Counter-traction using clips and rubber banding for endoscopic submucosal dissection of a laterally spreading tumor involving a diverticulum in the colon

In addition to the possibility of en bloc resection without size limitations, endoscopic submucosal dissection (ESD) is also a novel option for endoscopic treatment of lesions involving a diverticulum in the colon [1] or appendix [2]. Generally, when employing endoscopic mucosal resection, these types of lesions have a high risk of perforation or incomplete resection.

Here, we report a case of a laterally spreading tumor (LST) involving a colonic diverticulum that underwent successful en bloc resection by ESD using counter-traction with clips and rubber banding ([Video 1]).

Video 1 Counter-traction using clips and rubber banding for endoscopic submucosal dissection of a laterally spreading tumor involving a diverticulum in the colon.

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A man in his 60s was referred to our hospital for resection of a 40-mm LST in the ascending colon ([Fig. 1]). It was a granular LST with a regular vascular and pit pattern on blue-laser imaging but also involvement of a centrally located diverticulum, all of which were indications for ESD.

Fig. 1 A 40-mm laterally spreading tumor in the ascending colon with central diverticulum.

After the initial needle injection, ESD was initiated from the anal side using the DualKnife J (Olympus Medical, Tokyo, Japan) injecting glycerol mixture. We used counter-traction with clips and rubber bands ([Fig. 2]) to allow better exposure of the submucosal layer, as described previously [3]. Once the endoscope approached the diverticulum, a second traction using two clips and another rubber band was positioned to allow a maximal increase in the submucosal space. ESD was performed cautiously in the area of the diverticulum, and the location of the submucosal plane was determined by counter-traction. After dissection, we found an accumulation of “submucosal” fibers at the base of the diverticulum that were not perforated ([Fig. 3]). Finally, en bloc resection was completed in 50 minutes, and the diverticulum was closed to prevent delayed perforation. The patient was discharged without complications 24 hours later.

Fig. 2 Setting up a counter-traction by clips and rubber band.

Fig. 3 Diverticular area (arrows) after endoscopic submucosal dissection.

Pathological analysis revealed a tubulovillous adenoma measuring 52 × 40 mm, with high grade dysplasia and free margins.

Our proposed counter-traction technique using clips and rubber banding allows en bloc resection of large colonic adenomas involving diverticula, which would normally be treated by surgery or a full-thickness resection device.

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• References

• 1 Kato M, Uraoka T, Wada M. et al. Laterally spreading tumor involving a colon diverticulum successfully resected by endoscopic submucosal dissection. Gastrointest Endosc 2016; 84: 191-192
• 2 Utzeri E, Jacques J, Charissoux A. et al. Traction strategy with clips and rubber band allows complete en bloc endoscopic submucosal dissection of laterally spreading tumors invading the appendix. Endoscopy 2017; 49: 820-822
• 3 Jacques J, Charissoux A, Legros R. et al. Double-clip counter-traction using a rubber band is a useful and adaptive tool for colonic endoscopic submucosal dissection. Endoscopy 2018; 50: 179-181