Repeat endoscopic treatment is challenging for lesions that recur after endoscopic resection and for lesions involving a diverticulum because of the severe fibrosis surrounding such lesions [1]
[2]. We report the case of a tumor involving a diverticulum that recurred after colonic endoscopic submucosal dissection (ESD) and was successfully resected by the double-tunnel method.
A 72-year-old woman was diagnosed 2 years ago as having a laterally spreading tumor (LST) in her ascending colon measuring 30 mm in diameter ([Fig. 1 a]), which her previous doctor had attempted to treat by ESD. After making the circumferential incision, he faced a diverticulum during the process of dissection and discontinued the procedure. He cauterized the rest of the tumor.
Fig. 1 Endoscopic images showing: a the initial laterally spreading tumor measuring 30 mm in diameter in the ascending colon; b recurrent tumor involving a colonic diverticulum (blue arrow) after endoscopic treatment (a scar from this treatment is seen on each side of the lesion); c the two different tunnels on each side of the diverticulum (yellow arrow), which allowed good traction to be maintained and an appropriate dissection line to be identified.
This time, the patient was referred to our hospital for treatment of a recurrence of the diverticular tumor after the attempted ESD ([Fig. 1 b]). The tumor arose in a diverticulum and was surrounded by fibrosis, so we expected that lifting of the lesion after local injection would not be possible because of the lack of a soft submucosal layer. We had previously reported that the double-tunnel method is useful for lesions associated with severe fibrosis [3]. In addition to dealing with the fibrosis, we applied this method to apply traction to the diverticular area to pull the tumor out of the muscle layer into the lumen ([Video 1]). This technique allows good traction to be maintained and an appropriate dissection line to be identified, even in situations involving severe fibrosis in a diverticulum ([Fig. 1 c]). Using this method, we successfully performed en bloc resection of the tumor. The patient recovered without incident. Histological examination revealed an intramucosal carcinoma and confirmed the curative resection ([Fig. 2]).
Video 1 Colorectal endoscopic submucosal dissection using the double-tunnel method, allowing efficient and safe resection of a recurrent lesion arising from a diverticulum and surrounded by severe fibrosis.
Fig. 2 Histopathological appearances of the resected tumor: a macroscopic image (yellow arrow is pointing to the diverticulum); b microscopic image, showing an intramucosal carcinoma.
Use of the double-tunnel method enables safe en bloc resection of lesions with fibrosis, even of those arising in diverticula.
Endoscopy_UCTN_Code_CPL_1AJ_2AD
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