Post written by Martin Coronel, MD, and Phillip S. Ge, MD, from the Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas.

A 66-year-old man was referred for endoscopic resection of a 35-mm laterally spreading tumor at the hepatic flexure (Paris IIa+Is). A previous EMR attempt was unsuccessful due to nonlifting of the lesion during submucosal injection, and therefore ESD was indicated. A pediatric colonoscope was initially advanced to the hepatic flexure. However, because of a highly redundant left colon, the colonoscope could not be reduced into a stable, short position, which precluded a safe resection. A rigidizing overtube was therefore introduced onto the endoscope. The endoscope with the overtube was advanced until we reached the lesion. At this point, the endoscope was able to access the lesion from a short, reduced position, with 1-to-1 motion, which allowed us to safely perform ESD. A novel injectable needle-type knife was used to perform ESD. Moderate submucosal fibrosis was encountered; however, the novel ESD knife was able to consistently deliver robust submucosal injection via the center of the needle tip, thus providing reliable submucosal lifting and improved visualization of the dissection plane. An en bloc endoscopic resection was completed without perforation. The final histopathologic diagnosis was tubulovillous adenoma without high-grade dysplasia. The margins were negative, and thus complete and curative resection was obtained. The patient was discharged home after the procedure with an uncomplicated recovery course.

There were 2 novel technologies showcased in this video. First, the novel dynamic rigidizing overtube allowed for a stable endoscopic position in a challenging ESD at the hepatic flexure. In addition, we demonstrated the first worldwide use of a novel injectable needle-type ESD knife, highlighting its various potential advantages in challenging colorectal ESD.

Overtube-assisted colonoscopy allows for straightening of the colon to decrease loop formation. The rigidizing overtube was primarily used in this case to gain access to challenging locations in the right colon without loop formation. The novel ESD knife demonstrated in our case delivers the injection via the tip of the electrode, which theoretically allows for a more robust and focused injection. In addition, this ESD knife has several additional advantages including a locking mechanism to keep the knife in the open position, and a cleaning mechanism to unclog the injection port at the tip of the electrode.

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