A 56-year-old healthy patient underwent colonoscopy after a positive fecal occult
blood test result. This examination showed diverticulosis of the left side of the
colon and, at 20 cm from the anal verge, a 6-mm sessile polyp in the neck of a diverticulum
with intradiverticular extension ([Fig. 1 a]). Narrow-band imaging showed a large tubular pit pattern: Kudo type III-L ([Fig. 1 b]).
Fig. 1 a Sessile polyp in the neck of a diverticulum with intradiverticular extension, seen
in a 56-year-old healthy patient undergoing colonoscopy after a positive fecal occult
blood test result. b Narrow-band imaging shows a large tubular pit pattern.
Using a gastroscope (GIF-Q165; Olympus, Tokyo, Japan) with a conventional band ligator
device (Speedband Superview Super; Boston Scientific, Natick, Massachusetts, USA)
attached to the tip, we positioned the diverticular orifice and the polyp in the center
of the cap. The diverticulum (including the insertion area of the polyp) was then
suctioned and partially inverted into the cap of the endoscopic ligator, and an elastic
band was released around its neck ([Video 1]). The polyp was visible on the top of the inverted diverticulum ([Fig. 2]). Colonic tattooing was performed.
Elastic band ligation for the removal of a colonic tubular adenoma in a diverticulum.
Fig. 2 The polyp is visible on the top of the inverted diverticulum.
As a result of ischemia, necrosis, and cicatrization of the underlying tissues, the
elastic band contents fell off in a few days [1]. Endoscopic evaluation 2 weeks later showed a residual diverticulum adjacent to
the tattoo. A cicatricial area was identified on the neck of the residual diverticulum,
with no evidence of residual adenoma ([Fig. 3]).
Fig. 3 After 2 weeks, a cicatricial area is identified on the neck of the residual diverticulum,
with no evidence of residual adenoma.
Colonic diverticula do not have a muscular layer, so there is a high risk for perforation
when a standard snare excision technique is used for polyps extending into diverticula.
Elastic banding has recently been shown to be safe and highly effective in diverticular
bleeding [2]. It appears that this technique may also be safe and effective for the resection
of a colonic adenoma extending into a diverticulum [3]. It is also minimally invasive, so that perforation and the need to perform laparoscopy
or apply an over-the-scope-clip to close it can be avoided [4]
[5]. However, no specimen is obtained for histopathological analysis, which probably
limits the size and the pit pattern of the polyps in which this technique should be
used.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
