The case of endoscopic resection for large circumferential rectal LST with the subsequent development of tight stricture and its treatment. These are our disclosures. 62-year-old male was referred to our center with complaints of constipation over the last three months. We revealed lateral spreading tumor, granulomix subtype, that occupied 100% of the rectum from the anal verge up to 10-11 cm. Here you can see the examination of the LST lesion. Lesion was observed in the NBI mode and assessed by the NICE classification as type 2. We consider the ESD procedure the best way for LST treatment, because the risk of recurrence is low and quality of life remains good. Margins of the lesion were determined before performing the ESD procedure. Primary incision of the mucosa was performed by the dual knife from the side of the anal verge with the preliminary lifting of the incision site. We decided to use tunneling technique to create two tunnels and then connect them. There were no signs of samucosal fibrosis, but there were a lot of relatively large vessels of the samucosal layer, so in order to prevent bleeding, they were coagulated with the usage of coagrasper. Fortunately, we managed to avoid any major bleeding. During the procedure, we use different types of knives in order to make dissection safer, easier and faster. Here you can see some causal tunnel, and there you can see the final step when we connected two tunnels. The remaining mucosal tissue was cut by the claw grasping. After complete removal of the lesion, the assessment of the wound surface was performed. There were no signs of perforation or bleeding. Here you can see the whole lesion after its removal. The size of the lesion was 11 cm. Duration of the operation was 11 hours. Histopathological assessment revealed set cells rated adenoma of rectum with low-grade dysplasia. Post-operative course was uneventful. Betasonide 2 mg form had been administered from day 3 after ESD once daily for one month to prevent the development of rectal stricture. Colonoscopy one month after the ESD showed a circular healing wound surface with signs of mild inflammation. The lumen is freely passable by a 14 mm endoscope. Betasonide treatment was stopped after predetermined taper. Two months after ESD, patient complained of difficulties with defecation. Endoscopic examination revealed no signs of recurrence, but a tight structure 7 cm from annual verge with a length of about 2.5 cm. Not passable with a standard 12.8 mm endoscope. We decided to start treatment with balloon dilation of the structure. Within 10 months, 5 outpatient sessions of lumen dilation with a balloon from 12 to 18 mm in diameter with 7 atmosphere were performed to achieve a stable response for treatment. Sometimes, after balloon dilation, we observe small superficial ruptures in the stricture zone. After the treatment, the lumen was freely passable by a 14 mm endoscope, and there were no difficulties with edification. Patients who underwent total circumferential ESD of rectal tumor had a high risk of stricture formation, despite local steroid treatment. Multiple sessions of dilation might be necessary to elevate the stenosis and to achieve a steady response. Thank you for attention.

rectal lesion

lateral spreading tumor

endoscopic submucosal dissection

stricture formation

balloon dilation