CASE REPORT
A 72-year-old man presented for routine outpatient surveillance colonoscopy 6 months after endoscopic piecemeal resection of a polypoid lesion in the cecum performed elsewhere. During withdrawal, a small subepithelial lesion (SEL) was unexpectedly noted at the hepatic flexure. It appeared hard on gentle palpation with a snare sheath. We next caught the lesion in a cold snare resulting in marked mucosal congestion and luminal protuberance after gentle closure. During switching to a hot snare device, complete mucosal detachment (or mucosal scalping) occurred, providing full in vivo visualization of the nodule's surface. Under the assumption of a benign-appearing and superficially growing SEL, like small leiomyoma, the lesion was resected in standard fashion to gain resectional biopsy. Final pathology revealed a 5-mm lesion with multiple dilated lymphatic tumor vessels consistent with a submucosal colonic lymphangioma. The patient had an uncomplicated clinical course after clipping the resection base. With respect to the innocuous nature of the lesion, we abstained from considering additional endoscopic treatment of the small pedicle to deeper wall elements putatively left in place, such as by device-assisted full thickness resection (Figure 1).
Figure 1.
(A) Colonoscopic detection of a small lesion with inconspicuous overlying mucosa at the right flexure consistent with a SEL. (B) Cold snare entrapment resulting in increased luminal protuberance and congestion. (C) Full exposition of the SEL after mucosal scalping with the cold snare. (D) Resection base after standard electrosurgical resection with a hot snare with a putative remaining pedicle to deeper wall elements (subsequent clipping of the lesion not shown). SEL, subepithelial lesion.
Colorectal SELs are common in endoscopy practice with wide variation in endoscopic and/or clinical approaches. Comparable to practice guidelines of the overall more common SELs of the upper gastrointestinal tract, unequivocal histopathological clarification to exclude any malignant potential is considered critical. However, standard forcep biopsies are notorious for their limited sensitivity in adequate tissue diagnosis in this setting. Cold snare entrapment may be used when ineffective tissue cutting during cold snare closure occurs, such as capturing too much tissue. This procedure might be exploited when used for SELs; it may serve as an indirect assessment of depth and extent of colonic wall attachment and likewise as a tool to optimize luminal exposure. However, inadvertent tissue avulsion during release of lesion by the snare may result in mucosal scalping as a novel potential endoscopic approach to SELs to fully expose the SELs surface. After removal of the overlying mucosa, either forceps biopsy under direct endoscopic guidance or, as in this unique clinical case, endoscopic resection may follow. Because of limited individual experience with this technique, such as with esophageal granular cell tumors, systematic studies are clearly warranted to provide larger scale data on the utility and safety of this novel endoscopic approach. Potential procedure-related risk may include diffuse bleeding and inadvertent SEL disruption, so that a cautionary approach is considered prudent, particularly in difficult-to-access localizations and large lesion diameters.
DISCLOSURES
Author contributions: V. Zimmer wrote the manuscript and is the article guarantor. E. Eltze revised the manuscript.
Financial disclosure: None to report.
Informed consent was obtained for this case report.