En bloc endoscopic submucosal dissection of a 14-cm laterally spreading adenoma. of the rectum with involvement to the anal canal: expanding the frontiers of endoscopic surgery (with video)

Background: Endoscopic submucosal dissection (ESD) was recently developed in Japan for en bloc removal of laterally spreading tumors (LSTs). Although initially used for gastric tumors, ESD has now been applied to lesions elsewhere in the gut. Recent reports from Japan included removal of colorectal lesions up to 10 cm. Objective: To show the feasibility of ESD to remove en bloc, very large LSTs of the rectum, even when there is involvement to the dentate line. Design: Case report. Setting: The procedure was performed at an American GI unit. The patient was admitted to the hospital after the procedure for observation. Patients: A 53-year-old patient, with a 14-cm tubulovillous adenoma of the rectum, which, at its maximal extent, involved two thirds of the circumference of the rectum. The tumor extended distally to the dentate line. Interventions: En bloc submucosal dissection with a conventional needle-knife to remove the neoplasm. Main Outcome Measurements: Completeness of en bloc removal of the tumor and subsequent follow-up endoscopy that showed no residual neoplasm. Results: The tumor was able to be removed en bloc by ESD. The distal margin included squamous mucosa. At a 2.5-week endoscopic follow-up, a 3-mm focus of residual polyp was seen and removed. At the time of the last follow-up, there was complete healing of the wound and no residual neoplasm. Limitations: Single case. Conclusions: This case demonstrated the feasibility of using ESD to remove large laterally spreading rectal tumors, including when there was involvement to the dentate line (and the dissection line must include squamous mucosa of the anal canal). ESD is a promising alternative to conventional surgical techniques; however, additional published experience is needed.