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Endoscopic transmural hydro-dissection as a rescue therapy for rectal fibrotic adenoma
21 February 2018 (online)
The rectum is considered a feasible and safe area in which to perform endoscopic submucosal dissection (ESD)  . 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  . Transanal endoscopic microsurgery (TEM) has been shown to be an effective treatment for lower rectal carcinomas staged as T1 or T2 , 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.
The pocket creation method was adopted because of the expected submucosal fibrotic tissue . 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.
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]).
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.
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