# The continuous low-pressure saline perfusion method of endoscopic submucosal dissection for the circumferential tumor in the remnant rectum after the Hartmann’s procedure

## TL;DR

A new endoscopic method using continuous low-pressure saline perfusion safely removes large tumors in the remnant rectum after surgery.

## Contribution

A novel ESD technique using continuous low-pressure saline perfusion is introduced for fragile mucosa in the Hartmann’s remnant rectum.

## Key findings

- The procedure was completed safely within 140 minutes with excellent visibility and no adverse events.
- Pathology confirmed a well-differentiated adenocarcinoma with negative margins.
- 85% of the infused saline was recovered through the drainage tube.

## Abstract

Continuous low-pressure saline perfusion in endoscopic submucosal dissection (ESD) combines drainage tubes with saline-immersion therapeutic endoscopy, eliminating bubbles from high-frequency devices, enhancing visualization, and maintaining a deflated lumen. We applied this technique to safely resect a large circumferential lesion in the remnant rectum after the Hartmann’s procedure where the mucosa was very fragile.

An 82-year-old man with a 90-mm circumferential laterally spreading tumor in the Hartmann’s remnant rectum underwent ESD. A nasogastric drainage tube was inserted in an alpha shape, and continuous low-pressure saline perfusion in ESD was performed. The “Asclepius tube” technique also was used to maintain stable drainage and lumen deflation.

The procedure was completed safely within 140 minutes, with excellent visibility and no adverse events noted. Pathology showed an intramucosal, well-differentiated adenocarcinoma with negative margins. A total of 4000 mL of saline was infused, 85% of which was recovered through the drainage tube.

Continuous low-pressure saline perfusion in ESD is a safe and effective technique for large lesions in the Hartmann’s remnant rectum, providing stable lumen collapse, enhanced visibility, and minimal mucosal trauma.