Post written by Noriko Suzuki, MD, PhD, from The Wolfson Unit for Endoscopy, St Mark’s Hospital, London, United Kingdom.
We demonstrated the application of the double-tunneling (DoT) butterfly method for ESD on 4 cases with extensive rectal neoplasms. The key feature of the DoT butterfly method is the creation of 2 tunnels that are transformed into bilateral flaps, leaving a submucosal septum between them. This acts as a pillar to prevent rolling of the mucosal flap and optimize submucosal views throughout the resection.
Four rectal neoplasms measuring (maximum diameter) 7 cm, 8 cm, 9 cm, and 18 cm, respectively, were resected in 4 patients by use of the DoT butterfly method. Good traction was maintained during the entire procedure, allowing safe dissection of the submucosal layer. Initial creation of the 2 tunnels also allowed for submucosal fibrosis, when encountered, to be isolated and managed effectively. The lesions included recurrent adenoma (1 case) and dysplasia (1case) in longstanding ulcerative colitis. Curative R0 resection was confirmed in all 4 cases.
ESD of extensive lesions can be challenging due to the loss of orientation caused by rolling of the mucosal flap. A structured strategy to maintain optimal views and orientation is required. The DoT butterfly method appears to be safe, efficient, and useful. This could be an option for ESD of extensive rectal neoplasms.
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