Colonic tumor in a diverticulum removed by endoscopic submucosal dissection: Two-step strategy using multi-loop traction devices.

BRIEF EXPLANATION

Endoscopic submucosal dissection (ESD) has a high rate of en bloc resection for colorectal tumors. ESD for colonic lesions involving diverticula carries a high risk of perforation because diverticula lack the proper muscle layer. Further, difficulty in identifying the proper dissecting layer makes the procedure technically challenging. The usefulness of the traction methods for such lesions has been reported previously. , , The present case demonstrated that even a tumor involving a large diverticulum could be removed using a two‐step strategy with better traction throughout the procedure (Fig. 1).

Figure 1

Schema of a two‐step strategy. (a) Mucosal incisions were done for a lesion involving a large diverticulum. (b) First traction. (c) Second traction. (d) The inside of the diverticulum was scraped.

A 68‐year‐old man was diagnosed with a 20 mm laterally spreading tumor involving a large diverticulum in the ascending colon (Fig. 2a). The lesion completely covered a 10 mm diverticulum (Fig. 2b). We performed ESD for the lesion using FlushKnife BT‐S (1.5 mm, DK2620J; Fujifilm Medical, Tokyo, Japan) (Video S1). After the submucosal injection and circumferential mucosal incision, the submucosa outside of the diverticulum was dissected with a multi‐loop traction device (Boston Scientific, Tokyo, Japan) and endoclips (SureClip; Micro‐Tech, Nanjing, China) (first traction). The submucosal side of the specimen was then grasped firmly with another clip and a traction device so as to maintain a strong and stable traction (second traction, Fig. 2c,d). Due to the second traction, a good field of view was kept until the bottom part of the lesion was cut off. The retroperitoneal space was exposed after removing the lesion and the resection wound was closed using endoclips. Antibiotics were administered for 7 days after the procedure. The patient showed fever and mild abdominal pain only on postoperative day 1 and was discharged on postoperative day 8. Histopathological examination revealed adenoma with negative margins.

Figure 2

Endoscopic images of a 20 mm laterally spreading tumor involving a large diverticulum in the ascending colon. (a) Distant view. (b) Inside view of the diverticulum. The adenomatous mucosa was identified inside of the diverticulum by underwater observation. (c) The second traction was added to pull out the diverticulum part of the lesion more strongly. The advantage of this method over using the center loop of the first traction is that it has a stronger and more stable traction, with a lower risk of tears. (d) The inside of the diverticulum was scraped.

This two‐step strategy can be an option to improve the field of view during ESD, especially for lesions involving a large diverticulum.

CONFLICT OF INTEREST

Author T.K. has received honoraria for lectures from Olympus Corporation. Y.T. has received honoraria for lectures from Olympus Corporation and Fujifilm Medical Co., Ltd. The other author declares no conflict of interest for this article.

Video S1 Endoscopic submucosal dissection with a two‐step strategy for a colonic tumor involving a large diverticulum.

Click here for additional data file.