Endoscopic submucosal dissection for a large cecal adenoma covering an appendiceal orifice after appendectomy

Endoscopic submucosal dissection (ESD) is recommended for colorectal tumors that cannot be completely removed by snare-based techniques. Endoscopic resection for appendiceal orifice lesions (Toyonaga’s type 3: lesion entirely covers the orifice) is technically challenging because the appendiceal portion cannot be incised accurately ¹ . Such lesions can be endoscopically removed if the patient has undergone an appendectomy, but submucosal fibrosis is a potential issue. Several reports have shown that ESD using a traction device or underwater strategies are useful for such lesions ^{2 3 4} . We demonstrate ESD for a lesion using the water pressure method ( Video 1 ), which is a technique that uses the waterjet function of an endoscope to secure the working space ⁵ .

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Endoscopic submucosal dissection using the water pressure method for a large cecal adenoma covering the appendiceal orifice after appendectomy.

Video 1

A 62-year-old woman, who had undergone appendectomy for acute appendicitis 45 years previously, was diagnosed with a 35-mm laterally spreading tumor in the cecum on colonoscopy ( Fig. 1 ). The scar of the appendiceal orifice could not be identified because the lesion was covering it. We performed ESD for the lesion with a FlushKnife BT-S (1.5 mm, DK2620J; Fujifilm Medical, Tokyo, Japan).

Fig. 1.

A 35-mm laterally spreading tumor covering the appendiceal orifice after appendectomy.

A solution of sodium alginate was injected into the submucosa for thickening. The endoscope faced the lesion perpendicularly, and endoscope stability was poor due to respiratory fluctuations. To secure a stable field of view, the water pressure method was used while sucking air from the cecum. Severe fibrosis was partly visible in the submucosa during ESD ( Fig. 2 ). En bloc resection was achieved while maintaining a good visual field using the water pressure method ( Fig. 3 , Fig. 4 ). The procedure was completed without any adverse events.

Fig. 2.

Severe fibrosis was partly visible in the submucosa during submucosal dissection.

Fig. 3.

The water pressure method. a Before water injection. b Just after water injection.

Fig. 4.

The appendiceal orifice was identifiable in the resection wound.

The patient was discharged on postoperative day 4. Histopathological examination revealed a high grade tubulovillous adenoma with negative margins.

A large cecal adenoma covering the appendiceal orifice after appendectomy could be removed by ESD with the water pressure method.

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