The authors report a case of a 48-year-old Caucasian woman with a 3.5 cm residual
polyp embedded in tissue scar, as a result of three endoscopic piecemeal resection
sessions of a 10 cm sessile polyp of the lower rectum, previously diagnosed from biopsy
as tubulous-villous adenoma with high-grade dysplasia.
The patient was then submitted to en bloc resection with endoscopic submucosal dissection
(ESD) according to the technique of Yamamoto [1]
[2] ([Fig. 1] – [3]). The preparation of the patient consisted of mechanical bowel cleansing with polyethylene
glycol solution and 5 days of oral antibiotic therapy with ciprofloxacin (500 mg twice
daily) and metronidazole (500 mg three times daily).
The procedure was carried out using a single-channel upper gastrointestinal endoscope
with a water-jet system (Olympus GIF 1T-160, Tokyo, Japan). A transparent cap (ST-HOOD,
DH 15GR, Fujinon, Saitama, Japan) was attached to the tip of the endoscope in order
to apply tension to the submucosal connective fibers during dissection ([Fig. 4] – [5]). The procedure time was 2 hours. The postoperative course was uneventful and the
patient was discharged 2 days after the procedure.
The histological examination of the resected specimen described a residual adenomatous
tissue with high-grade dysplasia; the excision margins were negative (R0 resection).
The patient underwent control endoscopy 6 months later ([Fig. 6]), and multiple biopsies were taken of the resected area, which were negative at
the histological examination.
In cases of large polyps the standard of care is endoscopic piecemeal resection that,
unfortunately, carries two disadvantages: the margins of resection may be difficult
to evaluate by the pathologist, and in 14 % – 50 % of cases at least one additional
endoscopic session is required [3]. Notably, further endoscopic resection is often difficult as a result of fibrosis.
These concerns are emphasized in large villous sessile rectal polyps because of their
high potential for malignant transformation. In the reported case, the en bloc resection
of a residual polyp, not amenable to standard endoscopic treatment (including endoscopic
mucosal resection), was accomplished by ESD, avoiding a more invasive surgical procedure.
As reported for residual/recurrence of early gastric cancer after endoscopic mucosal
resection [4]
[5], ESD can be proposed as an interesting endoscopic “rescue therapy” for residual
rectal scar-embedded polyps.
Fig. 1 Creation of a submucosal cushion. About 40 ml of a mixed solution of hyaluronic acid
preparation (0.5 %), saline, and diluted epinephrine (1 : 40 000) was injected into
the submucosal layer. “No lifting sign” was present.
Fig. 2 Incision of the circumferential margins with standard needle knife in 120 W endocut
mode (Erbe ICC 200, Tubingen, Germany).
Fig. 3 Dissection of the submucosal layer with standard needle knife in 25 W forced mode.
When the submucosal tissue was particularly hard due to scarring, the dissection was
performed in 120 W endocut mode.
Fig. 4 Using a lateral movement and stressing the submucosal fibers using the transparent
cap. Hemorrhage or visible vessels were treated by soft 60 W electrocoagulation using
a coagulation forceps (Pentax SDB2422, Maeno-cho, Itabashi-ku, Tokyo, Japan) or by
positioning metallic clips (Quick clip 2, HX-201UR-135, Tokyo, Japan).
Fig. 5 Operatory field at the end of the procedure. The polyp was extracted and subsequently
orientated on a rigid support.
Fig. 6 The resected area 6 months after the procedure (“restitutio ad integrum”).
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