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 [1], 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 [2] [3], even for lesions deeply invading the appendiceal orifice (Toyonaga 3 lesions) with the help of traction device [4] [5].

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.

Fig. 1 A granular lateral spreading tumor invading the previous site of appendectomy.

Video 1 Endoscopic submucosal dissection of a lateral spreading tumor involving the appendiceal orifice using a multi-traction device.

Fig. 2 The submucosal space was well exposed at the two edges of the granular lateral spreading tumor thanks to the multi-traction device.

Fig. 3 Lesion after resection.

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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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
• 2 Jacob H, Toyonaga T, Ohara Y. et al. Endoscopic submucosal dissection of cecal lesions in proximity to the appendiceal orifice. Endoscopy 2016; 48: 829-836
• 3 Tashima T, Ohata K, Nonaka K. et al. Endoscopic submucosal dissection for laterally spreading tumors involving the appendiceal orifice. Surg Endosc 2017; 31: 5444-5450
• 4 Oung B, Rivory J, Chabrun E. et al. ESD with double clips and rubber band traction of neoplastic lesions developed in the appendiceal orifice is effective and safe. Endosc Int Open 2020; 08: E388-E395
• 5 Jacques J, Charissoux A, Legros R. et al. Double-clip counter-traction using a rubber band is a useful and adaptive tool for colonic endoscopic submucosal dissection. Endoscopy 2018; 50: 179-181

Publication History

Article published online:
08 September 2021