Endoscopic submucosal dissection for complete removal of a residual colorectal tumor involving a diverticulum

A 74-year-old man underwent endoscopic mucosal resection (EMR) for treatment of a 20-mm polyp close to a diverticulum in the ascending colon. Surveillance colonoscopy at 12 months showed a 10-mm polyp involving a diverticulum and surrounded by scars in the ascending colon ( Fig. 1 a ). Because the lesion was completely involving a diverticulum and water immersion could not show the “floating” effect on the tumor associated with the diverticulum ¹ , underwater EMR (UEMR) was discontinued. In addition, submucosal injection showed the nonlifting sign ² .

Fig. 1.

 Colonoscopic views showing: a a 10-mm polyp involving a diverticulum and surrounded by scars in the ascending colon of a 74-year-old man; b two multiloop traction devices attached using clips at the anal and oral edges of the lesion after circumferential mucosal incision; c the mucosal layer dropping into a muscular layer, with fibrosis also present, in the central part of the lesion; d the defect after en bloc resection had been achieved following partial muscular dissection.

We therefore decided to perform endoscopic submucosal dissection (ESD) ( Video 1 ). After a circumferential mucosal incision had been made, two multiloop traction devices (Boston Scientific, Tokyo, Japan) were attached at the anal and oral edges of the lesion using SureClips (MC Medical, Tokyo, Japan) to obtain countertraction ( Fig. 1 b ). Multitraction allowed us to dissect the submucosal layer easily and to visualize the central part of the lesion, where the mucosal layer dropped into the muscular layer with fibrosis. Because the fibrosis made identification of the submucosal layer difficult ( Fig. 1 c ), we performed partial muscular dissection. En bloc resection was successfully achieved ( Fig. 1 d ), and the muscle layer defect was immediately closed with SureClips. The patient was discharged from our hospital, without experiencing any adverse events. Histopathology revealed a high grade adenoma with negative margins ( Fig. 2 ).

Fig. 2.

 Microscopic view of the resected lesion, which showed a high grade adenoma completely involving a diverticulum, with negative margins.

Video 1  A residual tumor involving a diverticulum is completely removed by endoscopic submucosal dissection assisted by multiple traction devices, the use of which aids visualization and dissection of the submucosal layer.

Download video file ^{(40MB, mp4)}

ESD for colorectal tumors involving a diverticulum and residual tumors is technically challenging ^{3 4} . Traction devices have been reported to help with colonic ESD for lesions involving a diverticulum ⁵ . In our case, the residual lesion involved a diverticulum and showed submucosal fibrosis, which made the identification and dissection of the submucosal layer at the diverticulum difficult. The use of multiple traction devices enabled us to perform selective muscular dissection and minimize the muscle layer defect, resulting in efficient closure after complete resection of the lesion.

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