Hi, greetings from India. Herewith we are presenting a multiple pocket ESD for a large 15 by 12 centimeter anorectal LSDG mixed nodular type of polyp. The challenge is faced and the tricks for success. We have no disclosures. A 70 year old female was diagnosed with a large 15 by 12 centimeters LSDG with a big 2A component starting at the anal verge and crossing the rectal fold, reluctant to undergo surgery, was planned for ESD with a surgical backup. She had no significant comorbidity. Examination of the lesion showed that it was a large laterally spreading tumor with a 1S and a big 2A component reaching much above the proximal rectal fold. You can see this large bulky tumor here and the extent of the tumor encircling almost 90% of the lumen of the rectum and it was starting at the anal verge. NBI showed a JNAT 2A component and some areas were showing a JNAT 2B component as you can see here. Looking at the extent of the lesion, the plan of dissection was first devised. The first step was to make a tunnel from the anal verge posteriorly going to the proximal margin. The second tunnel would be on the left wall going to the lateral margin. Then the third tunnel we planned anteriorly going to the proximal margin and the fourth tunnel was planned on the right side reaching up to the proximal margin. Then we planned an incision on the proximal side and then to open up the lesion first from the left side and then from the right side changing the patient's position at each step to have the assistance of gravity. The dissection was started by injecting at the anal verge on the posterior aspect. There was a lot of vascularity and bleeding. The incision was kept with a dual knife J and the entry into the submucosal space made. Haemostasis was secured and dissection was done just above the muscle layer with injection and a precise sect current from the urbic and the first tunnel was created as you can see here going deep. Then we went on to making the second tunnel. Incision was kept on the right side as we showed in our figure and then the incision was extended joining almost the first incision and then entry into the tunnel was made. There were a lot of large vessels on the anal side and you can see this is the second tunnel. We had to do a lot of haemostasis and we stayed just in the SM3 layer. Large vessels as you can see this was an artery. We used a soft coagulation current at a 40 watt celly and they were coagulated. Dissection was carried on and the third tunnel was made as you can see here. After finishing all the tunnels, the incision was completed on the proximal aspect with the scope in retroflexion and then we started clearing the left side by lifting the left margin and dissecting below the left margin and completely releasing the left side of the lesion and joining it to the left side proximal margin. Once the left side was open, we started cutting the septum between the first and the second tunnel. We can see the entire exposed left side. Now what was remaining was division of the septum between the right tunnel and the central tunnel. So this septum was then found out and we started dissecting with a dual knife but then as you can see there was a lot of bleeding and a lot of large vessels which we tried to control with the grasper using coagulation current but still it was bleeding therefore we used the cap to tamponade, changed to a coag grasper and using again the soft coagulation current because hemostasis again there was a little bleeding so we used the coag grasper to coagulate and dissect the entire septum between the right and the central tunnels. Due to extreme fatigue of dissection of 12 hours, we stopped the procedure. The patient was ventilated overnight and the decision was taken to start the procedure again the next morning. The last septum on the posterior side was the most difficult. We tried to inject and lift it but could not. The last septum between the tunnel 1 and tunnel 4 was the thickest which was under the bulky part. We used the coag grasper, coagulate and cut to avoid bleeding from our previous experience of the septum 3 and we could dissect the entire septum out and we completed our dissection as you can see here. The rough area is the most area with most fibrosis and this is the lesion which we took out. It's a huge lesion as you can see. The histology came as a villus adenoma with dysplasia with foci of early adenocarcinoma with microinvasion to the superficial subduposa less than one millimeter. Follow-up showed the area of narrowing at the ESD site as expected but there was enough passage for the scope to pass through and the patient is under follow-up. The clinical implication of this case is a large LSD granular mixed nodular lesions are difficult to resect with ESD owing to their bulkiness with severe underlying fibrosis and non-lifting aid in these areas, increased vascularity with large tumor vessels, decreased working space with no possibility to use retraction devices except gravity due to the sheer size of the lesion, a pseudostock formation with severe muscular teethering and unclear planes of dissection.

anorectal polyp

endoscopic submucosal dissection

surgical backup

lesion dissection

large polyps