TRACTION STRATEGY WITH CLIPS AND RUBBER BAND ALLOWS COMPLETE EN BLOC ENDOSCOPIC SUBMUCOSAL DISSECTION OF LATERALLY SPREADING TUMORS INVADING THE APPENDIX

Endoscopic submucosal dissection is now the reference method to allow En Bloc resection of large colorectal neoplasia. Nevertheless, appendix invasion is still considered a contraindication of resection because of the risk of perforation and the difficulty to find the dissection space at the bottom of the appendix. We report here the case of a 72 years old men referred for resection of a 4 cm granular LST of the cecum invading deeply the appendix orifice.

As previously demonstrated, we used traction strategy with two clips and rubber band. After complete circumferential incision and trimming, we caught the lesion edge with a first clip grasping the rubber band. A second clip was then used to catch the rubber band and to move it at the opposite wall of the colon. Then, the second clip was fixed on the opposite colon wall and released. This traction is adaptive using inflation and deflation since the rubber band is more or less stretched. Inflating a lot, a strong traction was obtained and allowed to extract the appendicular mucosa outside of the appendix orifice. Finally, we were able to cut the deep fibrotic fibers fixing the mucosa to the bottom of the appendix. Pathological examination reveales a HGD LST G with complete En Bloc resection with margins (R0).

There were no complications during the procedure and in the postoperative. The patient was monitored for 48 hours given the known risk of early and late acute appendicitis of 3% and 5% respectively. In patients with an intact appendix there is a high risk of incomplete resection for lesion reaches and enters the appendiceal orifice with invisible margins (Type 3).

Thus appendiceal ESD is complex because of the technical difficulty of obtaining a complete resection and postoperative risk of appendicitis, but it seems feasible with traction methods.