Results of endoscopic biliary drainage in patients with malignant hilar stricture

Abstract In Malignant Hilar Biliary Stricture (MHBS) palliative biliary drainage is a frequent strategy, improving the quality of life, reducing pruritus, loss of appetite and relieving cholangitis. The endoscopic approach is an effective, although challenging procedure. This study aimed to evaluate technical and clinical success rates of biliary drainage by ERCP. This is a retrospective study including all patients with MHBS referred to Instituto do Cancer do Hospital de São Paulo (ICESP) submitted to biliary drainage by ERCP, between January 2010 and December 2017. Multivariable logistic regression was performed to evaluate predictors of clinical failure, as total bilirubin levels, Bismuth classification, number of hepatic sectors drained and presence of cholangitis. In total, 82 patients presenting unresectable MHBS were included in this study. 58.5% female and 41.5% male, with a mean age of 60±13 years. Bismuth classification grades II, IIIA, IIIB and IV were noted in 23.2%, 15.9%, 14.6% and 46.3%, respectively. Technical and clinical success was achieved in 92.7% and 53.7% respectively. At multivariable logistic-regression analyses, Bismuth IV strictures were related to higher clinical failure rates when compared to other strictures levels, with an Odds Ratio of 5.8 (95% CI 1.28‒20.88). In conclusion, endoscopic biliary drainage for malignant hilar biliary stricture had a high technical success but suboptimal clinical success rate. Proximal strictures (Bismuth IV) were associated with poor drainage outcomes.

Research progress of the diagnosis and treatment of pancreaticobiliary maljunction / 中华肝胆外科杂志

Pancreaticobiliary maljunction (PBM) is a congenital disease with pancreatic and bile ducts joining outside of the duodenal wall. The clinical symptoms of PBM are often characterized by a series of gallbladder and pancreatic disease. PBM has also gradually drawn attention due to recurrent of pancreatitis, bile duct stones and the malignant tumors of biliary system. With the innovative development of endoscopic minimally invasive technology, therapeutic endoscopy may provide new treatment options and ideas for PBM patients, and is expected to achieve the goal of endoscopic minimally invasive intervention to correct structural abnormalities in the pancreaticobiliary duct junction. This paper provided an overview of the definition, endoscopy diagnosis, the pathogenesis and therapeutic endoscopy progress of pancreaticobiliary maljunction.

Subphrenic splenic implantation after splenectomy： A case report / 中南大学学报(医学版)

Subphrenic splenic implantation is a rare disease, usually occurred followed the splenic trauma and splenectomy. Surgeries are often necessary for diagnosing and treating it. A 46-year-old male post-splenectomy patient, tolerating abdominal bloating and pain for more than 1 year, was admitted to the Second Xiangya Hospital, Central South University. Fundus bulge suggested a possibility of stromal tumors originating from the muscularispropria layer with endoscopic ultrasound. Slightly stomachic thickness was detected using enhanced computed tomography (CT). Without any improvement for symptoms after medication, the patient strongly requested to undergo an endoscopic therapy. Natural orifice transluminal endoscopic surgery (NOTES) result confirmed it as subphrenic splenic implantation with postoperative pathology. In this case, NOTES helped us to confirm the diagnosis, relieve the symptoms, as well as prevent secondary surgery injury, which would be helpful to other clinicians.

Miotomía endoscópica por vía oral (POEM) en un paciente pediátrico para tratamiento de la acalasia esofágica / Per oral endoscopic myotomy in a pediatric patient with achalasia

INTRODUCCIÓN: La acalasia es el trastorno motor primario más frecuente del esófago. Su incidencia reportada es baja, aún más en pacientes pediátricos. La miotomía de Heller laparoscópica corresponde al estándar actual de tratamiento. Durante los últimos años la miotomía endoscópica por vía oral (POEM) se ha posicionado como una alternativa terapéutica segura y tan efectiva como el Heller para la acalasia esofágica. OBJETIVO: Describir la técnica de POEM y reportar el primer caso pediátrico en nuestro país. CASO CLÍNICO: Paciente de 11 años, previamente sano, que se presentó con disfagia ilógica progresiva y baja de peso. El estudio concluyó una acalasia tipo II. Fue sometido a POEM y cursó un postoperatorio sin incidentes. A un año de la intervención se ha documentado resolución de la sintomatología, seguimiento endoscópico y manométrico sin complicaciones. CONCLUSIONES: El caso descrito corresponde al primer POEM en un paciente pediátrico en nuestro país. La acalasia esofágica es infrecuente en pediatría y el POEM ha demostrado éxito clínico y seguridad comparables a la miotomía de Heller laparoscópica en el corto y mediano plazo. El seguimiento a largo plazo permitirá determinar su rol definitivo en el tratamiento de pacientes pediátricos con acalasia esofágica.

INTRODUCTION: Achalasia is the most common primary motor disorder of the esophagus. Its reported incidence is low, even more in pediatric patients. Laparoscopic Heller myotomy is the current stan dard of treatment. During the last years, per-oral endoscopic myotomy (POEM) has been positioned as a safe and effective therapeutic alternative as the Heller procedure for esophageal achalasia. OBJECTIVE: To describe the POEM technique and report the first pediatric case in our country. CLINICAL CASE: 11-year-old patient, previously healthy, who presented with progressive dysphagia for solids and liquids and weight loss. The study concluded a type II achalasia. The patient underwent a POEM and had a postoperative course without incidents. One year after the intervention, symptomatic, endoscopic and manometric resolution have been documented. CONCLUSIONS: The described case is the first POEM in a pediatric patient in our country. Esophageal achalasia is uncommon in pediatrics and POEM has demonstrated clinical success and safety comparable to laparoscopic Heller myotomy in short and medium term. Long-term follow-up will determine its definitive role in the treatment of pediatric patients with esophageal achalasia.

Omental Patching and Purse-String Endosuture Closure after Endoscopic Full-Thickness Resection in Patients with Gastric Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, primarily arising from the stomach. With the widespread utilization of and technical advancements in endoscopy, gastric GISTs are being increasingly detected at an early stage, enabling complete endoscopic resection. Endoscopic full-thickness resection (EFTR) is an advanced technique that has been recognized as a treatment tool for neoplasms in the digestive tract in selected patients. Although a number of methods are available, closing large iatrogenic defects after EFTR can be a concern in clinical practice. If this potential problem is appropriately solved, patients with gastric GISTs would be suitable candidates for resection utilizing this technique. To our knowledge, this is the first study to propose omental patching and purse-string endosuture closure following EFTR as a feasible endoscopic option in patients with gastric GISTs.

Robotics for Advanced Therapeutic Colonoscopy

Although colonoscopy was originally a diagnostic imaging procedure, it has now expanded to include an increasing range of therapeutic interventions. These procedures require precise maneuvers of instruments, execution of force, efficient transmission of force from the operator to the point of application, and sufficient dexterity in the mobilization of endoscopic surgical instruments. The conventional endoscope is not designed to support technically demanding endoscopic procedures. In case of colonoscopy, the tortuous anatomy of the colon makes inserting, moving, and orientating the endoscope difficult. Exerting excessive pressure can cause looping of the endoscope, pain to the patient, and even perforation of the colon. To mitigate the technical constraints, numerous technically enhanced systems have been developed to enable better control of instruments and precise delivery of force in the execution of surgical tasks such as apposing, grasping, traction, counter-traction, and cutting of tissues. Among the recent developments are highly dexterous robotic master and slave systems, computer-assisted or robotically enhanced conventional endoscopes, and autonomously driven locomotion devices that can effortlessly traverse the colon. Developments in endoscopic instrumentations have overcome technical barriers and opened new horizons for further advancements in therapeutic interventions. This review describes examples of some of these systems in the context of their applications to advanced therapeutic colonoscopy.

Experimental Gastric Non-Balloon Devices

Endoscopic bariatric therapies (EBTs) are promising alternatives to the conventional surgeries used to treat obesity and related metabolic conditions, targeting gastrointestinal anatomical and physiological processes. Many EBTs are at various stages of development and are aimed at promoting an early sense of satiety via anatomical and physiological mechanisms. In the present study, we focused on relevant clinical issues and future perspectives with regard to gastric non-balloon methods treating obesity.

Muiticenter clinical study of endoscopic variceal ligation in the treatment of 61 cases of type 1 gastroesophageal varices bleeding / 中华消化杂志

Objective To investigate the clinical efficacy of endoscopic variceal ligation (EVL) in the treatment of type 1 gastroesophageal varices (GOV1).Methods From July 2016 to May 2017,at the First Affiliated Hospital of Anhui Medical University,NO.2 People's Hospital of Fuyang City and the Sixth People's Hospital of Shenyang,the efficacy of EVL in the treatment of patients with GOV1 were retrospectively analyzed.The number of ligation rings,emergency (bleeding within 24 hours) hemostasis,successful hemostasis,early rebleeding (from 72 hours to six weeks after operation),delayed rebleeding (at six weeks after operation) and disappearance of gastroesophageal varices were observed.Patients were followed up for six to 16 months and postoperative complications of EVL were evaluated.Results There were 61 patients with GOV1 (40 males and 21 females),and the mean age was (50.9±10.9) years.The number of ligation during EVL operation was one to six (mean 3.8 ± 1.9).Seven patients with active bleeding were all successfully achieved emergency hemostasis.One case had rebleeding in 72 hours after operation,and the hemostatic rate was 98.3 ％ (60/61).The early rebleeding rate was 11.5 ％ (7/61),the delayed rebleeding rate was 4.9％ (3/61),and the total rebleeding rate was 16.4％ (10/61).The disappearance rate of gastroesophageal varices was 85.2％ (52/61).The complication rate was 21.3％ (13/61).No post-ligation ulcer bleeding,spontaneous bacterial peritonitis and perforation were observed in all patients.Conclusions EVL can effectively control the acute hemmorrhage of GOV1 type gastric varices.The postoperative rebleeding rate and complication rate are low.However,the disappearance rate of varices is high.

Risk factors of recurrence for gastric mucosal lesions after endoscopic submucosal dissection / 中华消化内镜杂志

Objective To investigate the recurrence and risk factors of gastric high-grade intraepithelial neoplasia(HGIN)and early gastric cancer(EGC)after endoscopic submucosal dissection (ESD). Methods The clinical and follow-up data on 444 patients(451 lesion)with HGIN and EGC undergoing ESD in Digestive Endoscopy Center of Chinese PLA General Hospital from November 2006 to January 2016 were summarized, and the risk factors of recurrence were analyzed. Results A total of 410 patients were followed-up, and the recurrence rate was 3.2%(13 patients, 13 lesions), with mean recurrence time of 17.6±9.6 months(6-38 months). Univariate and multivariate analysis revealed that the size of the lesion>4.0 cm was the only risk factor of recurrence(P=0.012,OR=10.855,95%CI:1.673~70.442). Conclusion The rate of recurrence is increasing with the EGC extending, therefore, postoperative monitoring should be strengthened to patients with larger lesion.

Value of endoscopic resection technique of serous preservation for upper gastrointestinal tumor originated from muscularis propria / 中华消化内镜杂志

Objective To investigate the safety and efficacy of endoscopic subserosal dissection (ESSD)for patients with upper gastrointestinal submucosal tumors. Methods A retrospective study was performed on the data of 6 patients with submucosal tumor undergoing ESSD in Nanjing Drum Tower Hospital from October 2016 to February 2017. The surgery time, surgical success rate, postoperative pathology and complications were analyzed. Results All patients successfully completed surgery. One patient had serosal perforation. The mean diameter of tumor was 27.5±10.0 mm. The mean surgery time was 49±18 min. The postoperative pathology of lesions was very low risk stromal tumor. No serious complications occurred. Conclusion ESSD is safe and reliable for patients with tumor originated from muscularis propria.

Value of endoscopic resection on duodenal space-occupying lesions / 中华消化内镜杂志

Objective To assess the clinical value and safety of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for duodenal lesions.Methods The data of 12 patients with duodenal space-occupying lesions underwent EMR or ESD from January 2010 to December 2015 in Chinese PLA General Hospital were retrospectively analysed.Results All patients received operation, including 9 male and 3 female with mean age of 50.0 years(33.0-62.0 years).There were 8 lesions in duodenal bulb and 4 in descending part.The mean diameter of the lesions was 1.2 cm (0.5-3.0 cm).Three lesions were originated from mucosa, of which 2 were high-grade intraepithelial neoplasia and 1 was villous/tubular adenoma.Nine lesions were located in submucosa, including 3 cases of neuroendocrine neoplasm, 1 case of stromal tumor, 1 liomyoma case, 1 lipoma case, 1 case of Brunner glands adenoma, 1 case of ectopic pancreas, and 1 inflammatory lesion.One patient had perforation with rate of 8.3%(1/12) and was recovered after conserved treatment.The bleeding was very little during operation.No infection or stenosis happened.The mean hospitalized time was 6.0 days (1.0-12.0 days) after operation.No recurrence was found during 23.8 months(3.0-73.0 months) of follow-up.Conclusion EMR and ESD are effective and safe for treatment of duodenal space-occupying lesions.

Value of pancreatic stent placement for endoscopic resection of duodenal papilla adenoma / 中华消化内镜杂志

Objective To assess the application value of pancreatic stent placement for endoscopic resection of duodenal major papilla adenoma.Methods A total of 67 cases of duodenal major papilla adenoma that were confirmed by biopsy and underwent endoscopic papillectomy from August 2007 to July 2016 in endoscopy center of Drum Tower Hospital of Nanjing were analyzed retrospectively.There were 50 patients treated with pancreatic stent placement and 17 patients without as the control group.The general information, efficacy and complications of two groups were collected at the same time.Results There were no significant differences in gender(P=0.070), age(P=0.151) or tumor size(P=0.136) between pancreatic stent placement group and the control group.There were no statistical differences in en bloc resection rates or complete resection rates between the two groups.And there were no significant differences in short-term complications of bleeding(P=0.428), pancreatitis(P=0.982), cholangitis(P=1.000), perforation(P=1.000)or long-term complications of distal common pancreatic duct stricture between the two groups.Conclusion Pancreatic stent should not be routinely placed in endoscopic papillectomy, and should be considered for specific cases.

Comparison of endoscopic piecemeal mucosal resection and endoscopic submucosal dissection for treatment of esophageal mucosal lesion larger than 15mm / 中华消化内镜杂志

Objective To evaluate the clinical value of endoscopic piecemeal mucosal resection (EPMR) and endoscopic submucosal dissection (ESD) for treatment of esophageal mucosal lesion with diameter larger than 15 mm.Methods The data of 261 patients with esophageal mucosal lesions ≥15 mm and undergoing ESD (n=198) or EPMR (n=63) in Endoscopy Center of Zhongshan Hospital from September 2009 to August 2011 were retrospectively analyzed.Therapeutic effect, complications, and local recurrence were compared between the two groups.Results The lesion size was significantly larger in the ESD group than that in the EPMR group (3.02±1.13 mm VS 2.66±0.95 mm, P0.05) between the two groups.The rate of postoperative esophageal stricture was higher in the EPMR group than that of the ESD group [22.6% (14/62) VS 6.2% (12/194),P<0.05] except for 5 cases with further surgery treatment (4 cases in the ESD group and 1 case in the EPMR group).The local recurrence rate was also higher in the EPMR group than that of the ESD group [11.5% (7/61) VS 3.7% (7/190), P<0.05], except for 10 cases with positive margin.Conclusion The therapeutic effect of ESD is superior to that of EPMR for esophageal mucosal lesions with diameter larger than 15 mm due to lower rate of local recurrence and acceptable complications.

Clinical application of single forcep endoscopic purse-string suture closing the wound of cardia and gastric fundus after endoscopic full-thickness resection for patients with submucosal tumor(with video) / 中华消化内镜杂志

Objective To evaluate the efficacy and safety of single forcep endoscopic purse-string suture closing the wound of cardia and gastric fundus after endoscopic full-thickness resection (EFTR) for patients with submucosal tumor (SMT).Methods The clinical data of 32 patients with wound in the cardia and gastric fundus after EFTR for SMT undergoing single forcep endoscopic purse-string suture in Endoscopy Center of Renmin Hospital of Wuhan University from January 2015 to January 2016 were collected.Completion of operation, postoperative complication and follow-up results of these patients were retrospectively analyzed.Results All of the patients successfully received EFTR and purse-string suture.The maximal diameter of tumors was 1-4 cm.The suture time was 10-15 min, and postoperative hospital stay was 5-10 d.Low fever and upper abdominal pain were found in 13 and 20 cases respectively, and all cases were alleviated or restored after conservative treatment.All patients underwent gastroscopy during follow-up of 1 month, and titanium clip and nylon rope were found on the wound surface in 29 cases (90.6%).Three months after operation, 28 patients underwent gastroscopy, and titanium clip but no nylon rope was detected in 15 cases (46.9%).Conclusion Single forcep endoscopic purse-string suture can effectively treat the postoperative wound in the cardia and gastric fundus of patients with submucosal tumors after EFTR.

Efficacy and safety of endobiliary radiofrequency ablation with stent placement in treatment of non-resectable extrahepatic cholangiocarcinoma / 中华消化内镜杂志

Objective To study the efficacy and safety of endobiliary radiofrequency ablation (RFA) with stent placement in treatment of unresectable extrahepatic cholangiocarcinoma (EHCC).Methods The patients with unresectable EHCC in Hangzhou First People's Hospital between October 2013 and January 2015 were enrolled in a prospective, randomized, single-blind cohort study, and were assigned randomly into two groups: RFA+stent group and stent-only group.The jaundice fade time, stent patency period, overall survival rate, and postoperative adverse events were analyzed between two groups.Results Among 59 patients with non-resectable EHCC, 28 were divided into RFA+stent group, and 31 were in stent-only group.There was no statistical difference in preoperative serum total bilirubin between the two groups.Mean serum bilirubin decrease time was significantly lower in the RFA+stent group than that in the stent-only group[17.9 d(7-22 d) VS 29.9 d(10-55 d),P=0.03].The biliary patency period in RFA+stent group was significantly longer than that of stent-only group (8.9 months VS 4.5 months, P=0.02).The mean survival time in RFA+stent group was significantly longer than that of stent-only group[13.3 months(6.2-16.5 months) VS 8.6 months(4.5-11.7 months), P=0.000).Incidence of postoperative adverse events showed no statistical difference between the two groups(P=0.727).Conclusion RFA with stent placement is effective and safe as a palliative measure in the treatment of non-resectable EHCC, and it can significantly shorten the jaundice fade time, prolong the biliary patency period and overall survival, while without increase of the incidence of adverse events.

Animal model experiment on application of new magnetic anchoring and guidance system on endoscopic submucosal dissection(with video) / 中华消化内镜杂志

Objective To evaluate the safety and efficacy of a new magnetic anchoring and guidance system on endoscopic submucosal dissection(ESD)in pig models. Methods Two skilled operators performed ESD at the rectum part of 2 pigs with the help of a new magnetic anchoring and guidance system. The dissection time,dissection rate per unit time, en-bloc resection rate and complications were analyzed. Results Five simulated lesions underwent ESD with the help of the magnetic anchoring and guidance system. The dissection time was 26.6 min and the dissection rate was 0.38± 0.1 cm2/min. All the lesions were dissected totally. There was no perforation or delayed bleeding. Conclusion The new magnetic anchoring and guidance system is effective and safe for pig rectal ESD. It can effectively expose submucosal layer,and assist resection under the endoscopic observation.

Evaluation of narrow band imaging for children with abdominal Henoch?Schonlein purpura / 中华消化内镜杂志

Objective To evaluate value of narrow band imaging(NBI) endoscopy for children with abdominal Henoch?Schonlein purpura ( HSP ) . Methods A total of 46 patients with abdominal HSP were enrolled into the observation group(NBI intervention) from November 2010 to February 2016.Diagnostic rates of white light and NBI endoscopy in abdominal HSP patients, IgA positive rates of targeted biopsies and severe complications were retrospectively analyzed. A total of 25 abdominal HSP patients with no NBI intervention admitted from 2007 to 2009 were randomly enrolled into control group. Data of the control group were compared with those of observation group. Results In observation group, the diagnostic rate under NBI was significantly higher than that under white?light endoscopy[91. 3%(42/46)VS 67. 4%(31/46),χ2=8. 02,P<0. 05]. IgA positive rates of targeted biopsies under NBI was significantly higher than that under white?light endoscopy [ 95. 7%( 88/92 ) VS 69. 6%( 64/92 ) ,χ2 = 21. 79, P<0. 05 ] . Three patients developed such serious complications as digestive hemorrhage as predicted. Compared with control group, abdominal pain and blood stool relief time (10. 96±5. 32 d VS 19. 68±4. 29 d,t=7. 50,P<0. 01), fasting time(10. 37±5. 42 d VS 8. 80± 3. 71 d,t=7. 73,P<0. 01), hospital stay (18. 80±7. 11 d VS 23. 12±4. 36 d, t=3. 16,P<0. 01), time of stool occult blood negative ( 11. 41 ± 6. 30 d VS 19. 12 ± 4. 09 d, t=6. 22, P<0. 01 ) in observation group were significantly shortened. Conclusion NBI endoscopy is valuable for improving the diagnostic accuracy and biopsy accuracy and complication prediction of abdominal Henoch?Schonlein purpura in children.

Efficacy and safety of endoscopic retrograde cholangiopancreatography for children with pancreaticobiliary diseases / 中华消化内镜杂志

Objective To assess the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) for children with pancreaticobiliary diseases. Methods Data of children under 14 years old who have underwent ERCP in Nanjing Drum Tower Hospital between September 2007 and August 2016 were reviewed for completion, complications and therapeutic methods. Results A total of 41 children underwent 68 ERCP, including 6(8. 8%) diagnostic and 62(91. 2%) therapeutic procedures. All procedures were performed under deep sedation. Cannulation failed in only 1 child with anomalous junction of pancreaticobiliary duct. The procedure success rate was 98. 5%( 67/68 ) . There were 8 adverse events, including 7 mild post?ERCP pancreatitis and 1 fever. Incidence of adverse event was 11. 8%( 8/68) . There was no such severe adverse event as bleeding, perforation, death, or other anesthesia related adverse event. Thirty?two children ( 78. 0%) had follow?up, ranging from 2 month to 6 years. Children followed lived well with no long?term adverse event. Conclusion ERCP is an effective and safe procedure for the diagnosis and treatment of pancreaticobiliary diseases in children.

A report of 12 cases of pneumatosis cystoides intestinalis / 中华消化内镜杂志

Objective To investigate the characteristics and treatment for pneumatosis cystoides intestinalis (PCI). Methods Data of 12 PCI patients admitted to General Hospital of Tianjin Medical University from 1997 to 2015 were analyzed. The causes, endoscopic characteristics, therapeutic effects and prognosis were evaluated. Results Four cases were primary PCI due to long?term exposure to trichloroethylene or unknown reasons, while 8 other cases were secondary to Behcet's disease, connective tissue disease, emphysema, diabetes, therioma, etc. Endoscopic findings included bubble?like, linear,cobblestone?like, graped or beaded gas cysts, involving sigmoid in 6 cases, ascending colon in 3, descending colon in 2, duodenum in 2 and rectum in 1. After combination of medicinal and endoscopic treatment, symptoms of 8 patients were relieved, and the condition of 2 patients improved, while 2 patients died of malignancy. Conclusion Pneumatosis intestinalis is a rare disease, usually secondary to other diseases, which can be diagnosed by colonoscopy and ultrasonic endoscopy. Pathogenesis of PCI is still unclear. Single PCI can be cured with endoscopic resection. Multiple PCI can be managed with cyst clipping, antibiotics and intestinal flora regulator. Treatment of the original disease and early detection of complications can improve the prognosis and reduce recurrence of PCI.

Clinical application of tunnel technique on endoscopic submucosal dissection for colorectal laterally spreading tumor / 中华消化内镜杂志

Objective To investigate the clinic effect of tunnel technique on endoscopic submucosal dissection(ESD)for massive colorectal laterally spreading tumor(LST). Methods A retrospective study was conducted on the data of patients with colorectal large area LST(the shortest diameter>4 cm) undergoing ESD by tunnel technique from January 2015 to June 2016 in Digestive Endoscopy Center of Jiangsu Province Hospital of Traditional Chinese Medicine. The size of resected specimens, operation time, complications, pathology results, the number of en bloc resection and curative resection were analyzed. Results A total of 14 cases were collected, including 7 males and 7 females. The longest diameters of resected specimens were from 4.0 to 7.0 cm with mean size of 5.18 ± 0.49 cm. The operation times were from 40 to 120 min with mean time of 63.57±12.95 min. Intraoperative perforation occurred in 2 cases but no delayed perforation and bleeding occurred. Postoperative pathology showed 1 patient with adenoma hyperplasia with crypt abscess,3 patients with low grade intraepithelial neoplasia,6 patients with high grade intraepithelial neophasia,1 patient with carcinoma in situ, 1 patient with carcinoma in M3, and 2 patients with carcinoma in SM1. The number of cases who received en bloc resection, complete resection, and curative resection were 13, 13, and 13, respectively. Conclusion ESD by tunnel technique is safe and effective in the treatment of colorectal large area LST,which is worth popularizing in clinics.