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Create a Free AccountAnatomy - Colorectal
Endoscopic adventitial dissection of a rectal GI stromal cell tumor
Endoscopic adventitial dissection (EAD) is a novel resection technique that involves dissection in the “fourth space,” the space between the outer longitudinal muscle and the tunica adventitia of the rectum. EAD is the retroperitoneal equivalent of endoscopic subserosal dissection (ESSD), which involves dissection between the serosa and muscularis propria. The space between these 2 layers mainly consists of loose connective tissue, similar to the submucosa. The submucosal layer has been coined as the “third space” in which endoscopic procedures can be performed.Ileocolonic intussusception presenting as chronic diarrhea in an elderly woman
Intussusception represents the telescoping of a proximal segment of the GI tract (intussusceptum) into the lumen of an adjacent distal segment (intussuscipiens).1 While more common in children, it is considered one of the rare causes of mechanical large-bowel obstruction in adults accounting for 1% to 5% of cases. Malignancy accounts for nearly 65% of all cases of intussusception in adults, and surgery is considered a first-line option.2,3Endoscopic submucosal dissection of appendiceal lesions by using a novel adjustable traction device: A-TRACT-2
Endoscopic submucosal dissection (ESD) allows for en bloc resection of various lesions of the GI tract.1 Nonetheless, the technical difficulty of the procedure limits its widespread adoption, especially in the appendix where the procedure remains a challenge, even for experienced operators, combining an often-bad exposition and difficult access to the submucosa, frequently compromising R0 resection. Thus, several tools, including traction devices, have been developed to assist the intervention,2-4 but they all tend to lose traction force as the intervention progresses.Endoscopic submucosal dissection with the combination of a scissor-type knife and novel traction method for colonic neoplasm involving a diverticulum
As various devices and techniques emerge, colorectal endoscopic submucosal dissection (ESD) has become a relatively safe procedure despite the anatomical difficulty. However, ESD for colonic tumors near or involving a diverticulum remains challenging.1-6 We report a case of colonic neoplasm involving a diverticulum that was treated using ESD via a combination of a scissor-type knife and a novel traction method.Endoscopic management of gastrojejunocolic fistula after endoscopic gastrojejunostomy
Endoscopic ultrasound–guided gastrojejunostomy (EUS-GJ) is an alternative to endoscopic stent placement alone and surgical gastrojejunostomy for the management of gastric outlet obstruction (GOO). Similar technical and clinical success rates have been shown with EUS-GJ and endoscopic stent placement alone with lower rates of reintervention in the EUS-GJ group.1 When compared to the more invasive surgical GJ, EUS-GJ has shown similar rates of clinical success and lower adverse event rates.2,3 Rare EUS-GJ adverse events include perforation, peritonitis, bleeding, stent misdeployment, and migration.Use of a novel dual-action clip for closure of complex endoscopic resection defects
While there continues to be debate surrounding indications for closure, use of clips following endoscopic mucosal resection of large nonpedunculated polyps has been found to reduce risk of postprocedural bleeding,1-3 and clinically has also been performed to reduce risk of perforation because of muscularis propria injuries. While standard clips are effective for closure of 2- to 3-cm endoscopic mucosal resection sites in the colon, closure of endoscopic submucosal dissection (ESD) wounds is more technically challenging as the deeper dissection plane in ESD tends to result in a larger separation between the wound edges.Point blank: an endoscopic retrieval of an extraluminal bullet
A 36-year-old man with no medical history presented with multiple gunshot wounds to the right neck, left axilla, and pelvis. An entry wound in the right buttocks was noted without a corresponding exit wound. A CT scan identified the bullet near the rectum, and a leak from an administered barium enema further demonstrated the location. (Figs. 1 and 2) A laparoscopic diverting colostomy was performed, and advanced endoscopy was consulted for retrieval of the bullet for ballistics and closure of the subsequent rectal defect.Endoscopic tacking system as a novel tissue approximation measure for very large EMR defects
Defect closure post-EMR and endoscopic submucosal dissection (ESD) is recommended to decrease the risk of delayed bleeding and perforation. Current methods of tissue approximation and closure of mucosal defects have their limitations, including restricted maneuverability, need for scope withdrawal, or difficulty in apposing larger defects. Through-the-scope HeliX tacking system (Apollo Endosurgery, Austin, Tex, USA) is a novel tissue apposition device designed to mimic suture closure without the need to withdraw the endoscope or insert bulky devices on the tip of the endoscope.Novel articulating through-the-scope traction device
Endoscopic submucosal dissection (ESD) has become a standard approach for treating superficial GI neoplasia, but its adoption remains limited because of its steep learning curve and extensive resource utilization when performed by endoscopists in the earlier stages of the ESD learning curve.1,2 Furthermore, although traction strategy has emerged to improve clinical outcomes and increase procedural efficiency, current techniques and devices own inherent limitations such as technical complexity, lack of adjustability, or demanding preparation.Purely endoscopic appendectomy
Surgical/laparoscopic appendectomy requires abdominal wall incisions/punctures that can subsequently cause hernias, pain, and delayed return to work and regular physical activity after surgical/laparoscopic removal of the appendix.1 Natural orifice transluminal endoscopic surgery interventions were often performed with laparoscopic assistance and required advancement of an endoscope into the peritoneal cavity through gastric or vaginal wall with increased risk of infection and abdominal adhesions.Endoscopic intermuscular dissection with intermuscular tunneling for local resection of rectal cancer with deep submucosal invasion
The introduction of population-based screening has resulted in an increased incidence of early-invasive (T1) rectal cancer.1 For these tumors, local treatment is considered curative when the resection margins are negative (R0) and histological high-risk factors for lymph node metastasis (LNM) are absent. Although deep submucosal invasion has long been considered a high-risk factor,2 recent reports showed that Kikuchi level (Sm) 2 to 3 lesions without other high-risk factors are associated with a negligible LNM risk (<2%).Follow-up outcomes of mucosal defect closures after endoscopic resection using a helix tacking system and endoclips
The X-Tack endoscopic HeliX tacking system (Apollo Endosurgery, Austin, Tex, USA) has recently been approved by the Food and Drug Administration and is slowly gaining popularity for the closure of large tissue defects. Despite its increasing use, outcome data of using the X-Tack system for mucosal defect closure after endoscopic resection (ER) are limited. Here, we report the follow-up outcomes of a series of cases that underwent ER and mucosal closure aided by the HeliX tacking system.Endoscopic submucosal dissection to treat squamous cell carcinoma in situ of the anal canal
The standard treatment for invasive squamous cell anal cancer is chemoradiation treatment. However, treatment options for high-grade dysplasia (squamous cell cancer in situ) are either surgical excision or topical treatment modalities. There are a few case reports, mainly from Japan, about resecting early squamous cell anal cancer (high-grade dysplasia/carcinoma in situ) by endoscopic submucosal dissection. We present a case series of 3 patients from a western hemisphere population with squamous carcinoma in situ of the anal canal resected with endoscopic submucosal dissection (ESD).Utility of red dichromatic imaging for identifying the bleeding point in endoscopic hemostasis of colonic diverticular bleeding
An 82-year-old woman was admitted to our hospital because of hematochezia without pain. She had been admitted to our hospital several times in the previous year for colonic diverticular bleeding (CDB) and had already undergone multiple hemostatic treatments for the CDB. A previous plain computed tomography scan had showed multiple colonic diverticula in the ascending colon and sigmoid colon (Fig. 1), so recurrent colonic diverticular hemorrhage was the primary differential diagnosis.Quit screwing around: magnetic retrieval of an appendiceal foreign body
Appendiceal foreign bodies are uncommon but can lead to serious adverse events such as appendicitis and perforation. Patients can remain asymptomatic for many years before these adverse events develop. Data on incidence and optimal management are limited and largely restricted to case reports in both adults and children.1-6 In a review spanning 100 years with 250 identified case reports, objects that were sharp, thin, stiff, and pointed increased the risk of adverse events.7 Timely intervention is recommended before the development of localized inflammation or perforation.Full-thickness resection: troubleshooting, tips, and tricks for success in the colorectum
Endoscopic resection is a well-established modality for the minimally invasive treatment of superficial lesions throughout the colon and rectum. Although EMR and endoscopic submucosal dissection (ESD) provide excellent results, they have limited efficacy in certain situations, such as deeper lesions and lesions with dense submucosal fibrosis.1,2 In these situations, endoscopic full-thickness resection (EFTR) provides an alternative endoscopic resection modality, potentially sparing patients from surgical resection.Gauze extension method for specimens resected by endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) is a standard and reliable procedure for resection of GI neoplasms. Although ESD allows en bloc resection of large GI neoplasms,1 ESD specimens tend to contract because of burning and scarring of the margins during ESD (Fig. 1). When preparing ESD specimens for pathologic examination, including evaluation of the margins, specimens should be extended and pinned on a fixing board as quickly as possible.2,3 However, in most cases, the normal marginal mucosa from ESD specimens is thin and fragile, especially from the colon.Hybrid endoscopic submucosal dissection for anal canal fibroma
An 83-year-old bedridden woman was referred for a suspected rectal polyp that frequently protruded from the anus when passing stools. Although the mass would reduce spontaneously, she experienced extreme discomfort, tenesmus, and occasional rectal bleeding. Ambulatory proctoscopy at the surgery department suggested a tumor in the lower rectum or anal canal.Endoscopic fenestration for benign complete anastomotic obstruction following rectal surgery
An anastomotic stricture is a common adverse events after colorectal cancer resection with stapled anastomosis1,2; however, complete anastomotic obstruction is rare. Surgical revision is a feasible treatment option for this condition, albeit with a reportedly high morbidity rate.3,4 Few studies have reported on endoscopic puncture and balloon dilation for rectal anastomotic obstruction.5,6 However, the safety of endoscopic procedures performed using a 1-sided approach without guidance for the correction of anastomotic obstruction is compromised.Endoscopic submucosal dissection of a symptomatic giant colonic lipoma: technical tips for resection and specimen retrieval
Colonic lipomas are rare, benign subepithelial tumors of the colon. They are usually asymptomatic and found incidentally during colonoscopy.1 Symptoms correlate with the size of the lipoma; as such, approximately 75% of patients with giant colonic lipomas (>4 cm) are symptomatic.2,3 Symptoms include abdominal pain, constipation, intussusception, or bowel obstruction. Endoscopic resection is preferred over surgery for symptomatic lipoma.3 Various endoscopic resection techniques have been described.Direct clipping using underwater inversion method for colonic diverticular bleeding
Colonic diverticular bleeding is the most common cause of acute lower GI bleeding, sometimes requiring hemostatic interventions, such as endoscopic hemostasis, transcatheter arterial embolization, and surgery. Recently, various methods have been developed to achieve endoscopic hemostasis for colonic diverticular bleeding.1 Endoscopic clipping is widely used because of its rare association with tissue damage and is classified as direct or indirect types. Direct clipping is performed on the exposed vessel in the diverticulum, whereas indirect clipping is performed to close the responsible diverticulum in a zipper fashion.Endoscopic submucosal dissection using traction by a spring-and-loop with clip for a laterally spreading tumor in the inferior aspect of the cecum: a nonreferral center experience
Endoscopic submucosal dissection (ESD) has been widely accepted as a minimally invasive treatment for early colorectal neoplasms.1 However, cecal ESD remains a challenging treatment owing to the anatomical features of the cecum, such as the thin wall, and confrontation of the endoscope vertically with the muscular layer.Endoscopic ultrasound-guided ileosigmoidostomy using a lumen-apposing metal stent for palliation of malignant small-bowel obstruction
High-grade malignant small-bowel obstruction (SBO) is typically managed with surgical diversion (ileostomy) or palliative decompression via nasogastric tube or venting gastrostomy. These approaches have a significant impact on quality of life. Endoscopic palliation of malignant luminal obstruction by lumen-apposing metal stent (LAMS) placement is well established for duodenal obstruction. Distal SBO, however, is challenging to manage endoscopically. We present the case of a novel EUS-guided ileosigmoidostomy technique for the palliation of malignant distal SBO.Utilization of an overtube for placement of a lumen-apposing metal stent for removal of a capsule endoscope retained proximal to an ileal stricture
Capsule endoscopy is a noninvasive procedure used to evaluate the small bowel. Capsule retention remains a significant adverse event of capsule endoscopy, and endoscopic capsule extraction may be technically complicated when device-assisted enteroscopy is necessary to reach the retained capsule. The length and limited diameter of enteroscope working channels limit the endoscopic tools available and can make extraction of the capsule difficult. The presence of enteral strictures can also further complicate endoscopic extraction of a retained capsule.Multilevel stenting of malignant colonic obstructions from multilevel breast cancer colonic metastasis
Breast cancer frequently metastasizes to the bones, lungs, brain, and liver, whereas colonic metastasis from breast cancer is rare, with only a few cases reported to date.1 Colonic obstruction causes electrolyte and fluid imbalances and increases the risk of bowel necrosis and perforation, which can be life-threatening.2 The use of self-expanding metallic stents (SEMSs) was first reported in 1991, and SEMSs have been used in recent years for the palliation of malignant colonic obstruction.3 Studies have identified variations in the outcomes of SEMS placement when comparing patients with colorectal cancer and those with extracolonic malignancies.
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