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Band ligation-assisted endoscopic mucosal resection of an intradiverticular polyp

Open AccessPublished:January 09, 2021DOI:https://doi.org/10.1016/j.vgie.2020.11.017

      Introduction

      With over 140,000 new colorectal cancer cases anticipated in 2020 by the American Cancer Society, colonoscopy remains a standard of care in the screening and further evaluation of precancerous colorectal lesions.
      • Joseph D.A.
      • Meester R.G.S.
      • Zauber A.G.
      • et al.
      Colorectal cancer screening: estimated future colonoscopy need and current volume and capacity.
      Although a trained gastroenterologist is able to routinely perform screening colonoscopies as part of daily practice, the location of some polypoid lesions might pose a challenge.
      Colonic diverticula pose a particular challenge because they lack or have a weakened layer of muscularis propria owing to focal wall weakness and increased intraluminal pressures,
      • Gulwani H.
      Diverticulosis. Gulwani H. Diverticulosis.
      thus increasing the risk of perforation with intervention. We present the case of a healthy 50-year-old man who was seen for routine colonoscopy and was found to have diverticular disease and a polyp arising from a diverticulum in the descending colon.

      Case report

      A healthy patient presented to the endoscopy suite for routine colonoscopy. The examination showed diverticulosis of the sigmoid colon and, within the descending colon, a 7-mm polyp within the base of a diverticulum. The adjacent area was tattooed with India ink, and the remainder of the screening colonoscopy was completed and the colonoscope was withdrawn. At this time, the colonoscope was exchanged, and a single-channel upper forward-viewing endoscope (GIF-HQ190, Olympus, Tokyo, Japan) with a band ligating device attached to its tip (MBL-6-XL-C, Cook Medical, Bloomington, Ind, USA) was subsequently used.
      The diverticulum with the attached polyp was found by drawing attention to the mucosa previously marked with India ink within the descending colon (Fig. 1). Once the diverticulum was identified, full intermittent suction was performed to drive the diverticulum into the device, with resulting inversion of the diverticulum and the polyp. Intermittent suction allowed us to minimize the possibility of muscularis propria being present within the banded tissue.
      Figure thumbnail gr1
      Figure 1Descending colonic diverticulum containing sessile polyp.
      A single rubber band was deployed on the colonic wall from which the diverticulum originated (Fig. 2). After confirming the banding, the polyp was subsequently resected via hot snare polypectomy performed at the surface of the diverticulum, leaving the diverticulum intact with complete removal of the polyp and an R0 margin. The diverticulum was then retrieved for further histological examination, which revealed tubular adenoma (Fig. 3).
      Figure thumbnail gr2
      Figure 2A, Identification of polyp after inversion of diverticulum via endoscopic suction. B, Ligation of sessile polyp at its base by using an endoscopic ligating device.
      Figure thumbnail gr3
      Figure 3A, Hot snare polypectomy performed on inverted diverticular polyp. B, Base of diverticulum after hot snare polypectomy.
      The patient tolerated the procedure well without any further adverse events and was discharged home on the same day. One week after the procedure, the patient was contacted and reported that he remained symptom free.

      Case discussion

      Techniques to remove early neoplasms of the GI tract include polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, and, recently, the use of a full-thickness resection device. However, polyps arising within or near colonic diverticula pose an increased challenge to the gastroenterologist because of the increased risk of perforation. To minimize this risk, new techniques such as endoscopic full-thickness resection have been developed, which allows for complete resection of the lesion
      • Mão de-Ferro S.
      • Castela J.
      • Pereira D.
      • et al.
      Endoscopic full-thickness resection of colorectal lesions with the new FTRD system: single-center experience.
      ; nevertheless, despite its increased availability, it still requires additional training and poses additional costs.
      Alternative techniques, including band ligation of suspected lesions, have also been proposed to allow for induced ischemia and necrosis, resulting in the ligated contents falling off. However, as presented by Carmo et al,
      • Carmo J.
      • Marques S.
      • Chapim I.
      • et al.
      Elastic band ligation for the removal of a colonic tubular adenoma in a diverticulum.
      using band ligation alone limits histopathological analysis because no specimen is collected.
      By using the technique presented here, the polyp is safely removed and can still be sent for further histopathological analysis. The techniques and instruments readily available to the majority of gastroenterologists can be used, and no additional costs are incurred in comparison with full-thickness resection device usage (Video 1, available online at www.giejournal.org).

      Disclosure

      All authors disclosed no financial relationships.

      Supplementary data

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