Endoscopy 2021; 53(01): E13-E14
DOI: 10.1055/a-1163-7140
E-Videos

Cut the weeds and dig up the roots: clip-and-snare assisted endoscopic mucosal resection of a rectal neuroendocrine tumor

Wei-hui Liu*
1  Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences & Sichuan Provincial Peopleʼs Hospital, Chengdu, Sichuan, China
,
Shi Liu*
2  Department of Gastroenterology, The First Affiliated Hospital, Dalian Medical University, Dalian, Liaoning, China
,
Ying Gong
2  Department of Gastroenterology, The First Affiliated Hospital, Dalian Medical University, Dalian, Liaoning, China
,
Hideki Kobara
3  Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kita, Kagawa, Japan
,
Shi-Bin Guo
2  Department of Gastroenterology, The First Affiliated Hospital, Dalian Medical University, Dalian, Liaoning, China
,
Jian Gong
2  Department of Gastroenterology, The First Affiliated Hospital, Dalian Medical University, Dalian, Liaoning, China
› Author Affiliations
 

Endoscopic submucosal dissection (ESD) has been the preferred treatment of small gastrointestinal neuroendocrine tumors (NETs) (≤ 10 mm) without muscularis propria invasion [1]; however, the requirements of special instruments and complex skills have limited its widespread application [2]. In this regard, we developed a simple clip-and-snare assisted endoscopic mucosal resection (CS-EMR) technique for complete removal of a rectal NET ([Video 1]).

Video 1 Clip-and-snare assisted endoscopic mucosal resection of a rectal neuroendocrine tumor. A reopenable clip is used to lift the flat lesion away from the muscularis propria, allowing a preloaded snare to encircle the resulting “polyp” root below the clip and endoscopically resect it. The surgical wound is closed by clips.


Quality:

A 35-year-old man was referred for endoscopic treatment of a small rectal NET (6 mm). Because the NET was seen on colonoscopy to have a flat subepithelial surface ([Fig. 1 a]) and was evaluated on endoscopic ultrasonography (EUS) as not showing invasion of the muscularis propria, CS-EMR was used to achieve complete resection. As the transparent cap-covered single-channel endoscope, along with a pre-anchored snare, entered the rectum to target the tumor, a clip was inserted through the working channel of the endoscope and was used to grasp the mucosa adjacent to the tumor ([Fig. 1 b]). When the NET had been well lifted by the clip and transformed into a “pedicle polyp,” the snare was released from the endoscope and completely enveloped the root of the NET ([Fig. 1 c]). The NET was fully excised using a blended electrosurgical current ([Fig. 1 d]), leaving a clean surgical wound ([Fig. 1 e]). The wound was immediately closed by the lifting clip and application of a further clip ([Fig. 1 f]). Histological examination of the resected specimen revealed a G1 NET with negative margins ([Fig. 2]).

Zoom Image
Fig. 1 Endoscopic treatment of a rectal neuroendocrine tumor (NET) using the clip-and-snare assisted endoscopic mucosal resection (CS-EMR) technique. a Colonoscopy showed a subepithelial lesion (arrows) with typical NET features of poorly protruded surface and superficial yellowish mucosa. b The clip gently clamped and pulled the lesion toward the endoscope to separate it from the muscularis propria. c The snare was advanced beneath the clip and tightly trapped the root of the lesion. d The lesion was resected with standard polypectomy settings. e A clean surgical wound was displayed. f The surgical wound was perfectly closed with only two clips.
Zoom Image
Fig. 2 Histological appearance confirming the resected specimen as a G1 neuroendocrine tumor with negative margins.

Unlike the previously reported grasp-and-snare EMR, which requires a dual-channel endoscope to deploy a snare and a biopsy forceps through each channel [3], this CS-EMR needs only a single-channel endoscope. Unlike with the “underwater” EMR technique, which may be affected by blind vision once bleeding occurs [4], the CS-EMR has no risk of causing bleeding before resection. Therefore, the easy and safe CS-EMR technique is a promising alternative to replace ESD in the treatment of small NETs.

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Competing interests

The authors declare that they have no conflict of interest.

Acknowledgments

This study was supported by the Natural Science Foundation of Liaoning Province (No. 2019-ZD-0932) and the Project of Department of Education, Liaoning Province (No. LZ2019019).

* contributed equally to this paper



Corresponding author

Jian Gong, MD
Department of Gastroenterology
The First Affiliated Hospital
Dalian Medical University
222 Zhongshan Road, Dalian
Liaoning 116011
P. R. China   

Publication History

Publication Date:
29 May 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Endoscopic treatment of a rectal neuroendocrine tumor (NET) using the clip-and-snare assisted endoscopic mucosal resection (CS-EMR) technique. a Colonoscopy showed a subepithelial lesion (arrows) with typical NET features of poorly protruded surface and superficial yellowish mucosa. b The clip gently clamped and pulled the lesion toward the endoscope to separate it from the muscularis propria. c The snare was advanced beneath the clip and tightly trapped the root of the lesion. d The lesion was resected with standard polypectomy settings. e A clean surgical wound was displayed. f The surgical wound was perfectly closed with only two clips.
Zoom Image
Fig. 2 Histological appearance confirming the resected specimen as a G1 neuroendocrine tumor with negative margins.