Wide-field endoscopic mucosal resection of a giant laterally spreading rectal tumor with multi-band ligation EMR technique. Author disclosures are as listed. We present a case of a 51-year-old healthy woman who was found to have a large laterally spreading tumor of the rectum on her initial age-appropriate screening colonoscopy. The patient was referred to our center for consideration of surgical versus endoscopic resection of the lesion. Advanced tissue resection techniques such as endoscopic mucosal resection and endoscopic submucosal dissection have been established as therapeutic options for the management of advanced mucosal neoplasia of the colon. Ligation EMR is a well-established technique that is achieved through the creation of a pseudopolyp using a band ligator followed by electrocautery snare resection. While not performed routinely for the management of colonic lesions, ligation EMR is an integral component to the multimodal approach to the management of Barrett's esophagus. Ligation EMR can be safely performed in the rectum below the peritoneal reflection and may provide a potential role in the management of large rectal lesions that are amenable to endoscopic resection. The decision was made to start with a flexible sigmoidoscopy for repeat evaluation of the lesion and to proceed with resection depending on endoscopic findings. At the time of the endoscopy, a nearly circumferential, Paris IIa and laterally spreading granular tumor was found in the rectum extending from the dentate line approximately to the middle transverse rectal fold. As you will see in the following video, this lesion was resected in a piecemeal fashion utilizing a serial ligation EMR technique. In order to achieve a complete resection, a total of 54 band ligations with mucosal resection were required to be performed. Upon insertion of the endoscope, a flat, granular-type, laterally spreading polyp could be seen extending from the anal verge up to at least 5 centimeters into the rectum. The lesion was circumferential distally and about 80% circumferential more proximally. Using an argon cautery probe, the borders of the large, flat polyp were marked to facilitate identification of the extent of the lesion prior to resection. A mixture of saline with a few drops of methylene blue were injected under the flat polyp prior to commencing ligation-assisted EMR. The polyp was found to lift well in all areas. Utilizing a standard multiband EMR device, a suitable area of the polyp was identified and suctioned into the cap. Then a 7-fringe snare was placed below the band and the snare tightened. Force coagulation was used to resect the resulting pseudopolyp. In a stepwise fashion, further band-assisted resections were done. An area of polyp immediately adjacent to a previous resection is identified and the ligation and snare procedure repeated. The edge of the cap is positioned so that the remaining polyp is suctioned into the cap before band deployment. The resection margins are quite clean and no bleeding was encountered at all during the procedure. As can be seen, previous marking of the borders of the lesion was helpful to maintain orientation during the multi-step procedure. Towards the end of the procedure, some residual polyp was seen near the dentate line. Even in this distal and difficult location, the band and snare technique worked well. Finally, the edges of the resection were cauterized with snare-tip soft coagulation. Here is the appearance after a 54-band wide-field EMR resection. The appearance is very similar to what would be seen after an endoscopic submucosal dissection. The pathology specimen was reviewed and was consistent with adenomatous mucosa with tubular, villus, and serrated features. The patient did not experience any post-procedural complication and was without any complaint when she returned for a surveillance endoscopy three months later. At the time of endoscopic follow-up, mild narrowing of the rectum by a scar is seen, along with a small area of residual polyp. Powered endoscopic debridement was done to address the small amount of polyp which remained just above the anal verge. This resulted in complete removal of the residual polyp. As demonstrated in this video, ligation EMR can be safely performed for successful resection of large, laterally spreading granular tumors of the rectum that abut the dentate line. This is a novel application of an established technique that is commonly performed in general gastroenterology practice. While we are not suggesting that this approach is superior to traditional resection techniques, we pose that ligation EMR may serve as a potential alternative when faced with a technically challenging or lengthy ESD or traditional piecemeal snare EMR. Additionally, ligation EMR for rectal lesions may be adopted in situations where end-block resection is not required and when the patient or referring provider may not have access to tertiary referral centers capable of complex EMR or endoscopic submucosal dissection.

wide-field endoscopic mucosal resection

multi-band ligation technique

laterally spreading tumor

rectum

ligation EMR