Natural Orifice Transluminal Endoscopic Surgery (notes) Using Endoscopic Submucosal Dissection (esd) for a Large Left Colon Lesion in a High-risk Patient

I. Emre Gorgun, MD, Erman Aytac, MD, Feza H Remzi, MD

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio.


Natural orifice transluminal endoscopic surgery (NOTES) with endoscopic submucosal dissection (ESD) provides en bloc resection of large tumors in the upper gastrointestinal tract. However, this technique can be challenging in the colon due to risk of perforation. In this video, our technique using ESD in a high-risk patient with multiple co-morbid conditions who initially was referred for segmental colectomy is presented.

Method and procedure

This 88 years old man with past medical history of atrial fibrillation, B cell lymphoma s/p chemotherapy and hypertension underwent en bloc endoscopic submucosal dissection of a large left sided colonic lesion. The lesion was at 70 cm. from the anal verge involving 60 % of the circumference of the lumen. Using dual knife, the lesion was marked circumferentially with 3 mm clear margin. This was followed by submucosal lifting using albumin/indigo carmine solution injection. The dissection was facilitated using distal disposable cap that was attached at the end of the colonoscope. En bloc removal of the the lesion was achieved and the specimen measured 3.2 cm. in diameter.


Patient was discharged on postoperative day one with no complications. The final pathology revealed tubulovillous adenoma with clear deep and circumferential margins.


ESD is a safe and useful technique in carefully selected patients. With increasing experience its use will gradually expand and will more widely be used in large colonic lesions among surgeons.

Session: Video ChannelDay 3

Program Number: V120

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