Mucosal carcinoma arising in a colon diverticulum: endoscopic submucosal dissection using the novel “clip-band-tent” traction method

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.

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Conflict of Interest

Dr Ramos is a consultant for Erbe España Soluciones Médicas. All other authors disclosed no potential competing interests.

Acknowledgement

We are indebted to the endoscopy auxiliary staff for collaborating in this ESD.

• References

• 1 Jimenez-Garcia VA, Yamada M, Ikematsu H. et al. Endoscopic submucosal dissection in management of colorectal tumors near or involving a diverticulum: a retrospective case series. Endosc Int Open 2019; 7: E664-E671
• 2 Ramos-Zabala F, Gil-Páez C, Alzina-Pérez A. et al. “Trans-tattoo in immersion” method for the removal of a recurrent, previously tattooed adenoma using endoscopic submucosal hydrodissection. Endoscopy 2020; 52: E408-E410
• 3 Parra-Blanco A, Nicolas D, Arnau MR. et al. Gastric endoscopic submucosal dissection assisted by a new traction method: the clip-band technique. A feasibility study in a porcine model (with video). Gastrointest Endosc 2011; 74: 1137-1141
• 4 Yamamoto K, Hayashi S, Nakabori T. et al. Endoscopic submucosal dissection using endoclips to assist in mucosal flap formation (novel technique: “clip flap method”). Endoscopy 2012; 44: E334-E335
• 5 Ramos-Zabala F, García-Mayor M, Domínguez-Pino A. et al. Combination of immersion in saline solution, pocket-creation method, water-jet hydrodissection, and hybrid knife “probe mode” simplifies endoscopic submucosal dissection in giant rectal polyp. VideoGIE 2019; 4: 478-480

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Artikel online veröffentlicht:
06. Mai 2025