Post written by Salmaan Jawaid, MD, from the Division of Gastroenterology, Hepatology and Nutrition, University of Florida Health, Gainesville, Florida, USA.
With the assistance of a novel tissue retractor system, we successfully performed endoscopic submucosal dissection (ESD) of a large rectal lesion that had developed significant fibrosis from direct tattoo material. Typically, performing ESD of these types of lesions can be challenging and tedious because scar tissue and tattoo material can limit the ability to discern the submucosal plane. Moreover, the development of fibrosis can prevent optimal generation of tissue tension without the use of additional tissue tension degenerating devices. The novel tissue retraction system allowed us to generate effective dynamic tissue tension in multiple axes while maintaining our position within the dissection field. Although the tattoo material still limited visibility during parts of the dissection, having the ability to provide tissue tension in different directions without losing position allowed for a very precise and deliberate dissection. In this way, we were able to safely and efficiently resect the lesion en bloc within a reasonable amount of time without any immediate adverse events. Histopathology revealed tubulovillous adenoma with high-grade dysplasia with negative deep and lateral margins.
Endoscopists who focus on ESD of large bulky rectal lesions will likely encounter lesions that have unfortunately been directly tattooed into. Scar tissue and tattoo material can prevent clear identification of the tissue layers and limit the endoscopist’s ability to provide appropriate tissue tension with standard tension generating modalities. Moreover, these modalities can typically provide tissue tension in only one axis. By showcasing this video, we hope to demonstrate the ability of the novel tissue retractor system to provide dynamic tissue tension without losing position within the operative field. With this approach, endoscopists now have an alternative and efficient method to provide optimal en bloc resection of benign rectal lesions in the presence of scar tissue or tattoo material.
If tattooing the lesion is desired, the tattoo should be placed just proximal or distal to the lesion and never directly into it. With the availability of the novel tissue retractor system, endoscopists can now confidently and efficiently remove benign rectal lesions en bloc despite not having the optimal submucosal milieu for ESD.
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