Traction-assisted colorectal endoscopic submucosal dissection by use of clip and line for a neoplasm involving colonic diverticulum.

Endoscopic resection of a neoplasm involving a colonic diverticulum is challenging. We successfully treated 3 patients with colonic neoplasms involving a diverticulum with traction-assisted colorectal endoscopic submucosal dissection (ESD) using a clip and line (TAC-ESD).

The procedure was performed with a pediatric videocolonoscope (PCF-Q260JI, Olympus, Tokyo, Japan) with a cap (D-201-11804, Olympus) and an endoknife (Flushknife BT 1.5 mm, DK2618JB-15, Fujifilm, Tokyo, Japan). Before the procedure, the patient’s position was changed to move the colonic fluid to the opposite side of the lesion, and the mucosa was then thoroughly washed with jets of water. TAC-ESD was performed as follows: (1) a 3-0 polyester suture line was passed through the working channel before scope insertion; (2) a circumferential mucosal incision was made; (3) the accessory-channel end of the line was tied to the joint part of a half-opened endoclip (HX-610-090, Olympus) attached to an applicator; (4) the applicator with the retracted clip was inserted through the working channel; and (5) the clip was deployed at the anal side of the lesion.

A patient had a 20-mm laterally spreading tumor (LST) in the ascending colon with polypoid and flat parts, the latter extending into a diverticulum (Figs. 1A-E). After injection of the solution into the submucosa in the diverticulum, the tumor was lifted up from the bottom of the diverticulum. A mucosal incision was started at the diverticulum side and extended laterally; the specimen was then lifted up with the clip and line, and submucosal dissection was performed (Video 1, available online at www.VideoGIE.org). The other 2 cases were LSTs, each involving a diverticulum (21 mm and 30 mm, respectively), which were removed completely by use of the same technique (Figs. 1F-H and I-K). Shallow dissection of the submucosa in the diverticulum helped to avoid penetrative perforation into the peritoneal cavity. During TAC-ESD, the specimen and submucosa were lifted, allowing identification of an adequate submucosal plane for dissection of a neoplasm involving a diverticulum.

Figure 1

A, Case 1. Laterally spreading granular-type tumor in the ascending colon involving a diverticulum. B, The anal side of the specimen was grasped with the clip and line. C, Traction allowed good visibility of the submucosal plane. Transparent submucosa between the mucosa and subserosal fat in the diverticulum was dissected. D, Wound after endoscopic submucosal dissection, showing a defect in the muscularis propria at the diverticulum (yellow arrows). E, Resected specimen. F, Case 2. Laterally spreading 21-mm granular-type tumor in the ascending colon, involving a diverticulum. G, Wound after endoscopic submucosal dissection. H, Wound was completely closed with the endoclips. I, Case 3. Laterally spreading 30-mm granular-type tumor in the cecum overlying a diverticulum. J, Wound after endoscopic submucosal dissection with a small intraprocedual perforation. K, Wound, including a perforation hole, was completely closed with the endoclips.

Disclosure

All authors disclosed no financial relationships relevant to this publication.