Endoscopic submucosal dissection (ESD) is recommended for complete en bloc resection
of colonic lesions that are larger than 20 mm and with a high risk of limited submucosal
invasion, based on depressed morphology and an irregular or nongranular surface pattern
[1]. Recent studies have shown that countertraction techniques using clips and a rubber
band increase the R0 resection rate and significantly decrease the procedure time,
while also decreasing the complication rates (perforation and bleeding) [2].
We report here the case of an 87-year-old patient who was on no anticoagulant or antiplatelet
treatment and had no prior coagulation disorder. A pseudodepressed nongranular 15-mm
laterally spreading tumor (Paris 0-IIa + 0-IIc, Kudo Vn, Sano IIIb, JNET III, NICE
III) was found in the right colon. Although right hemicolectomy would have been the
standard therapy, because of the small size of the lesion and the advanced age of
our patient, we decided to perform a diagnostic en bloc resection using ESD with countertraction
([Fig. 1]). A 30 × 25-mm piece was retrieved and the dissection scar was closed with three
hemostatic clips (Resolution 360; Boston Scientific, USA) ([Video 1]).
Fig. 1 Schema of the endoscopic procedure showing: a the circumferential incision; b countertraction with clips and a rubber band; c closure of the mucosal defect; d retrieval of the resected specimen.
Video 1 Endoscopic submucosal dissection using countertraction is performed for a colonic
laterally spreading tumor; bleeding is later identified from the opposite colonic
wall and endoscopic hemostasis is achieved.
Several hours after the procedure, the patient presented with significant rectorragia,
so a second colonoscopy was performed. Active bleeding was observed from the colonic
wall that was opposite to the dissection scar, corresponding to the point where the
traction clip had been previously placed ([Fig. 2]; [Video 1]). Hemostasis was obtained using a hot biopsy forceps (EndoJaw Hot; Olympus, Japan)
and two hemostatic clips. The patient was discharged 48 hours later, having experience
no other adverse events.
Fig. 2 Endoscopic view showing bleeding from the opposite colonic wall.
To the best of our knowledge, this is the first report of active bleeding from the
opposing normal colonic wall, where a traction clip had been placed. Although very
rare, this case highlights the importance of gentle traction on the parietal clip
when retrieving the dissection specimen, and careful inspection of the site prior
to completion of the procedure.
Endoscopy_UCTN_Code_CPL_1AJ_2AD
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.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
