Gastrointestinal: Rectal laterally spreading tumor treated by whole‐circumferential endoscopic submucosal dissection

A 77-year-old woman underwent colonoscopy for colorectal cancer screening. Colonoscopy showed a pale, reddish, nodular and villous elevated circumferential lesion in the rectum (Fig. 1a). Magnifying endoscopy with narrow-band imaging revealed a regular vessel pattern with branching and villous surface structure (Fig. 1b). Magnifying chromoendoscopy with the use of crystal violet solutions revealed branching and villous surface structure (Fig. 1c). Barium enema examination (BE) disclosed a whole-circumferential laterally spreading tumor from the upper rectum to anal canal (Fig. 1d). The lesion is extended sufficiently under air insufflation. The colonoscopy and BE findings were suggestive of tubular and tubulovillous adenoma. The lesion was subsequently removed by whole-circumferential endoscopic submucosal dissection (ESD) with the combination use of Flush knife BT-S 1.5 mm (Fujifilm Co., Tokyo, Japan), SB knife Jr 2 (Sumitomo Bakelite Co., Tokyo, Japan), and IT knife nano (Olympus Co., Tokyo, Japan) (Fig. 2a). Thereafter, the lesion was retrieved by jumbo collecting net. The total procedure time was 627 min. Histological examination showed that the tumor was measured 205 × 148 mm in size (Fig. 2b) and contained tubular and tubulovillous adenoma with focal high grade dysplasia. The horizontal and vertical margins were free of tumor cells. To prevent post-ESD stricture, budesonide foam enema 2 mg was administered twice daily for 8 weeks after ESD, (Fig. 2c). Slight stricturing was noted despite 8 weeks of rectal budesonide therapy, and endoscopic balloon dilation (EBD) was performed twice a month, budesonide enema was discontinued 4 months after administration without tapering. Follow-up colonoscopy after 5 months demonstrated mucosal healing and the colonoscope could be advanced proximally (Fig. 2d). Post-ESD strictures can adversely affect the quality of life. Budesonide foam enema, has low rate of systemic side-effects, and has been reported as a candidate to prevent stenosis but has not established. More than 90% circumferential resection and/or ESD involving the anal canal are risk factors for the post-ESD stricture. This case suggests that a combination of the injection of budesonide foam enema and additional EBD may be useful even when the risk for post-ESD stricture is high.