This video elaborates on a novel technology and a new trans-anal platform to excise a complex left colonic lesion and prevent luminal narrowing. Authors. Disclosures. Slow adoption of colorectal ESD by western endoscopies using monopolar knives was due to procedure time constraints and a relatively high risk of short and long-term adverse events, including luminal stretch reformation. Compared to monopolar knives, bipolar devices have fundamental potential benefits such as precise tissue cutting by direct contact, use of low voltage current, and no requirement for a return plate. The components of this novel trans-anal technique are a novel ESD device incorporating a bipolar radiofrequency energy for tissue cutting and a microwave energy for coagulation. An enhanced trans-anal platform comprises a multiport apparatus permitting access to the novel ESD device and an additional carbon dioxide insufflation exchange system to maintain bowel wall distension. A 72 female patient was subject to a screening colonoscopy after a positive QFE test. A 9 by 8 centimeter lateral sputum tumor, a granular mixed lesion, was identified at the sigmoid descending junction with no signs of deeper invasion. During lesion assessment, the delineation of the margins was challenging and clearly difficult to identify due to the acute angulation of the sigmoid descending junction. Activation of the carbon dioxide insufflation exchange system resulted in an increase of the luminal pressure, improving remarkably the field of view and allowing a meticulous colonoscopy assessment. A wide proximal oral mucosal incision was first performed using the bipolar mode of the novel ESD device and yellow pedal. Low luminal pressure of 7 to 8 millimeters per mercury permitted minimal submucosal stress and thinning. A limited distal anal mucosal incision was then applied by keeping the same conditions. Similar pressure and bipolar mode conditions were also selected for the poly flap trimming, making the submucosal entry slicker and the opening of the submucosal tunnel visible. Short bursts of bipolar cuts of the submucosal space using again the yellow pedal were repeated to widen the submucosal tunnel. Microwave energy using the blue pedal was applied to pre-coagulate vessels from 6 to 10 seconds until bubbling and blanching effect were seen, resulting in a bloodless dissection. Following on the creation of the submucosal tunnel, the lateral mucosal incision right and left side were made to connect the initial proximal and distal incisions. This is a fundamental step for the excision of the complex lesions to complete a circumferential mucosal isolation of the lesion and secure free lateral margins. Submucosa then was further dissected by trimming the lateral margins while using the insulated hull of the novel ESD device to protect and prevent any muscle thermal injury. The curved tip of the novel ESD device maintained all the way a deep resection plane even when tattoo ink-induced fibrotic patches were encountered. Precision with bipolar cut was essential at this stage of the resection. Microwave energy was targeted by close contact to obtain a high power density with vessels for a focused hemostasis and to deliver effective coagulation and repeat it when necessary for large vessels more than 1 mm. Lateral sweeping bipolar cuts of the submucosal space were directed in and in from the tunnel to out the edges or in tension. At the end of the procedure, optimization of the submucosal tension was achieved by increasing the luminal pressure to 11-12 mm per mercury. Fine tuning of the interluminal pressure augments further the retraction forces on the lesion resulting in a continuous tension of the submucosal space essential for tunneling technique without causing any parotrauma. The inspection of the post-resection base revealed an intact mass layer with no signs of thermal injury. The pinned-out specimen showed R0 resection. Histology demonstrated tuberculosis adenoma with high grade dysplasia. At one year follow-up, a smoothly healed scar free of recurrence was seen and no signs of stenosis was noted. This novel transanal technique has got potential for achieving a bloodless submucosal tunneling dissection, maintaining visualization and tension on the tissue during dissection, avoiding short-term and long-term endoscopic complications and subsequently preventing a major operation. The combination of a novel endoscopic device and a new transanal platform is technically feasible by enhancing a safe submucosal dissection and augmenting the operation field of view in the left column. Future studies to define the efficacy of this novel transanal technique appears warranted.

colonic lesion

bipolar devices

trans-anal technique

ESD device

lateral sputum tumor