Novel technique of endoscopic submucosal dissection by using external forceps for early rectal cancer (with videos)

Background: Endoscopic submucosal dissection (ESD) is more difficult for rectal cancer than for gastric cancer. Objective: To evaluate the feasibility and safety of an ESD procedure by using external forceps for early rectal cancer. Design: A case series. Setting: A tertiary medical center. Patients: Thirteen patients with early-stage rectal cancer were enrolled. Twelve of the 13 lesions were granular-type laterally spreading tumors and 1 was a protruding tumor. Interventions: After circumferential incision around the lesion with a dual-knife or a flex-knife, bendable external forceps were introduced with the help of grasping forceps inserted through the accessory channel and anchored at the anal margin of the lesion. After the forceps were bent, they were locked. With gentle anal traction and bending applied with the forceps, the lesion was elevated, the submucosal layer was opened, and the submucosal layer was dissected from the grasped side, facilitating dissection of the submucosal layer under direct vision. Main Outcome Measurements: Technical success, complication rates. Results: The mean lesion size was 33.0 mm (range 20-80 mm), and the mean operating time was 60 minutes (range 20-150 minutes). All lesions could be resected en bloc with tumor-free margins. Major bleeding after ESD occurred in only 1 patient (7.7%), who did not require blood transfusion. Perforation did not occur in any patient. Limitations: Single-center experience, small number of patients. Conclusion: This ESD procedure using external forceps for early-stage rectal cancers is feasible and safe.