Double-tunneling butterfly method for endoscopic submucosal dissection of extensive rectal neoplasms

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is the preferred technique for en bloc resection of superficial colorectal neoplasms. Resection of extensive lesions with ESD can be challenging, owing to loss of orientation in the submucosal space. In this case series, we describe the double-tunneling (DoT) butterfly method for ESD of extensive rectal neoplasms. METHODS: The key feature of the DoT butterfly method is the creation of 2 tunnels that are transformed into bilateral flaps, leaving a submucosal septum between them. RESULTS: Four rectal neoplasms measuring (maximum diameter) 7 cm, 8 cm, 9 cm, and 18 cm, respectively, were resected in 4 patients by use of the DoT butterfly method. The lesions included recurrent adenoma (n = 1) and dysplasia (n = 1) in longstanding ulcerative colitis. Curative R0 resection was confirmed in all 4 cases. Histologic examination showed tubular adenomas with low-grade dysplasia in 1 of 4 patients and focal high-grade dysplasia in 3 of 4 patients. One patient experienced postprocedural bleeding that required endoscopic reintervention. CONCLUSION: The DoT butterfly method appears to be useful for the resection of extensive rectal neoplasms. A prospective study is required to assess whether these results can be reproduced in a large cohort of patients.