Society: ASGE

Introduction
Malignant colorectal polyps are defined as lesions that invade into the submucosa and represent early colorectal cancer (T1 by the TNM Classification of Malignant Tumors system). Management of these lesions depends on the depth of invasion which can be estimated endoscopically using various classification methods that assess lesion morphology and surface features. Superficially invasive lesions are generally amenable to endoscopic resection techniques whereas deeply invasive lesions are typically managed with surgical resection given the high risk of invasion beyond the submucosa. Here, we describe successful endoscopic resection of a deeply invasive colon lesion in a non-surgical candidate using hybrid endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) with the full-thickness resection device (FTRD).

Case
A 71-year-old male with a history of chronic kidney disease stage IV, type II diabetes mellitus, peripheral arterial disease and below-the-knee amputation, and recently diagnosed pulmonary embolism was found to have a colon mass on imaging after presenting with acute on chronic anemia. Colonoscopy revealed a 30 mm polypoid lesion (Paris classification 0-Is) in the hepatic flexure with features concerning for submucosal invasion (NICE classification Type III), including superficial ulceration and oozing with minimal contact (Figure 1A). After multidisciplinary discussion, the patient was felt to be a poor surgical candidate and thus endoscopic resection using endoscopic submucosal dissection (ESD) was pursued in case the invasion of the cancer was limited to superficial submucosa.

Procedure
A circumferential incision surrounding the lesion was made and endoscopic submucosal dissection was performed (Figure 1B). During dissection, invasion into the muscularis propria was visualized (Figure 1C) and thus the decision was made to use the full-thickness resection device (FTRD) to complete the resection.

The grasping forceps were used to pull the lesion into the device cap and the clip was deployed. Given the presence of submucosal invasion, gentle intermittent suction was applied to ensure complete entrapment of the lesion into the FTRD cap. The snare was closed and the lesion was resected using electrocautery (Figure 1D). The final pathology report revealed T2 invasive adenocarcinoma (Figure 2) with negative resection margins (R0).

Conclusions
While deeply invasive colon lesions are traditionally removed surgically, endoscopic resection using hybrid ESD-EFTR may offer an alternative treatment approach in select patients who are non-surgical candidates. In this case, initial submucosal dissection allows for the lesion to be more pliable and hence more amenable to be completely pulled into the FTRD cap which allowed for complete endoscopic resection of a T2 adenocarcinoma.

Figure 1. A) A 30 mm polypoid lesion with overlying ulceration is seen at the hepatic flexure (Paris classification 0-Is, NICE Type III). B) An initial circumferential incision around the lesion is made for ESD. C) Lesion invasion into the muscularis propria is visualized during submucosal dissection. D) Final view of the resection site showing appropriate position of the clip.

Figure 1. A) A 30 mm polypoid lesion with overlying ulceration is seen at the hepatic flexure (Paris classification 0-Is, NICE Type III). B) An initial circumferential incision around the lesion is made for ESD. C) Lesion invasion into the muscularis propria is visualized during submucosal dissection. D) Final view of the resection site showing appropriate position of the clip.

Figure 2. Final pathology of the lesion shows T2 invasive adenocarcinoma with negative (R0) resection margins

Figure 2. Final pathology of the lesion shows T2 invasive adenocarcinoma with negative (R0) resection margins

Introduction
Comorbidities and hostile surgical fields make esophago-bronchial fistula surgery difficult. Mismatch between the distal stent flare and gastric conduit diameter limit fully covered metal stent (FCMS) use in esophago-gastro-bronchial fistulas. We successfully managed a case of esophago-gastro-mediastino-bronchial fistula in a patient with a history of esophagectomy by combining a FCMS, percutaneous endoscopic thoracotomy and a retrograde PEJ-G tube. This management approach changed the disease course from requiring hospice to being back in the community.

Case Presentation
A 69-year-old man with history of esophageal cancer post-Ivor Lewis esophagectomy and chemoradiation, right lung partial pneumonectomy due to post-operative anastomotic leak who developed recurrent aspiration pneumonias and pulmonary edema requiring ICU admissions. These recurrent pneumonias and pulmonary edema over the prior 4 years were secondary to frequent collection of secretions in the persistent post-pneumonectomy cavity at the post-surgical site. He was given the option to go to hospice versus novel endoscopic intervention. He opted for the latter.

Endoscopy revealed a disrupted esophagogastric anastomosis around 15mm, and an esophago-gastro-mediastino-bronchial fistula in the upper third of the esophagus (Figure 1). Endoscopic management involved placing a percutaneous endoscopic thoracotomy tube, double lumen percutaneous endoscopic jejuno-gastric tube with a locking loop drain and FCMS across the defect (Figure 2). Endoscopic suturing approximated esophagogastric anastomosis.

A follow up endoscopy with gastrografin swallow was performed with observation under fluoroscopy (video). The retrograde drain suctioned contrast without spillage into the thoracic cavity. The patient was taught to aspirate from both tubes after drinking thin liquids for comfort.

The patient continues to do well clinically and is seen every three months for tube exchanges for the last 4 years. He has not had any pulmonary infections since the intervention. He manages mucus plugs or secretions in the lungs by connecting the thoracic tube to low intermittent suction, which improves oxygenation. He eats comfort foods by mouth and suctions them out. He maintains his weight through jejunostomy site feeding.

Conclusion
A patient with a complex refractory esophago-gastro-mediastino-bronchial fistula after Ivor-Lewis esophagectomy was treated with stenting, endoscopic thoractotomy and a double lumen PEJ-G tube with locking loop drain. This allowed for feeding via the first lumen of the PEJ tube and suctioning via the retrograde jejunogastric tube to prevent aspiration. Percutaneous thoracotomy tube with PEG bumper was used as a backup to suction any remaining contents that could have reached the post pneumonectomy space.

Figure 1. Demonstration of Communication Through Esophago-Gastric Anastomosis to the Post Pneumonectomy Cavity/ Dead Space

Figure 1. Demonstration of Communication Through Esophago-Gastric Anastomosis to the Post Pneumonectomy Cavity/ Dead Space

Figure 2. (a) Thoracotomy with PEG tube to drain cavity. (b) Retrograde double lumen percutaneous endoscopic jejunogastric tube inserted retrograde into esophagogastric anastomotic site. (c,d) Contrast injected into fully covered metal stent with locking loop drain to suction out any orally consumed material with suction off (c), and suction on (d).

Figure 2. (a) Thoracotomy with PEG tube to drain cavity. (b) Retrograde double lumen percutaneous endoscopic jejunogastric tube inserted retrograde into esophagogastric anastomotic site. (c,d) Contrast injected into fully covered metal stent with locking loop drain to suction out any orally consumed material with suction off (c), and suction on (d).

Meher Oberoi

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