COUNTER TRACTION USING CLIPS AND RUBBER BANDING FOR ENDOSCOPIC SUBMUCOSAL DISSECTION OF A LATERALLY SPREADING TUMOR INVOLVING A DIVERTICULUM IN THE COLON

In addition to the possibility of en bloc resection without size limitations, endoscopic submucosal dissection (ESD) is also a novel option for endoscopic treatment of lesions involving a diverticulum in the colon or appendix. Generally, when employing EMR, these types of lesions have a high risk of perforation or incomplete resection.

Here, we report a case of a laterally spreading tumor (LST) involving a colonic diverticulum that underwent successful en bloc resection by ESD using counter traction with clips and rubber banding. A man in his 60 s was referred for resection of a 40 mm LST in the ascending colon. The lesion was confirmed as a granular LST with a regular vascular and pit pattern in NBI but also involvement of a centrally located diverticulum, all of which were indications for ESD.

After the initial needle injection, ESD was initiated from the anal side using the Dual Knife J dosed with glycerol. We used counter traction with clips and rubber bands to allow better exposure of the submucosal layer as described previously. Once the endoscope approached the diverticulum, a second traction using two clips and another rubber band was positioned to allow a maximal increase in the submucosal space on the side of the diverticulum.

Finally, en bloc resection was completed in 50 minutes, and the diverticulum was closed to prevent delayed perforation. Pathological analysis revealed a tubulovillous adenoma with high-grade dysplasia with free deep and lateral margins measuring 52 × 40 mm. Following the ESD procedure, the patient was discharged without complications 24 hours later.