Double-Scope Endoscopic Submucosal Dissection for a Laterally Spreading Cecal Tumor.

CASE REPORT

A 75-year-old man, who had undergone anterior resection and temporary diverting ileostomy for an obstructed rectal cancer 3 months prior, had a laterally spreading cecal tumor located 20 cm from the ileal stoma near the appendiceal opening (Figure 1). The lesion was considered difficult to remove en bloc by endoscopic mucosal resection. Therefore, we introduced double-scope endoscopic submucosal dissection (ESD) for this lesion. The procedure was performed using FlushKnife-BTS (Fujifilm Co, Tokyo, Japan) and VIO300D (ERBE, Tübingen, Germany). We used glycerin solution (glycerol; 10% glycerin with 0.9% NaCl plus 5% fructose) for injection fluid. Mucosal incision and submucosal dissection of the anal side of the lesion were made to form a mucosal flap using a transanal main endoscope (PCF-Q260J; Olympus, Tokyo, Japan) (Figure 2). After the circumferential mucosal incision, the flap was grasped and pulled with forceps using another scope inserted from the ileal stoma (GIF-Q260J; Olympus). The second scope provided effective traction and good visualization, facilitating the oral-side submucosal dissection (Figure 3). Complete resection was achieved without any adverse events. The patient had neither abdominal pain nor hematochezia postoperatively and was discharged on post-ESD day 6 as scheduled. Histological examination of the resected specimen revealed tubulovillous adenoma with negative margins.

Figure 1.

Endoscopic view of a laterally spreading tumor near the appendix opening in the cecum before endoscopic submucosal dissection.

Figure 2.

Schema showing double-scope endoscopic submucosal dissection using 2 scopes inserted from different entrances, the anus and ileal stoma.

Figure 3.

(A) Endoscopic view from the transanal scope during endoscopic submucosal dissection; effective traction was achieved by grasping the mucosal flap using the trans-stoma scope. (B) Endoscopic view from the trans-stoma scope at the initiation of dissection after making the flap.

ESD is an efficacious therapeutic method for early gastrointestinal neoplasms and requires high-level endoscopic skill because it is a 1-handed procedure.[1] In procedures for the right-sided colon, especially the cecum, severe fibrosis and poor maneuverability can pose challenges, and obtaining effective countertraction is important to complete the treatment.[2] There are some previous reports of double-scope ESD from the same sites for pharyngeal, gastric, or left-sided colorectal tumors.[3-5] To our knowledge, however, this is the first report demonstrating the efficacy of right-sided colonic double-scope ESD. Unlike other traction methods such as clips, this method is significantly advantageous in that repeated adjustments can be made and an appropriate view can be obtained in each situation. Use of 2 endoscopes from different sites can be a safe and useful treatment option in colorectal ESD for patients after stoma construction.

DISCLOSURES

Author contributions: All authors wrote and edited the manuscript. T. Takehara is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.