Recurrent tumor involving a diverticulum after colonic endoscopic submucosal dissection successfully resected by the double-tunnel method
Repeat endoscopic treatment is challenging for lesions that recur after endoscopic resection and for lesions involving a diverticulum because of the severe fibrosis surrounding such lesions  . We report the case of a tumor involving a diverticulum that recurred after colonic endoscopic submucosal dissection (ESD) and was successfully resected by the double-tunnel method.
A 72-year-old woman was diagnosed 2 years ago as having a laterally spreading tumor (LST) in her ascending colon measuring 30 mm in diameter ([Fig. 1 a]), which her previous doctor had attempted to treat by ESD. After making the circumferential incision, he faced a diverticulum during the process of dissection and discontinued the procedure. He cauterized the rest of the tumor.
This time, the patient was referred to our hospital for treatment of a recurrence of the diverticular tumor after the attempted ESD ([Fig. 1 b]). The tumor arose in a diverticulum and was surrounded by fibrosis, so we expected that lifting of the lesion after local injection would not be possible because of the lack of a soft submucosal layer. We had previously reported that the double-tunnel method is useful for lesions associated with severe fibrosis . In addition to dealing with the fibrosis, we applied this method to apply traction to the diverticular area to pull the tumor out of the muscle layer into the lumen ([Video 1]). This technique allows good traction to be maintained and an appropriate dissection line to be identified, even in situations involving severe fibrosis in a diverticulum ([Fig. 1 c]). Using this method, we successfully performed en bloc resection of the tumor. The patient recovered without incident. Histological examination revealed an intramucosal carcinoma and confirmed the curative resection ([Fig. 2]).
Video 1 Colorectal endoscopic submucosal dissection using the double-tunnel method, allowing efficient and safe resection of a recurrent lesion arising from a diverticulum and surrounded by severe fibrosis.
Use of the double-tunnel method enables safe en bloc resection of lesions with fibrosis, even of those arising in diverticula.
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02 September 2020 (online)
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