Endoscopic Resection of Lumenal-Occluding Laterally Spreading Tumor of the Sigmoid Colon

An elderly patient presented with recurrent hematochezia and anemia. On colonoscopy a large polypoid lesion partially obstructing the lumen of the sigmoid colon was seen (A, B).

The lesion extended over a fold and spread about two thirds to three fourths (75%) of the colon lumen circumference (A, B, C). The proximal part of the LST could be clearly seen and recognized. It was characterized as a laterally spreading tumor (LST), granular surface (G), with large polypoid protrusions (P) (LST-G-P).

Options to treat this lesion were a) surgery (hemicolectomy), b) endoscopic submucosal dissection (ESD), c) piecemeal endoscopic mucosal resection pEMR), and d) hybrid ESD-EMR, e) knife-assisted resection (KAR), and f) a combination of KAR, hybrid ESD-EMR and piecemeal EMR (1-4).

Surgery was not an option. Therefore, we proceeded with endoscopic resection.

The key elements for success were:

1) Creation of a generous submucosal cushion. We used Eleview ® and normal saline with epinephrine (1:20,000). The bluish color of the Eleview ® clearly allows for a) demarcation of the lesion (differentiate between normal mucosa and neoplastic tissue (Panel E), and b) separate neoplastic tissue from the submucosa, c) provide a dissection place, d) decrease the chances of perforation (“safety cushion”), and e) by using some epinephrine we decreased active bleeding during the procedure, thus improving the cleanliness of the operating field and allowing us to dissect mor efficiently.

2) Performing KAR and hybrid ESD-EMR. The circumferential incision allowed for a clear lateral R0 resection. We have observed many cases of piecemeal EMR for similar lesions, and often the borders are hard to resect and the endoscopist must perform electrocoagulation or ablation of the entire margin. Indeed, some guidelines recommend that ablation and or electrocoagulation of the borders be performed when performing pure piecemeal EMR or EMR (3). However, if one performs KAR or hybrid ESD-EMR circumferential incision, such as this case, it is not necessary to ablate the borders, as those are clean and free of neoplastic tissue (3). The circumferential “pre-cutting” or knife-assisted resection is useful to provide an R0 resection.

3) After circumferential incision and some endoscopic submucosal dissection (Panels F and G) we resected the bulk of the lesion using snare (EMR), and the few remaining remnants using repeated injection and piecemeal EMR. During part of the procedure, we used underwater EMR technique. The final resection site was about ¾ or 75% of the lumen circumference. The resected lesion (and fragments) size measured together 8 cm.

This case shows the concept of “personalized endoscopic resection”. First, we “personalized” the patient, who was a poor surgical candidate and offered the option of organ-sparing endoluminal surgery. Second, we “personalized” the lesion. The lesion was well-studied, interrogated and resected using various endoscopic techniques and categorized as “complex colon polyp” (1, 2). Essential aspects for a success were a) focus on safety, using measures to prevent complications, b) aiming at R0 and c) avoiding a “tunnel vision” and sticking to only one technique, but instead “thinking outside the box” and optimizing the “toolbox approach”, and thus using various endoscopic resection methods, which resulted in a successful resection.

References:

1. Mönkemüller K, Neumann H, Malfertheiner P, Fry LC. Advanced colon polypectomy. Clin Gastroenterol Hepatol. 2009 Jun;7(6):641-52. doi: 10.1016/j.cgh.2009.02.032. Epub 2009 Mar 10. PMID: 19281865.

2. Angarita FA, Feinberg AE, Feinberg SM, Riddell RH, McCart JA. Management of complex polyps of the colon and rectum. Int J Colorectal Dis. 2018 Feb;33(2):115-129. doi: 10.1007/s00384-017-2950-1. Epub 2017 Dec 28. PMID: 29282496.

3. Mathews AA, Draganov PV, Yang D. Endoscopic management of colorectal polyps: From benign to malignant polyps. World J Gastrointest Endosc. 2021 Sep 16;13(9):356-370. doi: 10.4253/wjge.v13.i9.356. PMID: 34630886; PMCID: PMC8474698

4. Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, et al. Endoscopic removal of colorectal lesions: recommendations by the US multi-society task force on colorectal cancer. Gastroenterology. (2020) 158:1095–129. doi: 10.1053/j.gastro.2019.12.018

About the authors

Troy Pleasant, MD

Gastroenterologist

RMG Gastroenterology, Raleigh, North Carolina, USA

Troy Pleasant, MD, is a gastroenterologist with RMG Gastroenterology in North Carolina. He earned his medical degree from Eastern Virginia Medical School, completed internal medicine residency at Wake Forest Baptist Hospital in Winston-Salem, and completed his gastroenterology fellowship at Carilion Clinic / Virginia Tech in 2025. His clinical interests include colorectal cancer screening, inflammatory bowel disease, IBS, and esophageal disorders.

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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