorrhoid band ligation scar during rectal ESD [5].
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Publication History
Article published online:
18 June 2025
© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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References
- 1 Libânio D, Pimentel-Nunes P, Bastiaansen B. et al. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2023; 55: 361-389
- 2 Aslan F, Akpinar Z, Yurtlu DA. et al. Single tunneling method with endoscopic submucosal dissection for treatment of a rectal giant (18-cm) laterally spreading tumor. Endoscopy 2017; 49 (Suppl. 01) E114-E116
- 3 Stasinos I, Toyonaga T, Suzuki N. Double-tunneling butterfly method for endoscopic submucosal dissection of extensive rectal neoplasms. VideoGIE 2020; 5: 80-85
- 4 Aslan F, Akpınar Z, Kucuk M. et al. Multiple tunneling technique for treatment of rectal circumferential laterally spreading tumor with endoscopic submucosal dissection. VideoGIE 2016; 2: 32-34
- 5 Ferreira FB, Cardoso M, Lourenço LC, Horta D. CC-14 – Long(o) time no see … – ESD of a distal rectum LST over an hemmoroidopexy scar [abstract]. https://www.sped.pt/images/Live/programafinal_livesped2023.pdf