A novel guidewire technique for endoscopic mucosal resection of ileocecal valve lesions

Large nonpedunculated colorectal polyps (LNPCPs) of the ileocecal valve (ICV) are challenging to resect endoscopically due to their difficult location and limited access. However, endoscopic resection can be highly successful and surgeries avoided [1]. A retrospective cohort study of 118 ICV lesions followed over 18 years demonstrated clinically successful endoscopic mucosal resection (EMR) in only 76.3%, with recurrence observed in 16.5% at first follow-up [2]. Technical advances such as margin thermal ablation with soft-tip snare coagulation (STSC), cold avulsion with adjuvant STSC of nonlifting areas, and assessment of deep mural injury have significantly improved outcomes such that Vosko et al. reported clinically successful EMR in 93.9% with a recurrence rate of 4.6% [3]. Notably, clinical success declines with increasing terminal ileal extension and greater circumferential ICV involvement. Deep terminal ileal involvement (≥10 mm) was associated with EMR failure requiring surgery [3]. Therefore, here we report here a novel adjunct technique in which the use of an ultrastiff guidewire improves access to the terminal ileum, thereby facilitating safe and precise endoscopic resection, particularly in the terminal ileum ([Video 1]).

Guidewire-assisted endoscopic mucosal resection of a fully circumferential large, nonpedunculated colorectal polyp of the ileocecal valve with terminal ileal extension.Video 1

A 73-year-old man was referred for resection of a 60-mm Paris 0–IIa, nongranular, fully circumferential ICV lesion with ileal extension. EMR was challenging due to the lesion location and difficult access ([Fig. 1] a, b). Conventional maneuvers such as transabdominal pressure and position change did not improve visualization. The ileal extent of the lesion could not be accurately determined, nor could the ileum be sufficiently maneuvered. An ultrastiff guidewire was therefore passed through the scope into the ileum. This opened the terminal ileum significantly and allowed access to accurately visualize the extent of the lesion and provide a greater working field ([Fig. 1] c). Safe and precise sequential EMR was made possible and furthermore facilitated effective margin thermal ablation, and defect assessment to rule out deep mural injury ([Fig. 1] d). There were no complications from the procedure, and the histology returned a diagnosis of tubular adenoma with low-grade dysplasia ([Video 1]).

Fig. 1 a Endoscopic view of the 60-mm, fully circumferential Paris 0–IIa, nongranular ileocecal valve lesion. b Access into the terminal ileum was difficult. c Access improved with the insertion of an ultrastiff guidewire. d Endoscopic appearance after resection and margin thermal ablation.

We demonstrate a novel technique of how a through-the-scope ultrastiff guidewire can effectively facilitate EMR of difficult ICV lesions, particularly in those extending into the terminal ileum.

Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AD

• References

• 1 Nanda KS, Tutticci N, Burgess NG. et al. Endoscopic mucosal resection of laterally spreading lesions involving the ileocecal valve: technique, risk factors for failure, and outcomes. Endoscopy 2015; 47: 710-718
• 2 Ponugoti PL, Broadley HM, Garcia J. et al. Endoscopic management of large ileocecal valve lesions over an 18-year interval. Endosc Int Open 2019; 7: E1646-1651
• 3 Vosko S, Gupta S, Shahidi N. et al. Impact of technical innovations in EMR in the treatment of large nonpedunculated polyps involving the ileocecal valve (with video). Gastrointest Endosc 2021; 94: 959-968.e2