Rectal reconstruction after endoscopic submucosal dissection for removal of a giant rectal lesion (2019)

Endoscopic submucosal dissection (ESD) allows en bloc removal of large GI-tract lesions.1Draganov P.V. Gotoda T. Chavalitdhamrong D. et al.Techniques of endoscopic submucosal dissection: application for the Western endoscopist?.Gastrointest Endosc. 2013; 78: 677-688Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 2Farhat S. Chaussade S. Ponchon T. et al.Endoscopic submucosal dissection in a European setting: a multi-institutional report of a technique in development.Endoscopy. 2011; 43: 664-670Crossref PubMed Scopus (144) Google Scholar, 3Uraoka T. Parra-Blanco A. Yahagi N. Colorectal endoscopic submucosal dissection: is it suitable in western countries?.J Gastroenterol Hepatol. 2013; 28: 406-414Crossref PubMed Scopus (73) Google Scholar However, removal of large tumors creates big mucosal defects, which can cause delayed bleeding and delayed perforation.4Oka S. Tanaka S. Kanao H. et al.Current status in the occurrence of postoperative bleeding, perforation and residual/local recurrence during colonoscopic treatment in Japan.Dig Endosc. 2010; 22: 376-380Crossref PubMed Scopus (120) Google Scholar, 5Fujiya M. Tanaka K. Dokoshi T. et al.Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection.Gastrointest Endosc. 2015; 81: 583-595Abstract Full Text Full Text PDF PubMed Scopus (217) Google Scholar, 6Kantsevoy S.V. Bitner M. Mitrakov A.A. et al.Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos).Gastrointest Endosc. 2014; 79: 503-507Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar In addition, resection of circumferential or nearly circumferential tumors can result in subsequent stenosis, requiring endoscopic dilation, placement of stents, or even surgical correction.7Iizuka H. Kakizaki S. Sohara N. et al.Stricture after endoscopic submucosal dissection for early gastric cancers and adenomas.Dig Endosc. 2010; 22: 282-288Crossref PubMed Scopus (57) Google Scholar, 8Shi Q. Ju H. Yao L.Q. et al.Risk factors for postoperative stricture after endoscopic submucosal dissection for superficial esophageal carcinoma.Endoscopy. 2014; 46: 640-644Crossref PubMed Scopus (97) Google Scholar, 9Ohara Y. Toyonaga T. Tanaka S. et al.Risk of stricture after endoscopic submucosal dissection for large rectal neoplasms.Endoscopy. 2016; 48: 62-70PubMed Google Scholar, 10Abe S. Sakamoto T. Takamaru H. et al.Stenosis rates after endoscopic submucosal dissection of large rectal tumors involving greater than three quarters of the luminal circumference.Surg Endosc. 2016; 30: 5459-5464Crossref PubMed Scopus (19) Google Scholar Various measures have been suggested to prevent delayed bleeding (closure of mucosal defect with endoscopic clips) and stenosis (local injection of triamcinolone, insertion of betamethasone suppositories, and oral prednisone in tapered doses) after removal of large GI-tract lesions.9Ohara Y. Toyonaga T. Tanaka S. et al.Risk of stricture after endoscopic submucosal dissection for large rectal neoplasms.Endoscopy. 2016; 48: 62-70PubMed Google Scholar, 11Hashimoto S. Kobayashi M. Takeuchi M. et al.The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic submucosal dissection.Gastrointest Endosc. 2011; 74: 1389-1393Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar, 12Yamaguchi N. Isomoto H. Nakayama T. et al.Usefulness of oral prednisolone in the treatment of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma.Gastrointest Endosc. 2011; 73: 1115-1121Abstract Full Text Full Text PDF PubMed Scopus (221) Google Scholar, 13Shoji H. Yamaguchi N. Isomoto H. et al.Oral prednisolone and triamcinolone injection for gastric stricture after endoscopic submucosal dissection.Ann Transl Med. 2014; 2: 22PubMed Google Scholar, 14Liaquat H. Rohn E. Rex D.K. Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions.Gastrointest Endosc. 2013; 77: 401-407Abstract Full Text Full Text PDF PubMed Scopus (201) Google Scholar We now report the use of the endoscopic suturing device Overstitch (Apollo Endosurgery, Austin, Tex, USA) for reconstruction of rectal mucosa to prevent delayed adverse events after endoscopic removal of a giant rectal lesion. A 51-year-old man had experienced a discharge of mucus from the rectum for 2 months. His colonoscopy revealed a giant granular-type laterally spreading tumor (LST-GM 0-IIa+Is) starting at the dentate line and occupying the entire length of the rectum (Fig. 1; Video 1, available online at www.VideoGIE.org). The lesion was removed en bloc by ESD with the use of a HybridKnife (Erbe USA, Marietta, Ga, USA) and DualKnife-J (Olympus America, Center Valley, Pa, USA), assisted by multidirectional traction with a DiLumen (Lumendi LLC, Westport, Conn, USA) double-balloon interventional platform (Figure 2, Figure 3). Removal of the lesion created a very large mucosal defect, practically eliminating approximately 90% of the rectal mucosa (Figure 4, Figure 5). Endoscopic rectal reconstruction was performed with an Overstitch endoscopic suturing device. The entire mucosal defect was completely closed with 2 continuous sutures (Figure 6, Figure 7). After ESD and rectal reconstruction, the patient was completely asymptomatic and pain free, and he was discharged home on day 2 after the procedure.Figure 2Dissected anal margin of the polyp is connected to the fore-balloon of the DiLumen using endoscopic clip.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Fore-balloon is pushed in the oral direction pulling the anal margin of the polyp and exposing the submucosal space under the giant rectal lesion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Straightforward view demonstrates large mucosal defect after ESD exposing muscularis layer of the rectum.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Retroflex view demonstrates large mucosal defect after ESD exposing muscularis layer of the rectum.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Straightforward view demonstrates complete restoration of the rectal mucosa after completion of endoscopic suturing.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7Retroflex view demonstrates complete restoration of the rectal mucosa after completion of endoscopic suturing.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Pathologic examination of the resected 17.0- × 10.1- × 0.3-cm specimen (Fig. 8) demonstrated a tubulovillous adenoma with focal high-grade intraepithelial neoplasia. The resected margins were negative for neoplastic changes, confirming R0 resection. Repeated colonoscopy in 3 months (Fig. 9) demonstrated complete restoration of the rectal mucosa without any stenosis. There was no residual polypoid tissue. In conclusion, dynamic multidirectional retraction with a double-balloon interventional platform markedly facilitated colonic ESD. In our patient with a giant rectal laterally spreading tumor, endoscopic reconstruction of the colonic mucosa allowed complete closure of the large mucosal defect after lesion removal, eliminated postprocedural pain, and prevented delayed bleeding and stenosis after colonic ESD. Dr Kantsevoy is a consultant for Apollo Endosurgery, Aries, Endocages, LumenDi, Medtronic, Olympus and Vizballoons; is a cofounder of Apollo Endosurgery and Endocages; is a shareholder in Apollo Endosurgery; holds equity in Endocages, LumenDi; and is in active litigation with LumenR. All other authors disclosed no financial relationships relevant to this publication. The authors would like to thank LumenDi LLC (Westport, Conn, USA) for providing DiLumen double-balloon interventional platform and Apollo Endosurgery (Austin, Tex, USA) for providing Overstitch endoscopic suturing device for this procedure. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkOWNmNDA5ZTBlZTljNDM2MGRkZWQ3ZDdhNTY4NzFlZiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NTg1MzkwfQ.YLXfiGWaUP4Zr2-17vLsCohP5vp4LYQ_BX7_05oRfqhUq13SeHzCdQnUK01pzZUDIKvvaplpvUYe9fe3H70-jyoeqgdoXzsDwC3XmXwdOEB25_onqU2xKilJ2vuJGuGScXI6e7lHbuP0fjukwX_O3fcTMIMLa00yycaMXOnfHYPmKdcLlE-8KnLI-WpIyoDYb4G14oZBtze0N6TeBN16VpvBqn6Lmpwg-EeTpghztJlQRJ_UWcddOVIAfF7xiLYgjxDOllg5oYHN7MztFM4Ms8pvWrdoiE7-JF1Oimogv4jP3-aY7bNRNvMhHmSvR7Y-N1XbIOs-wU9nu2X6J04lxA Download .mp4 (79.42 MB) Help with .mp4 files Video 1Endoscopic submucosal dissection of a giant laterally spreading tumor facilitated by double-balloon interventional platform and use of endoscopic suturing device for reconstruction of rectal mucosa.