Colorectal Cancer Screening & Early Detection | Dr. Xu Meidong (Gastroenterology) | CMCS Shanghai

About Dr. Xu Meidong

Dr. Xu Meidong is a renowned endoscopist at Shanghai East Hospital, Tongji University, specializing in early gastrointestinal cancer detection and endoscopic submucosal dissection (ESD). He is a pioneer in advanced endoscopic techniques in China and has trained numerous specialists across the country. Dr. Xu's research focuses on improving early colorectal and gastric cancer outcomes through precision endoscopy and standardized ESD practice.

Case Overview

A 52-year-old male executive with a family history of colorectal cancer (father diagnosed at age 60) underwent precision colonoscopy at Shanghai East Hospital as part of proactive cancer screening. He had no gastrointestinal symptoms. Dr. Xu Meidong identified a 2.0 cm × 1.8 cm lateral spreading tumor (LST) in the sigmoid colon — invisible to standard white-light endoscopy alone, but clearly delineated by chromoendoscopy and magnification. Endoscopic ultrasound confirmed the lesion was confined to the mucosal layer with no lymph node involvement. Dr. Xu performed en bloc endoscopic submucosal dissection (ESD) in 45 minutes, achieving R0 resection with negative lateral and deep margins. A microperforation encountered during dissection was immediately closed with hemoclips — no surgical conversion required. The patient was discharged on day 5 with no stoma, no abdominal incision, and no residual disease.

Patient Background

• Age / Sex: 52-year-old male
• Occupation: Corporate executive
• Chief Complaint: Colonic lesion identified on health screening — no rectal bleeding, no abdominal pain, no weight loss
• Risk Factors: Father diagnosed with colon cancer at age 60; sedentary lifestyle; high red meat intake; low vegetable consumption
• Medical History: No significant prior conditions

Screening & Endoscopic Diagnosis

The patient presented for a precision colonoscopy — a high-definition, multi-modality examination performed personally by Dr. Xu Meidong, specifically designed to detect flat and early-stage lesions that standard colonoscopy may miss.

White-Light Endoscopy

• Advancement to the sigmoid colon (approximately 25 cm from the anal verge) revealed a 2.0 cm × 1.8 cm lateral spreading tumor (LST) with slightly irregular surface texture, erythematous mucosa, and indistinct margins

Chromoendoscopy & Magnification (NBI / FICE)

• Indigo carmine dye spray: Clearly delineated the lesion boundary and surface architecture
• Magnified pit pattern (Kudo classification): Type IV pattern in the majority of the lesion (neoplastic); Type VI pattern in focal areas — indicating high-grade dysplasia / intramucosal carcinoma
• Microvascular pattern (JNET classification): Type 2B — irregular microvascular architecture consistent with high-grade neoplasia

Endoscopic Ultrasound (EUS)

• Lesion confined to the mucosal layer (M layer); muscularis mucosae intact; no submucosal invasion (SM1 negative)
• No regional lymph node enlargement

Endoscopic Diagnosis

Lateral spreading tumor, granular type (LST-G); high-grade dysplasia / intramucosal carcinoma. Lymph node metastasis risk: <1% based on current Japanese and Chinese colorectal cancer guidelines.

Clinical Decision Making

Conventional surgical perspective: A colonic mass of this size would traditionally prompt segmental colectomy with lymph node dissection — open or laparoscopic surgery, with potential temporary stoma formation.

Dr. Xu Meidong's endoscopic assessment: "According to current Japanese and Chinese colorectal cancer treatment guidelines, this lesion is T1 stage — intramucosal carcinoma — with a lymph node metastasis risk below 1%. For this category of early cancer, ESD is the preferred curative treatment: no incision, bowel preservation, and complete oncological resection. Surgery is not indicated."

Final plan: Colonic ESD — en bloc resection of the entire lesion in a single procedure.

ESD Procedure

Technical Challenges

• Location in the sigmoid colon: high bowel mobility and looping tendency, making scope stability difficult
• Lesion size >2 cm: en bloc resection technically demanding; perforation risk elevated

Step-by-Step Procedure

1. Marking: Argon plasma coagulation (APC) used to place circumferential marking dots 3–5 mm outside the lesion boundary
2. Submucosal Injection: Dr. Xu employed a triangular traction technique — sequential injection of glycerol fructose + methylene blue + epinephrine solution at the oral, anal, and lateral aspects of the lesion to achieve adequate mucosal lifting and create a safe dissection plane
3. Circumferential Mucosal Incision: Dual knife used to make a full circumferential mucosal incision outside the marking dots
4. Submucosal Dissection:
   • IT knife 2 used for progressive submucosal dissection
   • Critical adaptation: On reaching the anal aspect of the lesion, submucosal fibrosis was encountered (secondary to chronic inflammation). Dr. Xu immediately switched to a Hook knife and adjusted the electrosurgical mode (Endocut Q) to maintain precise dissection without deep muscle injury
5. Microperforation Management: During basal dissection, a 2 mm microperforation occurred with minimal gas leakage. Dr. Xu immediately applied hemoclips in a purse-string closure pattern — sealing the defect endoscopically without surgical conversion. No peritoneal signs developed.
6. En Bloc Resection: Complete specimen retrieved; resection surface clean with no active bleeding

Operative Data

• Procedure Time: 45 minutes
• Resection: En bloc (single-piece); specimen size 2.2 cm × 2.0 cm
• Perforation: Microperforation (2 mm); closed endoscopically; no surgical conversion

Pathology & Post-operative Management

Pathology Report

• Gross: En bloc specimen, 2.2 cm × 2.0 cm; intact margins
• Histology: Tubulovillous adenoma with focal high-grade intraepithelial neoplasia; intramucosal well-differentiated adenocarcinoma
• Resection Margins: Lateral and deep margins negative — R0 resection confirmed
• Lymphovascular Invasion: Absent

Post-operative Course

• Day 0–1: Nil by mouth; IV fluid support; abdominal examination monitored — no peritonitis
• Day 3: Clear liquid diet commenced; progressive diet advancement
• Day 5: Discharged home

Surveillance Plan

Colonoscopy at 3 months, 6 months, and 1 year post-procedure. Dr. Xu's note: "Post-ESD scar surveillance is essential. The 3–6 month endoscopy confirms scar healing and excludes residual or recurrent disease. This is not optional — it is part of the curative protocol."

Expert Commentary — Dr. Xu Meidong

1. Precision Endoscopy Is the Foundation of Early Cancer Detection

Many hospitals perform colonoscopy to answer one question: is there a polyp? We ask a different question: is there an early cancer? For flat lesions like LST, chromoendoscopy combined with magnification is the gold standard. Without dye spray and magnified pit pattern analysis, this lesion — which appeared as subtle mucosal erythema on white-light endoscopy — could easily have been dismissed or biopsied incompletely. If missed, this patient would likely have progressed to advanced colorectal cancer within one to two years. The difference in prognosis between stage I and stage III colorectal cancer is not incremental — it is the difference between cure and palliation.

2. ESD Quality Standards: En Bloc and R0

ESD is not simply about removing the lesion. It is about removing it in one piece with clean margins. En bloc resection enables complete pathological assessment of lateral and deep margins — the only way to confirm curative intent. Piecemeal resection, by contrast, makes margin assessment impossible and recurrence rates unacceptably high. Our team requires all junior endoscopists to complete a minimum of 100 hours of ex vivo model training before performing ESD on patients. Technical standardization is not bureaucracy — it is patient safety.

3. Complication Management: Recognition and Immediate Response

Perforation is the most feared complication of ESD — but it is manageable. The key is immediate recognition and endoscopic closure before gas and luminal contents contaminate the peritoneal cavity. In this case, the 2 mm microperforation was identified within seconds, closed with hemoclips in a purse-string pattern, and the procedure was completed without interruption. No peritonitis. No surgery. No stoma. This outcome is not luck — it is the result of technical preparation, situational awareness, and a team that has rehearsed exactly this scenario.

4. Screening Age Should Move Earlier

This patient was 52 years old with a first-degree family history of colorectal cancer. Current guidelines recommend that individuals with a first-degree relative diagnosed with colorectal cancer begin screening at age 40 — or ten years before the age at which the relative was diagnosed, whichever is earlier. As endoscopists, our mission is not only to treat disease — it is to prevent it. Every early cancer we detect and cure endoscopically is a surgery that was never needed, a stoma that was never formed, and a life that was never disrupted.

How CMCS Shanghai Coordinated This Case

China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through one-year endoscopic surveillance. Our coordination included:

• Pre-arrival risk assessment and specialist referral to Dr. Xu Meidong's endoscopy team at Shanghai East Hospital, Tongji University — specifically for precision colonoscopy rather than standard screening
• Arrangement of bowel preparation protocol, anesthesia consultation, and pre-procedure dietary guidance in the patient's language
• Bilingual interpretation during pre-procedure consultation, including detailed explanation of LST classification, ESD versus surgical options, perforation risk, and surveillance protocol
• Procedure-day logistics including hospital registration, endoscopy suite coordination, and family waiting area support
• On-site medical interpretation during the post-procedure recovery period and pathology result discussion
• Post-discharge coordination of 3-month, 6-month, and 1-year surveillance colonoscopy scheduling, including remote pathology result translation and communication with the patient's home physician

For international patients and expatriates in Shanghai, colorectal cancer screening is frequently deferred due to unfamiliarity with the local medical system, language barriers, or uncertainty about the quality of endoscopic care available. CMCS exists to remove those barriers — connecting patients with China's leading endoscopists for precision screening that meets and exceeds international standards, with every step explained, coordinated, and followed through.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.