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Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic treatment, providing en bloc resection of early malignant lesions. En bloc removal of large colorectal lesions is difficult and requires a long time. We report a successful resection of a circumferential laterally spreading tumor in the colon by colorectal ESD with this new and different technique that we believe is used here for the first time. The procedure was performed in the endoscopy unit while the patient was sedated with spinal anesthesia by an anesthesiologist. To achieve en bloc resection and to benefit from gravity-assisted ESD, our plan was first to open 3 different tunnels from the beginning of the lesion toward the proximal site according to the gravitational behavior and maneuvering of the endoscope, and then to connect the tunnels (Fig. 1). A mixture of sodium hyaluronate, indigo carmine, and epinephrine was preferred for submucosal elevation at the anal site of the lesion, where there was a possibility of fibrosis. For the proximal site of the lesion, a mixture of saline solution, epinephrine, and indigo carmine was preferred for cheaper and easier injection. In total, 280 mL of the saline solution mixture and 20 mL of the sodium hyaluronate mixture were used. During the whole procedure, only the dual knife (regular type) was used, with the current set to dry cut (effect 2, power 30 watt) and swift coagulation (effect 4, power 30 watt) with the Erbe Vio 300D electrocautery unit (Erbe Elektromedizin, Tuebingen, Germany).

Multiple tunneling technique for treatment of rectal circumferential laterally spreading tumor with endoscopic submucosal dissection