Post written by Fabian Emura, MD, PhD, FASGE, from the Division of Gastroenterology, Universidad de La Sabana, Chía, and the Advanced GI Endoscopy, EmuraCenter LatinoAmerica, Bogotá DC, Colombia.

This video case describes how we applied surgically vascular control principles to reduce the risk of adverse events during third space endoscopy. As the risk of bleeding from large rectal LST-Gs extended to the dentate line with associated internal hemorrhoids is clinically significant, we selectively approached vessels minimizing the risk of bleeding using direct coagulation of small and a step-by-step fashion for larger ones. Our novel technique for larger vessels consisted of blunt and lateral exposure, coagulation at the proximal and distal sides, and transection of the vessel through sealed segments.

This case was unique because, besides the risk of bleeding from hemorrhoids and large-caliber vessels, the lesion’s size, the presence of submucosal fibrosis, and the narrow lumen of the annal canal made the procedure even more challenging. We, therefore, selected the retroflex view approach allowing dissection from proximal to distal avoiding initial contact with hemorrhoids and dissected the submucosal using 2 different levels, shallow first to avoid large submucosal vessels and then deeper above the muscle layer to the shut off blood supply to hemorrhoids by penetrating vessels. This significantly facilitated hemorrhoids’ vascular control and allowed an en bloc curative resection without intraoperative or postoperative bleeding. 

The novel approaches described can help therapeutic endoscopists minimize bleeding risk during ESD of large rectal LSTs extended to the dentate line with hemorrhoids and facilitate an en bloc curative resection. Interestingly, probably due to rectal submucosal healing and coagulation of penetrating vessels obliterating blood supply to submucosal veins, the patient got rid of hemorrhoids!

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