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Colonic diverticula lack a muscular layer because they typically develop as a result of the herniation of mucosa and submucosa through a muscle layer that the vasa recta penetrates. The herniation is caused by increased intraluminal pressure. Endoscopic resection of tumors near colonic diverticula is difficult and dangerous because of the aforementioned anatomic features. Endoscopic resection–related adverse events have been reported.
the removal strategy for small colorectal tumors involving a diverticulum remains unclear. We report the successful resection of a colonic tumor partially extending into a colonic diverticulum using an S-O clip for traction (Video 1, available online at www.VideoGIE.org).
A flat, elevated lesion with a diameter of 8 mm was observed in the ascending colon. The lesion partially extended into the diverticulum, and the margin of the lesion inside the diverticulum was barely identifiable (Fig. 1). The lesion was diagnosed as Japan Narrow-band Imaging (NBI) Expert Team classification type 2A based on the regular vessel and surface pattern with NBI magnification (Fig. 2). Furthermore, indigo carmine dye spray revealed type IIIL pit pattern (Fig. 3). We diagnosed the lesion as a low-grade adenoma.
Figure 1A flat, elevated lesion with a diameter of 8 mm in the ascending colon extends into the diverticulum.
Although we planned to perform CSP, it seemed impossible to properly snare the whole tumor because of its bend into the diverticulum and the narrow space. To overcome this technical difficulty, we used an S-O clip to grasp the nonneoplastic mucosa near the lesion outside the diverticulum and displace it to the contralateral oral side of the tumor (Figs. 4 and 5).
Figure 4Clipping onto the nonneoplastic mucosa near the lesion outside the diverticulum.
After creation of traction, the tumor inside the diverticulum was exposed (Fig. 6). Although the tumor within the diverticulum was more easily identified, recognition of the lesion margin inside the diverticulum remained difficult. After filling the diverticulum with water for expansion, we could visualize the entirety of the tumor, including the margin within the diverticulum (Fig. 7).
Figure 6The tumor inside the diverticulum was exposed after creation of traction.
The snare tip was fixed to the margin of the tumor inside the diverticulum, and en bloc resection was achieved (Fig. 8). NBI did not reveal residual tumor after the resection (Fig. 9). The pathologic findings indicated a low-grade adenoma. Although both horizontal and vertical margins were indefinite, the complete resection was carried out endoscopically.
Figure 8An en bloc resection was achieved by cold snare polypectomy.
We successfully performed CSP for the resection of a colonic tumor partially extending into a diverticulum. The technical highlight of this case was the use of an S-O clip to extract the tumor from the diverticulum and use of water filling to expand the diverticulum. If the S-O clip is not available, a clip with loop thread can be an alternative option.
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