Endoscopic Submucosal Dissection as a Rescue Therapy for Ineffective Endoscopic Mucosal Resection in Ileal Pouch, Nongranular, Laterally Spreading Tumor

CASE REPORT Restorative proctocolectomy is the most effective treatment to reduce colorectal cancer incidence in patients affected by familial adenomatous polyposis (FAP) syndrome.1 Despite being uncommon, patients with FAP could develop small bowel and ileal pouch laterally spreading tumors, burdened by potential malignant evolution (Figure 1). Therefore, close surveillance and endoscopic mucosal resection (EMR) strategy are indicated.2,3Figure 1.: Nongranular, flat, laterally spreading tumor of the ileal pouch in a patient affected by familial adenomatous polyposis syndrome.However, because of anastomotic fibrosis and postsurgical strong adhesions in the abdominal and peritoneal cavity, standard polypectomy or EMR can be challenging and even ineffective to treat ileal pouch LSTs. In this case, endoscopic submucosal dissection may represent the rescue treatment.4 We report the case of a 60-year-old patient with FAP, who underwent a restorative proctocolectomy with ileal pouch anal anastomosis in 2011. Follow-up colonoscopy revealed a 30 mm nonelevated, nongranular laterally spreading tumor (0-IIb, Paris Classification) of the ileal pouch (Figure 2).Figure 2.: Ileal pouch after endoscopic submucosal dissection of nongranular laterally spreading tumors. The image shows the exposed muscular layer also over the suture line.The patient was scheduled for piecemeal EMR. However, due to the severe fibrosis, poor submucosal lifting, and the inability to capture the adenomatous tissue using different types of snares, this approach was ineffective. Therefore, in the same session, the procedure was switched to endoscopic submucosal dissection using a hook-tip knife (Video 1). The dissection was performed over the longitudinal muscular layer and beyond, until the surgical staple suture was encountered. An en bloc resection was obtained, and no intraprocedural adverse events were reported. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Endoscopic submucosal dissection of ileal pouch laterally spreading tumor.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_kcdm8p2p"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Postprocedural observation was uneventful, and the patient was discharged 1 day after the procedure. Pathology revealed glandular tubulovillous adenoma with high-grade dysplasia extended to one of the lateral margins; therefore, a strict follow-up was scheduled (Figure 3). After 3 months, endoscopy showed an ulcerated area corresponding to the scar healing progress (Video 2). The superficial glandular aspect was seen in the anal edge of the scar. Thus, a further endoscopic check was scheduled for the next 3-6 months.Figure 3.: Microscopic view revealed glandular tubulovillous adenoma with high-grade dysplasia and free vertical margin. Hematoxylin/eosin stain 2×. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"Endoscopic check performed 3 months after endoscopic submucosal dissection.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_vlvgk110"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Given the poor therapeutic options in patients affected by FAP who have already undergone ileal pouch restoration, endoscopic techniques such as submucosal, intermuscular, or full-thickness dissection should be considered as the first therapeutic approach mostly to avoid definitive ileostomy. DISCLOSURES Author contributions: Conceptualization: G. Grande and R. Casciola. Writing—original draft preparation: F. Barbaro, T. Schepis, R. Casciola, S. Cocca, S. Russo. Writing—review and editing: G. Grande, H. Bertani, R. Conigliaro. Supervision: R. Conigliaro. Giuseppe Grande is the article guarantor. Financial disclosure: Giuseppe Grande: consultant for Olympus, ERBE, Boston Scientific, Alfa Sigma, Mayoly. Federico Barbaro: consultant for Olympus. Informed consent was obtained for this case report.