Complete resection of a 225-mm circumferential rectosigmoid intramucosal carcinoma by endoscopic submucosal dissection

Abstract

A 58-year-old man presented with a fully circumferential, granular-type, laterally spreading tumor in the rectosigmoid (● Fig.1a, ● Fig.1b), which was diagnosed as an intramucosal cancer using magnifying endoscopy. En bloc resection was accomplished by endoscopic submucosal dissection (ESD) using the pocketcreation method [1]. Three submucosal pockets were created, leaving submucosal tissue between the pockets to maintain traction until the end of the ESD procedure. Circumferential mucosal incision at the proximal border of the cylindrical tumor was performed before completion of submucosal dissection in order to avoid visual interference of a flap from the resected distal portion. The resected tumor was extracted by defecation (● Fig.1c,● Fig.1d) [2]. Pathological examination showed an intramucosal, well-differentiated, adenocarcinoma in an adenoma, with negative resection margins and no lymphovascular invasion. The patient was discharged without complications. Betamethasone suppositories (1.0mg/day) were given for 8 weeks to prevent stricture formation. Although the patient remained free of obstructive symptoms, follow-up colonoscopy at 2 months revealed stenosis at the ESD site. This was dilated using endoscopic balloon dilation up to 16.5mm in diameter in a stepwise manner over three sessions (● Fig.1e,● Fig.1f) [3]. At the 7-month follow-up, the patient was asymptomatic. In this patient, a 210-mm-long circumferential tumor was completely resected. To the best of our knowledge, this is the first description of curative ESD for a circumferential rectosigmoid intramucosal cancer >200mm long. Although obstructive symptoms are almost inevitable following ESD of a long circumferential esophageal lesion, this patient experienced no obstructive symptoms. The risk of obstruction after circumferential ESD may be lower in the colon and rectum [4] than in the esophagus, owing to a larger lumen and possible self-dilation by stool. Colorectal circumferential ESD is feasible and may have a low risk of post-ESD obstruction.