Modified Pocket Endoscopic Submucosal Dissection Technique for Resection of a Giant Rectal Lateral Spreading Tumor

Lateral spreading tumors in the rectum (LST’s) may be granular or nongranular. Granular LST’s (LST-G) can have a nodular component that may harbor intramucosal or invasive cancer. En bloc resection of these lesions is therefore mandatory to provide optimum histological assessment and for the resection to be potentially curative. Endoscopic submucosal dissection (ESD) provides improved curative resection rates and reduced recurrence as compared with piecemeal endoscopic mucosal resection (EMR).[1] ESD, however, is technically challenging, involves prolonged procedure times and has associated adverse events.[2] Pocket ESD has been described as a variation to simplify the standard ESD procedure as it maintains submucosal (SM) elevation and tissue lift, provides retraction, and thereby permits quicker dissection.[3] [4]

Pocket ESD involves mucosal incision on anal aspect, creation of SM pocket under the lesion, followed by extension and completion of mucosal incision to deliver the specimen. By retaining the peripheral mucosa, fluid leakage is reduced and SM elevation is better maintained. The tip of the endoscope in the SM pocket facilitates tissue traction, facilitating SM dissection in a plane parallel to the muscularis. However, pocket ESD is difficult to perform in very large lesions as the pocket becomes too wide and unwieldy to handle and optimum retraction cannot be maintained. This video case report demonstrates a modification of the standard pocket ESD technique which enabled us to safely resect a large rectal LST.

Publikationsverlauf

Artikel online veröffentlicht:
04. Mai 2020

• References

• 1 Saito Y, Fukuzawa M, Matsuda T. et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc 2010; 24 (02) 343-352
• 2 Takeuchi Y, Iishi H, Tanaka S. et al. Factors associated with technical difficulties and adverse events of colorectal endoscopic submucosal dissection: retrospective exploratory factor analysis of a multicenter prospective cohort. Int J Colorectal Dis 2014; 29 (10) 1275-1284
• 3 Hayashi Y, Miura Y, Yamamoto H. Pocket-creation method for the safe, reliable, and efficient endoscopic submucosal dissection of colorectal lateral spreading tumors. Dig Endosc 2015; 27 (04) 534-535
• 4 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 (02) E123-E129