Post written by Hiroyuki Aihara, MD, PhD, from the Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA.

This patient underwent an endoscopic piecemeal removal of an 11-mm flat lesion in the sigmoid colon in 2011. Her follow-up colonoscopy in 2016 revealed a 30-mm recurrent lesion at the previous polypectomy site. The lesion was accompanied by significant scarring and tattooed area. This patient was initially referred for surgery; however, after a discussion between the surgeon and patient, she was referred to us for an endoscopic submucosal dissection (ESD). This lesion was successfully removed with ESD with pocket creation method (PCM).

We reported this case to show the advantage of PCM in ESD. In this technique, maintenance of the peripheral mucosa helps avoid fluid leakage common in fibrotic lesions, maintaining the submucosal bleb. Furthermore, the pocket maintains ideal countertraction during dissection. A significantly fibrotic area was observed at the center of the lesion; however, this area was successfully dissected without muscle injury. Finally, this lesion was removed in en-bloc fashion with negative horizontal margins.

Currently, a number of recurrent colonic benign lesions are often referred for surgery after unsuccessful piecemeal resection attempts. As described in this case report, most of those cases can be successfully removed by ESD with PCM; however, these lesions are often accompanied by significant fibrosis and tattooed area which make ESD very challenging. Deep biopsy, tattoo placement, and unnecessary polypectomy attempts should be avoided for lesions being considered for ESD.

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