Use of a self-made additional working channel for underwater endoscopic mucosal resection of a rectal neuroendocrine tumor

A 39-year-old man was diagnosed with an 8-mm neuroendocrine tumor (NET) in the rectum ( Fig. 1 a ). Endoscopic ultrasonography indicated that the lesion was confined to the submucosa. In order to get an en bloc resection, we developed an underwater endoscopic mucosal resection (EMR) technique assisted by an additional working channel (AWC) that we made ourselves.

Fig. 1.

 The process of underwater endoscopic mucosal resection assisted by a self-made additional working channel. a An 8-mm neuroendocrine tumor (NET) was located in the rectum of a 39-year-old man. b After the snare was placed around the lesion, a reopenable clip grasped the lesion in the water. c The clip was pulled back in the water so the NET became an artificial protrusion for resection. d No residual lesion was observed in the wound, and there was no bleeding or perforation. e The fresh specimen was stretched and fixed. f The histological appearance of the resected specimen showed a grade 1 NET with negative vertical and horizontal margins.

A nasal oxygen tube about 30 cm in length was taped to the outside of the endoscope to become an AWC. The snare could move back and forth and rotate freely through the tube ( Video 1 ). After the snare was placed around the lesion through our self-made AWC, the lesion was grasped underwater with a reopenable clip ( Fig. 1 b ). The clip was pulled back in the water and the snare was tightened to perform resection with an Endocut Q (effect 3, cut duration 2, cut interval 4) ( Fig. 1 c ). The wound was clean and without bleeding or perforation ( Fig. 1 d ). Finally, the fresh specimen was stretched and fixed on a foam plate with the mucosal surface facing downward ( Fig. 1 e ). Histological examination showed a grade 1 NET with negative vertical and horizontal margins ( Fig. 1 f ).

Video 1  Underwater endoscopic mucosal resection to remove a rectal neuroendocrine tumor with the assistance of a self-made additional working channel.

Download video file ^{(47.6MB, mp4)}

Edris Wedi et al. reported that a commercially available system called EMR+ was a practical method of overcoming the limitations of classical EMR ¹ . We believe that our self-made AWC using a nasal oxygen tube, which is a very easily accessible thing, can achieve the same effect. Combined with the advantages of underwater EMR, this technique can be successfully and inexpensively applied to deal with gastrointestinal NETs, most of which are in the submucosa.

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