Narration
Traction-assisted colorectal endoscopic submucosal dissection using clip and line for neoplasms involving colonic diverticulum
Endoscopic resection of neoplasm involving colonic diverticulum is technically difficult because of high risk of perforation.
We have recently reported traction-assisted colonic endoscopic submucosal dissection (ESD) using clip and line (TAC-ESD) technique facilitated performance of colorectal ESD procedure.
We successfully treated 3 patients with colon tumors involving a diverticulum with TAC-ESD.
Equipments for TAC-ESD are pediatric videocolonoscope, which is mounted a cap on the tip, an endoknife, a 3-0 polyester suture line, and an endoclip
The steps of TAC-ESD for colonic lesions involving diverticulum are presented.
Case 1 is a 70-year-old man with a type Is+IIa lesion, 30 mm in size located in the ascending colon.
A polypoid lesion was seen adjacent to the diverticulum in the ascending colon.
A flat part was extended into a diverticulum.
We introduce TAC-ESD method. A 3-0 polyester suture line was passed through the working channel using grasping forceps before scope insertion. And both ends of the line was tied each other at outside of the scope.
After the scope insertion, the sodium hyaluronate was injected into the submucosa in the diverticulum, so that the mucosa was lifted up and the anal edge of the lesion was confirmed. Mucosal incision was started from the diverticulum part, and then it was extended circumferentially.
After completion of the circumferential incision, the line was cut at the scope head, and the accessory-channel end of the line was tied to the joint part of a half-opened endoclip attached to an applicator. Then the clip was retracted into the applicator, and the applicator was inserted through the working channel, pulling another end of the line from the anus.
The clip was deployed at the anal side of the lesion. The line was pulled gently to lift up the specimen. The submucosal dissection was carried out and, at the diverticulum, the transparent submucosal plane between the mucosa and subserosal fat was dissected.
The edge of the defect of the muscularis propria at the diverticulum was indicated with yellow arrows.
The wound was finally completely closed with the endoclips.
Resected specimen
Procedure time was 60 minutes. And we could achieve en bloc resection with no adverse event. Histological examination of the specimen revealed the lesion was intramucosal carcinoma with clear resection margin.
Case 2 was a 64-year-old man with a type IIa lesion 20 mm in size, which extended into the diverticulum in the ascending colon. The lesion was completely removed by the same method. Procedure time was 27 minutes. The histological finding was tubular adenoma with clear resection margin.
Case 3 was a 76-year-old man, with a Type IIa lesion 30-mm in size, which located over the diverticulum in the cecum. It was also resected by the same method. In this case, a small intraprocedual perforation was seen at the diverticulum but it was completely closed with endoclips. Histological finding was tubulovillous adenoma. Vertical margin was positive in one part because dissection plane went up to the muscularis mucosae.
In conclusion, TAC-ESD provided good visibility of the submucosa at the diverticulum and enabled dissection in the adequate depth of the submucosal plane.
The method is feasible and useful for resection of colonic neoplasm involving diverticulum.