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Successful planned piecemeal endoscopic resection using gel immersion and an over-the-scope clip for a lesion extensively extended into the colonic diverticulum
Successfully planned piecemeal endoscopic resection using gel immersion and an over-the-scope clip for a lesion extensively extended into the colonic diverticulum.
Endoscopic resection (ER) for lesions extending into the diverticulum, which are difficult to resect endoscopically, is performed using various techniques.
Saline-immersion therapeutic endoscopy facilitated en bloc endoscopic submucosal-subserosal dissection of a sigmoid diverticulum containing a refractory adenomatous lesion.
Endoscopic resection using a full-thickness resection device (FTRD; Ovesco Endoscopy AG, Tübingen, Germany) has been attempted for removing difficult colorectal lesions, thus avoiding surgical resection.
FTRD includes an over-the-scope clip (OTSC) and a snare premounted on a cap. However, it is not approved for use in Japan. Therefore, we performed and reported cases of ER using an OTSC for difficult GI lesions, although this technique is limited to ≤10-mm lesions.
Gel immersion endoscopy can control GI bleeding by flushing out blood and clots to secure a clear visual field. Furthermore, gel immersion endoscopy can provide a clearer view of the lesion margin than in underwater conditions. Gel immersion endoscopic mucosal resection (GIEMR) is applicable for lesions that are generally considered unamenable to ER.
Herein, we report a case of collaboration of GIEMR and OTSC techniques to achieve ER of a lesion that had extensively extended into the colonic diverticulum.
Case
A 78-year-old man was referred to our institute for the treatment of a flat elevated (20-mm diameter) lesion observed around and within the diverticulum near the ileocecal valve of the ascending colon (Fig. 1). The lesion was evaluated preoperatively for ER indications using conventional endoscopy, followed by image-enhanced endoscopy with magnification
The tumor was diagnosed as nonsubmucosally invasive carcinoma. Furthermore, no lymph node or distant metastasis was observed on an abdominal CT scan. The Japan Gastroenterological Endoscopy Society guidelines for colorectal ER recommend endoscopic submucosal dissection for this lesion
; however, the associated perforation risk was considered high. Therefore, we planned piecemeal ER as a minimally invasive treatment.
Figure 1Endoscopic views. A, 20-mm flat elevated lesion around and into the diverticulum near the ileocecal valve of the ascending colon. The size of the diverticulum was approximately 10 mm. B, The lesion extended considerably into the diverticulum, almost covering the orifice.
Figure 2Preoperative endoscopic appearance of the lesion. A, Conventional endoscopic imaging. B, Magnification endoscopy with narrow-band imaging (NBI) for the green square in panel A. The image shows that the lesion had a variable caliber with irregular distribution and an irregular obscure surface pattern. These findings correspond with a type 2B lesion, according to the Japan NBI Expert Team classification. C, Magnifying chromoendoscopy with crystal violet staining for the purple square in panel A. The image shows that the lesion had pits of irregular arrangements. These findings correspond to a VI-low grade type pit pattern classification.
The procedure was performed with the patient under conscious sedation. The lesion border was marked via an electrosurgical snare tip. Underwater EMR was attempted initially. However, the injected water mixed with any luminal residue and a clear visual field could not be obtained easily (Fig. 3A). Subsequently, carbon dioxide insufflation was discontinued, and we injected the gel,
filling the perilesional lumen (Fig. 3B). Gel immersion endoscopy secured a clear lesion margin view; the lesion was resected with a snare (Fig. 4). Most of the gel was suctioned, and we reinserted an endoscope with a 12/6t OTSC. The residual lesion inside the diverticulum was sufficiently suctioned into the applicator cap, and the OTSC was successfully deployed perilesionally. The lesion inside the diverticulum protruded into the lumen, and it was resected above the OTSC using a snare without any adverse events. Endoscopically, no tumor residues were evident (Fig. 5). The procedure time was 15 minutes (Video 1, available online at www.giejournal.org).
Figure 3Difference in endoscopic view between underwater and gel immersion. A, Underwater view. Injected water mixed with luminal residues; securing a clear view of the lesion was challenging. B, Gel immersion view. We injected gel (VISCOCLEAR; Otsuka Pharmaceutical Factory, Tokushima, Japan) through the accessory channel (BioShield irrigator; US Endoscopy, Mentor, Ohio, USA).
Figure 4Gel immersion endoscopic mucosal resection (GIEMR). A, The accurate snaring of the lesion in clear gel immersion view. The lesion is resected with a snare (SnareMaster: 25-mm diameter; Olympus, Tokyo, Japan) without local injection. B, Resection defect after GIEMR. The lesion outside the diverticulum is completely resected, and only the lesion inside the diverticulum remains (yellow square).
Figure 5Endoscopic resection using an over-the-scope clip (OTSC) for a lesion remaining inside the diverticulum. A, The OTSC (Ovesco Endoscopy GmbH, Tübingen, Germany) is deployed outside the diverticulum. The remaining lesion is resected above the OTSC with a snare. B, Resection defect without perforation. The small protrusion tissue (yellow arrow) may be a perforating branch vessel within the diverticulum.
The patient was hospitalized after the procedure, and antibiotics were administered for 2 days postoperatively. On postoperative day 2, oral intake was resumed. He did not develop any somatic symptoms or adverse events and was discharged on postoperative day 3. Pathologically, the tumor was diagnosed as an intramucosal adenocarcinoma in high-grade adenoma without lymphovascular invasion. The horizontal and vertical margins were inconclusive and negative, respectively (Figs. 6 and 7). On follow-up endoscopic examination, the mucosal defect had a residual OTSC and scarred entirely within 2 months, without residual tumor (Fig. 8).
Figure 6Macroscopic images of the piecemeal resected specimens. A, Gross appearance of the tumor outside the diverticulum (22 × 21 mm). B, Gross appearance of the tumor inside the diverticulum (17 × 12 mm). C and D, Histopathologic mapping of the specimens. The laterally spreading adenoma lesion is shown in yellow, whereas the focal adenocarcinoma component is marked in red.
Figure 7Histopathologic examination of specimens with a loupe (H&E, orig. mag. ×9.5 [A] and mag. ×17 [B]). A, Microscopic images of the tumor outside the diverticulum. B, Microscopic images of the tumor inside the diverticulum. In both specimens, the tumor is diagnosed as an intramucosal adenocarcinoma in high-grade adenoma with no lymphovascular invasion. The horizontal margin is diagnosed as inconclusive and the vertical margin is diagnosed as negative.
Figure 8Follow-up endoscopic images. A, A conventional endoscopic image. The resection defect completely scarred within 2 months. B, Weak magnification endoscopic image with narrow-band imaging. No residual tumors were identified.
We achieved ER of a lesion that had considerably extended into the colonic diverticulum using 2 different ER techniques. In situations where the lesion has extended into the colonic diverticulum and an FTRD is unavailable, the aforementioned treatment strategies can be used. However, in cases of OTSC misdeployment, we should perform this procedure in an environment where clip-cutting devices (remOVE system; Ovesco Endoscopy)
Successfully planned piecemeal endoscopic resection using gel immersion and an over-the-scope clip for a lesion extensively extended into the colonic diverticulum.
References
Ikezawa N.
Toyonaga T.
Tanaka S.
et al.
Feasibility and safety of endoscopic submucosal dissection for lesions in proximity to a colonic diverticulum.
Saline-immersion therapeutic endoscopy facilitated en bloc endoscopic submucosal-subserosal dissection of a sigmoid diverticulum containing a refractory adenomatous lesion.
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