Complex Double Balloon-Assisted Colonic ESD: First Human Experience

Abstract

Complex colorectal polyps (defined as >2cm) or those positioned in difficult anatomic locations may be major endoscopic challenges. Double-balloon systems have been predominantly confined for use in small bowel enteroscopy, however recently its utility has been explored in the lower intestine. Despite clear benefits of ESD (R0 resection and low recurrence rate), it remains a technically challenging procedure with higher perforation rates compared to EMR. In these 2 cases, we employed a unique ESD approach facilitated by a novel endoscopic double balloon system which permitted polyp tissue retraction, increased stability and improved visualization. Clinical case details: 1 - 74 year old male, 3 polyps located in the ascending colon and hepatic flexure. PMH: CHF; CAD s/p Stents; AICD; DM 2- 68 year old male, large complex polyp located in the ascending colon. PMH: OSA, PVC, HLD, HTN ESD technique (briefly): The balloons were deployed behind and in front of the lesion. After the balloons were inflated, a sealed ‘therapeutic zone' was created. A mucosal incision was made at the proximal lesion margin and developed. The incision leading edge was developed further. At the appropriate point the mucosal edge was clipped to the base of the fore balloon. Using variable tension on the fore balloon, tissue dissection continued until resection. After the procedure, the specimen was removed using the fore-balloon as a specimen retrieval bag. The technique was feasible (see Table 1), safe and effective. The double balloon system enabled complex ESD. This led to an enhanced sense of scope stability in a difficult anatomical locations. The additional benefits of retraction and specimen retrieval appeared to be additive and should be studied further.Table: Table. Case data and clinical observationsFigure: Patient 1 - polyps removed.Figure: Patient 2 - polyps removed.