Endoscopic techniques have emerged as a pivotal component in the treatment of early gastrointestinal cancer. Endoscopic intermuscular dissection (EID) serves as a technique facilitating deeper resection in the rectum to achieve R0 resection of advanced dysplasia, scar tissue adjacent to dysplasia, or T1 cancer (1, 2). In this case study, we used a novel bipolar endoscopic scissor device to enhance patient outcomes.

Case Presentation: An 89-year-old female presented with lower gastrointestinal bleeding under Apixaban, due to atrial fibrillation and chronic heart failure. Colonoscopy revealed an eroded broad-based 2.5 cm polyp in the distal rectum. During initial intervention, a snare resection was performed. Conventional histology revealed rectal cancer extending to the resection margin (R1). Further immunohistochemical staining confirmed a malignant melanoma. Clinical examination and imaging studies yielded no evidence of additional manifestations.  After MDT discussion, we opted for an endoscopic approach to avoid colonostomy for the elderly patient with significant comorbidities. For the second intervention, we used a novel bipolar scissor device „SpydrBlade Flex™“ by CreoMedical, to facilitate deep intermuscular dissection within fibrotic tissue adjacent to the anal verge. A tapered cap and water irrigation were employed to establish close contact with muscular vessels. After injection of saline and indigo carmine, we started with a  circular incision around the former resection ulcer with open jaws. Subsequently, a layer-by-layer underwater dissection was performed, utilizing a grasping, lifting, and pulling technique. The adaptive energy enabled continuous cutting regardless of tissue thickness, without a charring effect. The resection was completed using rubber band traction. Bleeding vessels were coagulated by super-high frequency (SHF) microwave effect without changing the device. The resection plane was adjusted using hemoclips. Further clinical course of the patient was uneventful, with no signs of wound infection or bleeding, and normal bowel movements. Histological examination revealed no residual melanoma, confirming an R0 resection.

Discussion: Endoscopic intermuscular dissection (EID) is an evolving technique aimed at achieving an oncological R0 resection in early rectal malignancy. The novel endoscopic bipolar scissor device with adaptive energy facilitates safe resection in narrow spaces and fibrotic tissue, while microwave coagulation provides adequate hemostasis without changing the device (3).