Thulium laser–assisted colorectal endoscopic submucosal dissection

TL;DR

A thulium laser was successfully used for colorectal endoscopic submucosal dissection, showing potential as a safer and more precise alternative to traditional tools.

Contribution

Demonstrates the feasibility of thulium laser in colorectal endoscopic submucosal dissection with no adverse events.

Findings

Thulium laser–assisted ESD was completed in 75 minutes without coagulation forceps.

No intraoperative or delayed adverse events occurred during the procedure.

The final pathology showed a tubulovillous adenoma with clear margins.

Abstract

Thulium laser is emerging as an alternative energy source in endourologic applications due to its precise cutting capabilities, reliable hemostasis, and limited thermal injury. These features have promoted its adoption in urology and sparked interest in gastrointestinal endoscopy. In endoscopic submucosal dissection (ESD), thulium laser offers potential advantages over conventional electrosurgical knives, including shallow penetration depth, powerful coagulation, and precise dissection.

We describe the use of thulium laser–assisted colorectal ESD in a 68-year-old man with a 3.5-cm rectal polyp. Submucosal injection was followed by incision and complete dissection using the thulium laser.

En bloc thulium laser–assisted ESD of the rectal lesion was completed in 75 minutes without the requirement for coagulation forceps. There were no intraoperative or delayed adverse events. The final pathology was tubulovillous adenoma with clear margins.

This case demonstrates the feasibility and potential benefits of thulium laser–assisted colorectal ESD. The precise cutting capabilities, shallow penetration depth, and effective coagulation properties of the thulium laser make it an exciting prospect as an alternative to conventional electrosurgical knives for colorectal ESD. Thulium laser–assisted ESD may offer a safe and effective alternative to conventional knives in colorectal ESD. Larger prospective studies are needed to confirm its safety and efficacy.

Figures

Rectal endoscopic submucosal dissection. A, A 3.5-cm Paris Is lesion. B, Incision. C, Dissection. D, Pinned specimen.

Thulium laser system. A, The energy source. B, Laser fiber.

Full text

Background

Thulium laser is emerging as an alternative energy source in endourologic applications, because of its improved cutting capabilities, reliable hemostasis, and limited thermal injury of adjacent tissue. These features have promoted its adoption in urology for endoscopic enucleation of prostate, bladder tumor resection, and stone management.1 The safety, efficacy, and precision observed in endourologic procedures have sparked interest in the use of the thulium laser for gastrointestinal endoscopy (Fig. 1).2Figure 1. Rectal endoscopic submucosal dissection. A, A 3.5-cm Paris Is lesion. B, Incision. C, Dissection. D, Pinned specimen.

In endoscopic submucosal dissection (ESD), thulium laser offers potential advantages over conventional electrosurgical knives. Notably, the laser has a very shallow depth of penetration (∼0.2 mm), which may help reduce the risk of perforation versus traditional electrosurgical knives with a penetration depth of 2 to 3 mm.3 It also offers a powerful coagulation effect useful in the dissection of vascular submucosal tissue, as well as a precise target tissue effect that enables exact dissection.

Here, we describe the off-label use of the thulium laser system (SOLTIVE SuperPulsed Laser System; Olympus, Tokyo, Japan), which delivers ultrashort pulse widths and precise energy modulation (Video 1, available online at www.videogie.org). This system offers adjustable power settings (2-60 W) and adjustable pulse durations (200 μs to 50 ms), allowing for tailored energy delivery (Fig. 2).Figure 2. Thulium laser system. A, The energy source. B, Laser fiber.

Case

A 68-year-old man was referred for endoscopic resection of a proximal rectal polyp after a positive fecal immunochemical test result. The polyp was a 3.5-cm Paris Is, Japan Narrow-Band Imaging Expert Team classification 2B, located in the proximal rectum requiring en bloc resection (Fig. 1). ESD was performed with the patient under general anesthesia. To minimize carbonization, an underwater technique was used, analogous to endourologic laser procedures. The laser was set at 0.1 J per pulse, with a frequency of 80 Hz, delivering a total power output of 8 W. Following submucosal injection with hydroxypropyl methylcellulose, a circumferential mucosal incision was made using the thulium laser fiber, and subsequent submucosal dissection was completed. The laser provided precise tissue dissection and reliable hemostasis, without the need for hemostatic forceps. The en bloc ESD was completed in 75 minutes without adverse events. Histopathology was a tubulovillous adenoma with high-grade dysplasia and R0 resection. The patient was discharged the same day and had an uneventful recovery.

Discussion

This case demonstrates the feasibility of thulium laser–assisted ESD in colorectal lesions. The laser's precise cutting, effective coagulation, and shallow penetration depth contributed to efficient dissection while minimizing thermal injury and perforation risk. Our experience is consistent with that of previous reports, with, to our knowledge, Cho et al4 first describing thulium laser use in gastric ESD over a decade ago, and Tontini et al2 later demonstrating its efficacy in ex vivo colorectal models. Larger prospective studies are needed to confirm its safety and efficacy for broader application in ESD.

Patient Consent

Informed consent was obtained from the patient for publication of the case details and accompanying video.

Disclosure

All authors disclosed no financial relationships.