A 78-year-old woman had undergone a screening colonoscopy in 2010, which revealed an 11-mm flat lesion in the sigmoid colon. This was removed by EMR in a piecemeal fashion, and the area was tattooed. A subsequent colonoscopy in 2016 revealed a 30-mm flat lesion at the previous EMR site. She was referred to our hospital for endoscopic submucosal dissection (ESD).
Under white light, the EMR scar and tattooed area were observed at the left side of the lesion (Fig. 1). Magnified narrow-band imaging demonstrated dilated but regular capillaries, suggestive of a noninvasive pattern (Fig. 2).1
Figure 1.
Under white light, EMR scar and tattooed area were observed at the left side of the lesion.
Figure 2.
Magnified narrow-band imaging demonstrating dilated but regular capillaries, suggestive of a noninvasive pattern.
The pocket creation technique was chosen for the removal of this lesion (Video 1, available online at www.VideoGIE.org).2, 3, 4, 5, 6, 7 In the pocket creation technique, maintenance of the peripheral mucosa helps avoid fluid leakage, which is common in fibrotic lesions, and maintenance of the submucosal bleb. Furthermore, the pocket maintains ideal countertraction during dissection.
A significantly fibrotic area was observed at the center of the lesion (Fig. 3); however, this area was successfully dissected without muscle injury by the injection of additional solution to identify the dissection plane. Despite significant fibrosis, this technique allowed the ESD to be completed safely (Fig. 4).
Figure 3.
A significantly fibrotic area was observed at the center of the lesion; however, the dissection plane was successfully identified by a submucosal injection with 6% hydroxyethyl starch solution.
Figure 4.
The lesion was removed in en-bloc fashion.
Pathologic examination showed the lesion to be an adenoma measuring 3.2 × 3.0 cm with negative horizontal and vertical margins (Fig. 5).
Figure 5.
Histopathology showing the lesion to be an adenoma, 3.2 × 3.0 cm, with negative horizontal and vertical margins (H&E).
Disclosure
Dr Aihara and Dr Thompson are consultants for Olympus America. The other author disclosed no financial relationships relevant to this publication.
Footnotes
This video was awarded the “Best of the Best Video Award” at Digestive Disease Week 2017.
Written transcript of the video audio is available online at www.VideoGIE.org.
Supplementary data
Pocket creation method in endoscopic submucosal dissection of a recurrent colonic flat lesion.
References
- 1.Sano Y., Ikematsu H., Fu K.I. Meshed capillary vessels by use of narrow-band imaging for differential diagnosis of small colorectal polyps. Gastrointest Endosc. 2009;69:278–283. doi: 10.1016/j.gie.2008.04.066. [DOI] [PubMed] [Google Scholar]
- 2.Hayashi Y., Sunada K., Takahashi H. Pocket-creation method of endoscopic submucosal dissection to achieve en bloc resection of giant colorectal subpedunculated neoplastic lesions. Endoscopy. 2014;46:E421–E422. doi: 10.1055/s-0034-1377438. [DOI] [PubMed] [Google Scholar]
- 3.Miura Y., Hayashi Y., Lefor A.K. The pocket-creation method of ESD for gastric neoplasms. Gastrointest Endosc. 2016;83:457–458. doi: 10.1016/j.gie.2015.08.068. [DOI] [PubMed] [Google Scholar]
- 4.Shinozaki S., Hayashi Y., Lefor A.K. What is the best therapeutic strategy for colonoscopy of colorectal neoplasia? Future perspectives from the East. Dig Endosc. 2016;28:289–295. doi: 10.1111/den.12566. [DOI] [PubMed] [Google Scholar]
- 5.Sakamoto H., Hayashi Y., Miura Y. Pocket-creation method facilitates endoscopic submucosal dissection of colorectal laterally spreading tumors, non-granular type. Endosc Int Open. 2017;5:E123–E129. doi: 10.1055/s-0042-122778. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Yoshida N., Naito Y., Kishimoto M. Endoscopic submucosal dissection of T1 cancer with colonic diverticulum by pocket-creation method. Dig Endosc. 2017;29:726–727. doi: 10.1111/den.12897. [DOI] [PubMed] [Google Scholar]
- 7.Miura Y., Shinozaki S., Hayashi Y. Duodenal endoscopic submucosal dissection is feasible using the pocket-creation method. Endoscopy. 2017;49:8–14. doi: 10.1055/s-0042-116315. [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Pocket creation method in endoscopic submucosal dissection of a recurrent colonic flat lesion.