We report the case of an endoscopic submucosal dissection of a granular type adenoma spreading over eight tenths of the rectum, and sparing a healthy strip of the posterior rectal aspect, in a 75-year-old man, using an electrosurgical endo-knife with a water-jet function, the Flush-knife..
Here we can see through both a direct and retroflex view this almost circumferential lesion. Here this healthy strip of mucosa is clearly visible. The injection of saline and of hyaluronic acid is started at the lower part of the lesion on its left border at the level of the anorectal junction. A circumferential incision is performed. Using the grasper, hemostatic maneuvers are carried out either prophylactically or curatively at the level of the vessels situated at the anorectal junction. To do so, a soft coagulation current is used. Then the procedure is continued with the circumferential dissection of the anorectal junction, hence exposing larger vessels that are managed by hemostatic forceps in a prophylactic fashion. Then the incision of the lesion's left border is started. A small polyp is encountered and resected. Here is the lesion's right border.
Then a tunnelization is begun underneath the lesion on the patient's right side. Here the vessels that originate from the muscularis propria and divide within the submucosa present a kind of vine stock aspect. The muscularis propria is down, below. The submucosa and the lesion are above on this view. The coagulation is performed with a forced coagulation current using the Flush-knife. The forced coagulation is also used for the dissection. When using the hemostatic forceps, it is a soft coagulation current that is used. Here again the vine stock aspect is visible; we see the vessel's retraction induced by the soft coagulation current. We see here the right margin of the lesion that is incised towards its upper section with an Endo-cut current E 2 3 3. The dissection is continued to the left margin. Above we can see the anterior surface, the muscularis propria, and below the lesion that is attached to the wall by large vessels. With a large foreign body grasper, the en-bloc resected lesion is retrieved. Here we can see the rectum's aspect following the resection with the healthy mucosal strip remaining. The histology confirms that the lesion was a tubulovillous and serrated adenoma with focal high-grade dysplasia. The deep and lateral resection margins were perfectly healthy. The lesion measured 15 by 10cm. The whole procedure took 4 hours and 30 minutes. CO2 was insufflated. During the 6 months that followed, the patient was treated three times with balloon dilations up to 20mm in order to facilitate the passage of faeces. Apart from a residual ulceration, the endoscopic and histological controls did not show any recurrences at 6 months. In conclusion, ESD with Flush-knife provided a safe and successfull en-bloc resection of this large rectal adenoma.
Dimitri Coumaros, MD, University Louis Pasteur, Strasbourg, France