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Endoscopic submucosal dissection of a lateral spreading tumor involving the appendiceal orifice using a multi-traction device.
Endoscopic submucosal dissection (ESD) is the technique of choice for the resection of large superficial colorectal lesions , but it can be technically challenging in some situations. For this reason, lesions involving the appendiceal orifice have long been removed surgically. However, recent findings have found that ESD is effective and safe in that situation  , even for lesions deeply invading the appendiceal orifice (Toyonaga 3 lesions) with the help of traction device  .
Here we report the case of a 70-year-old woman with a history of appendectomy who underwent a colonoscopy that revealed a granular lateral spreading tumor (LST-G) of 3 cm invading the previous site of the appendectomy (Toyonaga 3a) ([Fig. 1]). An ESD using a multi-intertwined loop device was chosen ([Video 1]). After circumferential mucosal incision around the lesion, the first loop of the device was attached to one edge of the lesion with a hemostatic clip. Then a second loop was attached to the opposite edge of the lesion. Then the entire device was attached to the opposite colonic wall. The submucosal space was well exposed at the two edges of the LST-G, allowing a safe dissection during the whole procedure with an en-bloc resection ([Fig. 2], [Fig. 3]). The patient was discharged the day after without experiencing any adverse event. The pathology report showed a high-grade dysplasia with a focus of intramucosal adenocarcinoma that was completely resected by the ESD. Owing to the curative resection, an endoscopic follow-up was decided.
Video 1 Endoscopic submucosal dissection of a lateral spreading tumor involving the appendiceal orifice using a multi-traction device.
This case highlights that ESD can be safely performed in the appendiceal orifice even with a history of appendectomy. The use of a multi-traction device helped to obtain very satisfying exposure of the submucosal space. A randomized control study evaluating this device would be necessary to confirm this promising result.
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Article published online:
08 September 2021
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