A 74-year-old man underwent endoscopic mucosal resection (EMR) for treatment of a
20-mm polyp close to a diverticulum in the ascending colon. Surveillance colonoscopy
at 12 months showed a 10-mm polyp involving a diverticulum and surrounded by scars
in the ascending colon ([Fig. 1 a]). Because the lesion was completely involving a diverticulum and water immersion
could not show the “floating” effect on the tumor associated with the diverticulum
[1], underwater EMR (UEMR) was discontinued. In addition, submucosal injection showed
the nonlifting sign [2].
Fig. 1 Colonoscopic views showing: a a 10-mm polyp involving a diverticulum and surrounded by scars in the ascending colon
of a 74-year-old man; b two multiloop traction devices attached using clips at the anal and oral edges of
the lesion after circumferential mucosal incision; c the mucosal layer dropping into a muscular layer, with fibrosis also present, in
the central part of the lesion; d the defect after en bloc resection had been achieved following partial muscular dissection.
We therefore decided to perform endoscopic submucosal dissection (ESD) ([Video 1]). After a circumferential mucosal incision had been made, two multiloop traction
devices (Boston Scientific, Tokyo, Japan) were attached at the anal and oral edges
of the lesion using SureClips (MC Medical, Tokyo, Japan) to obtain countertraction
([Fig. 1 b]). Multitraction allowed us to dissect the submucosal layer easily and to visualize
the central part of the lesion, where the mucosal layer dropped into the muscular
layer with fibrosis. Because the fibrosis made identification of the submucosal layer
difficult ([Fig. 1 c]), we performed partial muscular dissection. En bloc resection was successfully achieved
([Fig. 1 d]), and the muscle layer defect was immediately closed with SureClips. The patient
was discharged from our hospital, without experiencing any adverse events. Histopathology
revealed a high grade adenoma with negative margins ([Fig. 2]).
Video 1 A residual tumor involving a diverticulum is completely removed by endoscopic submucosal
dissection assisted by multiple traction devices, the use of which aids visualization
and dissection of the submucosal layer.
Fig. 2 Microscopic view of the resected lesion, which showed a high grade adenoma completely
involving a diverticulum, with negative margins.
ESD for colorectal tumors involving a diverticulum and residual tumors is technically
challenging [3]
[4]. Traction devices have been reported to help with colonic ESD for lesions involving
a diverticulum [5]. In our case, the residual lesion involved a diverticulum and showed submucosal
fibrosis, which made the identification and dissection of the submucosal layer at
the diverticulum difficult. The use of multiple traction devices enabled us to perform
selective muscular dissection and minimize the muscle layer defect, resulting in efficient
closure after complete resection of the lesion.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
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