Post written by Deepak Madhu, MD, MRCP, DM, from the Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan.

A 79-year-old patient underwent endoscopic submucosal dissection (ESD) for resection of a colonic polyp. The resection was complicated by an intraprocedural perforation, which an endoscopic omental patch closed. A surveillance endoscopy performed 1 year later showed local recurrence of the polyp at the site of perforation.

A multidisciplinary decision was made to resect the lesion endoscopically, taking into account disease characteristics, age, frailty, and patient preference. The resection was difficult owing to transmural fibrosis resulting from the previous macro-perforation. The fibrosis led to difficulty in opening the submucosal space after mucosal incision. Traction was used to overcome this.

As dissection proceeded, 2 additional challenges became evident: difficulty in endoscopically discerning the muscle layer separately in parts of the fibrotic space and variable thickness of the fibrotic space, which was very thin in some areas.

In areas where the fibrotic space was thinnest, the dissection had to be performed close to the serosa (Fig. 3), which served as a guide to the plane of dissection. The difficulty in endoscopically discerning the muscle layer separately was largely because of the poor submucosal lift in the fibrotic space, resulting in an absence of differential staining of the submucosa usually relied upon to identify the plane of dissection.

Once ESD was completed successfully and safely, the area of the defect where the serosa was visible endoscopically was closed with through-the-scope hemostatic clips.

This video article showcases the feasibility of endoscopic resection in patients who have recurrence of a colonic polyp at a site of previous perforation.

Other endoscopists can learn that:

• Traction with tunnel method can facilitate ESD in cases with severe fibrosis in the submucosa.
• Transmural fibrosis at a site of previous perforation can result in poor lift with submucosal injection, leading to absence of differential staining that is usually relied upon to identify submucosa distinctly during ESD. In such cases, serosa can serve as a guide to the plane of dissection. 

Dissection close to serosa (serosa indicated by black arrows).

Read the full article online.

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