Circumferential ileocecal valve removal for a colonic polyp using underwater endoscopic mucosal resection

A 65-year-old man with constipation and a positive fecal occult blood test had previously undergone a colonoscopy in another hospital, which had revealed a polyp measuring 40 mm in diameter at the cecum. He was referred to our hospital for treatment of the lesion, with colonoscopy revealing a polypoid lesion on the upper lip of the ileocecal valve ([Fig. 1 a]). Because no definitive endoscopic findings suggestive of deep submucosal invasion were revealed by magnifying narrow-band imaging and chromoendoscopy, underwater endoscopic mucosal resection (UEMR) was performed using an electrosurgical snare (33-mm wide; Captivator II; Boston Scientific, Natick, Massachusetts, USA). As it was impossible to observe the distal side of the lesion when it was snared, we snared the whole ileocecal valve. Forced coagulation mode was used briefly twice and the lesion was then removed using Endocut Q mode. The lesion was completely resected along with the ileocecal valve ([Fig. 1 b]; [Video 1]). We did not perform any additional procedures, such as steroid injection, which has been reported to be effective in preventing stricture after semicircumferential removal of esophageal lesions, because there is no clear evidence regarding such use for ileocecal lesions.

Fig. 1 Endoscopic images showing: a a polypoid lesion, which measured 40 mm in diameter, on the ileocecal valve; b the resection site following complete resection of the lesion along with the ileocecal valve by underwater endoscopic mucosal resection.

Video 1 A polypoid lesion was completely resected along with the ileocecal valve by underwater endoscopic mucosal resection.

Histological examination of the resected lesion showed an intramucosal well-differentiated tubular adenocarcinoma in an adenoma ([Fig. 2]).

Fig. 2 Macroscopic appearance of the resected specimen, which was shown to be an intramucosal well-differentiated tubular adenocarcinoma in an adenoma, with no submucosal invasion.

At colonoscopy 6 months after the UEMR, the ileocecal valve was scarred without local residue or stenosis ([Fig. 3]). The patient’s constipation had improved.

Fig. 3 Endoscopic image 6 months after the underwater endoscopic mucosal resection showing a scarred ileocecal valve with no local residue or stenosis.

Endoscopy_UCTN_Code_TTT_1AQ_2AD