Endoscopic submucosal dissection (ESD) may be considered challenging for treating
a colonic tumor involving a diverticulum [1] or having tattoo-induced fibrotic submucosal [2]. Here, we report a case of a laterally spreading tumor (LST) tattooed arising from
a colonic diverticulum resected by saline immersion ESD ([Video 1]). A 83-year-old woman with a previous left hemicolectomy for sigmoid adenocarcinoma
was referred to our hospital for an organ-sparing approach. On endoscopic examination,
in the ascending colon, a lesion with granular nodular mixed LST morphology was detected
inside of a diverticulum which was completely involved ([Fig. 1]). Surface pattern evaluation classified this lesion as JNET2A according to the Japan
NBI Expert Team classification. We performed the technique with the following steps
([Fig. 2]): circumferential mucosal incision using the ERBEJET hydrodissection system (Erbe),
which allowed the diverticulum to be released from the tattoo-induced fibrotic wall
([Fig. 3]); the “clip-band-tent” traction method was used as a variant of the clip-band technique
[3] for the eversion of the diverticulum, stabilizing the submucosal layer view and
providing adequate tension, which allowed better recognition of the dissection line
([Fig. 4]); we easily identified the fibrotic submucosal layer using immersion in saline solution
and the clip-flap traction method [4], which enabled precise dissection using the T-type HybridKnife in probe mode [5] and a VIO 3 unit set at preciseSECT mode (Erbe) with a narrow safety margin. En
bloc resection was achieved without any adverse events ([Fig. 5]) and the diverticular orifice and mucosal defect were closed using resolution clips
(Boston Scientific). The patient was discharged 24 hours after ESD. Histopathological
examination showed a well-differentiated adenocarcinoma confined to the mucosal layer
and free lateral and vertical resection margins.
Fig. 1 Endoscopic image showing a laterally spreading granular-type tumor in the ascending
colon arising from the base of the diverticulum with evidence of a previous endoscopic
tattoo around it. Surface pattern evaluation classified this lesion as JNET2A according
to the Japan NBI Expert Team classification.
Fig. 2 Graphical representation of endoscopic submucosal dissection with the “clip-band-tent”
traction method for eversion of the diverticulum: a illustration of the laterally spreading granular-type tumor arising from the base
of the diverticulum and endoscopic tattoo around it; b circumferential mucosal incision; c the “clip-band-tent” traction method is used as a variant of the clip-band technique
for the eversion of diverticulum; d the clip-flap traction method is used facilitating submucosal layer visualization
during saline immersion dissection.
Fig. 3
a Endoscopic image showing a circumferential mucosal incision T-type Hybridknife using
an ERBEJET hydrodissection system, which allowed the diverticulum to be released from
the tattoo-induced fibrotic wall. b The defect of the muscularis propria at the diverticulum is indicated with yellow
arrows.
Fig. 4 Endoscopic image showing an optimal eversion of the diverticulum by the “clip-band-tent”
traction method.
Fig. 5 Macroscopic appearance of the resected specimen.
Large superficial tumor of the colon involving a diverticulum removed by endoscopic
submucosal dissection using the novel “clip-band-tent” traction method and T-type
Hybridknife used in probe mode.Video 1
The “clip-band-tent” traction method could be a promising variant of traction-assisted
ESD for lesions involving a diverticulum as it significantly facilitates the precision
of the technique.
Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AD
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
