Circumferential rectal laterally spreading tumor resected by endoscopic submucosal dissection in a Western center.

A 78-year-old patient without relevant past medical history underwent colonoscopy for chronic diarrhea. Examination identified a laterally spreading tumor (LST), mixed-granular-type (nodules up to 1 cm) in the rectum, from the pectin line to the rectosigmoid transition. The LST covered 100% of the circumference of this segment (▶Fig. 1). Endoscopic evaluation was compatible with an adenomatous lesion with preserved pit pattern (Kudo IIIL/IV classification), without unequivocal endoscopic suspicion of invasive lesion (NICE 2; JNET 2B). After multidisciplinary evaluation, endoscopic resection by endoscopic submucosal dissection (ESD) was decided. The procedure was performed with the patient under general anesthesia. A gastroscope (GIF-HQ190; Olympus, Tokyo, Japan) and carbon dioxide insufflation were used. The lesion was gradually elevated with a colloid solution (Voluven [Fresenius Kabi Norge AS, Halden, Norway] + indigo carmine+ adrenaline), and the excision was performed by ESD using the FlushKnife (Fujifilm Corp., Tokyo, Japan) and the IT Knife nano (Olympus) (▶Fig. 2). En bloc resection was achieved, obtaining a circumferential specimen with a length of 15 cm, corresponding to the entire rectal mucosa (▶Fig. 3, ▶Video1). The procedure time was 420 minutes. Antimicrobial prophylaxis with a single dose of ceftriaxone (2 g) was given. There were no immediate complications and the patient was discharged 24 hours after the procedure. Histological examination revealed a tubulovillous adenomawith high grade dysplasia. Although the patient remained asymptomatic, endoscopic evaluation after 2 months revealed stenosis at the ESD site. Balloon dilation up to 15mm (diameter) was performed in a single session (▶Fig. 4). ESD is an organ-sparing endoscopic technique that allows en bloc resection of superficial gastrointestinal lesions regardless of their size, optimizing the histological evaluation [1]. This is particularly important in the rectum because of the high morbidity associated with the alternative surgical approaches [2]. Although described in Asian case reports [3, 4], to our knowledge this is the first report showing endoscopic treatment by ESD of a giant circumferential colorectal LST in a Western center.