En bloc underwater endoscopic mucosal resection of a large laterally spreading tumor in the colon after endoscopic tattooing

Underwater endoscopic mucosal resection (UEMR) is an alternative technique to standard polypectomy for managing complex cases. The primary advantage of UEMR is that it causes less bowel lumen distension, potentially allowing the capture of a larger mucosal surface area [1].

A 64-year-old woman was referred to our hospital after colonoscopy revealed cecal cancer and a 25-mm laterally spreading tumor (LST) in the transverse colon, diagnosed as intramucosal cancer ([Fig. 1] a, b). Initially, we thought that both the transverse colon and the cecal tumor would need to be removed surgically, leading to the tattooing of the anal side of the LST ([Fig. 1] c). However, endoscopic resection of the LST in the transverse colon would reduce the invasiveness of surgery. Therefore, we chose UEMR as the method for en bloc resection of the LST ([Fig. 1] d, e, [Video 1]).

Fig. 1 Endoscopy images. a An invasive cancer in the cecum. b A 25-mm laterally spreading tumor (LST) located in the transverse colon. c Tattooing at the anal side of the LST. d Underwater endoscopic mucosal resection (UEMR) of the LST. e Mucosal defect after UEMR, showing black-colored submucosal tissue.

Tattooing and en bloc removal of a laterally spreading tumor in the transverse colon with underwater endoscopic mucosal resection.Video 1

The LST was resected en bloc using an extra-large snare (33 mm, Captivator II; Boston Scientific, Marlborough, Massachusetts, USA) ([Fig. 2] a, b). Histopathological examination revealed an intramucosal adenocarcinoma with adenoma, without lymphovascular involvement and no tumor involvement of the resection margins ([Fig. 2] c, d).

Fig. 2 Findings from the resected tumor. a En bloc resected specimen. b The submucosal side of the lesion, showing non-neoplastic mucosa around the lesion. c Microscopic image of the resected specimen indicating an intramucosal adenocarcinoma with adenoma, without lymphovascular involvement and no tumor involvement of the resection margins. d Macrophages containing carbon pigments in the submucosal layer.

After endoscopic tattooing for colorectal lesions, endoscopic submucosal dissection (ESD) is challenging due to fibrosis and unclear anatomical layers in the submucosal layer [2]. Conversely, UEMR has shown its effectiveness in treating local residual/recurrent colorectal lesions, suggesting its usefulness for lesions with fibrosis [3]. In a previous report, UEMR was performed in a piecemeal manner for a tattooed tumor [4]. However, UEMR for 20–30-mm lesions is reportedly comparable to ESD in terms of local recurrence [5]. In the current case, even a 25-mm lesion could be resected en bloc with UEMR, resulting in precise pathological assessment. This case demonstrates the advantage of UEMR for a large LST even after endoscopic tattooing.

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Conflict of Interest

Y. Takeuchi is a member of the Editorial Board of Endoscopy. X. H. Ma, K. Kasuga, A. Isshiki, S. Ishihara, T. Masuo, and T. Uraoka declare that they have no conflict of interest.

• References

• 1 Uedo N, Nemeth A, Johansson GW. et al. Underwater endoscopic mucosal resection of large colorectal lesions. Endoscopy 2015; 47: 172-174
• 2 Chiba H, Tachikawa J, Kurihara D. et al. Successful endoscopic submucosal dissection of colon cancer with severe fibrosis after tattooing. Clin J Gastroenterol 2017; 10: 426-430
• 3 Ohmori M, Yamasaki Y, Iwagami H. et al. Propensity score-matched analysis of endoscopic resection for recurrent colorectal neoplasms: a pilot study. J Gastroenterol Hepatol 2021; 36: 2568-2574
• 4 Rodrigues JP, Pinho R, Sousa M. et al. Underwater endoscopic mucosal resection of a laterally spreading tumor overlying a previous endoscopic carbon tattoo. Endoscopy 2018; 50: e231-e232
• 5 Inoue T, Nakagawa K, Yamasaki Y. et al. Underwater endoscopic mucosal resection versus endoscopic submucosal dissection for 20–30 mm colorectal polyps. J Gastroenterol Hepatol 2021; 36: 2549-2557

Publication History

Article published online:
08 November 2024