VIDEOGIE Todd H. Baron, MD, G. S. Raju, MD, Editors for VideoGIE
Large superficial tumor of the colon involving a diverticulum removed by endoscopic submucosal dissection
Figure 1. A, B, Large superficial tumor, a laterally spreading tumor, in the ascending colon with a diverticulum in the middle of the tumor. C, Modified SO clip, consisting of a metallic clip attached by a nylon thread to the edge of a 5-mm rubber strip ring, which is connected to a nylon loop at the other end. D, The use of the traction device, a modified Sakamoto-Osada (SO) clip, resulted in improved exposure of the cutting line. The subperitoneal tissue was visualized at the bottom of the diverticulum. E, Resected specimen of tumor 32 30 mm. F, Pathologic view of tubular adenoma, with margin free of tumor tissue (H&E, orig. mag. 40).
Endoscopic submucosal dissection (ESD) is effective for removing large superficial tumors throughout the colorectum and unusual sites such as within the appendix or sites that involve the ileocecal valve. We report the first case of a large superficial colonic tumor involving a diverticulum successfully treated by ESD. A 67-year-old woman had several diverticula in the ascending colon and a large superficial tumor extending in part inside a diverticulum in the middle of the tumor (Fig. 1 A, B). After we lifted the tumor by submucosal injection, the surrounding mucosa was incised with a DualKnife (Olympus America, Center Valley, Pa), followed by submucosal dissection extending to near the diverticulum. These steps were repeated from the anal side of the tumor. The submucosal vascularization around the diverticulum was very rich, making the procedure more difficult. For dissection inside the diverticulum, a traction device, the modified SO clip (Fig. 1 C, D), pulled the tumor toward the opposite colonic wall, improving exposure of the cutting line (Video 1, available online at www.giejournal. org). Subsequently, submucosal dissection was done
www.giejournal.org
carefully with a hook knife until subperitoneal tissue was visualized at the bottom of the diverticulum (Fig. 1E). After en bloc resection, the artificial ulcer including the diverticulum was closed with clips. The postoperative course was uneventful, and pathologic examination revealed a tubular adenoma (Fig. 1F). DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Hideaki Ritsuno, MD, PhD, Naoto Sakamoto, MD, PhD, Taro Osada, MD, PhD, Shingo P. Goto, MD, PhD, Sumio Watanabe, MD, PhD, Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
http://dx.doi.org/10.1016/j.gie.2015.05.002
Volume
-,
No.
-
: 2015 GASTROINTESTINAL ENDOSCOPY 1
Large superficial tumor of the colon involving a diverticulum removed by endoscopic submucosal dissection
Figure 1. A, B, Large superficial tumor, a laterally spreading tumor, in the ascending colon with a diverticulum in the middle of the tumor. C, Modified SO clip, consisting of a metallic clip attached by a nylon thread to the edge of a 5-mm rubber strip ring, which is connected to a nylon loop at the other end. D, The use of the traction device, a modified Sakamoto-Osada (SO) clip, resulted in improved exposure of the cutting line. The subperitoneal tissue was visualized at the bottom of the diverticulum. E, Resected specimen of tumor 32 30 mm. F, Pathologic view of tubular adenoma, with margin free of tumor tissue (H&E, orig. mag. 40).
Endoscopic submucosal dissection (ESD) is effective for removing large superficial tumors throughout the colorectum and unusual sites such as within the appendix or sites that involve the ileocecal valve. We report the first case of a large superficial colonic tumor involving a diverticulum successfully treated by ESD. A 67-year-old woman had several diverticula in the ascending colon and a large superficial tumor extending in part inside a diverticulum in the middle of the tumor (Fig. 1 A, B). After we lifted the tumor by submucosal injection, the surrounding mucosa was incised with a DualKnife (Olympus America, Center Valley, Pa), followed by submucosal dissection extending to near the diverticulum. These steps were repeated from the anal side of the tumor. The submucosal vascularization around the diverticulum was very rich, making the procedure more difficult. For dissection inside the diverticulum, a traction device, the modified SO clip (Fig. 1 C, D), pulled the tumor toward the opposite colonic wall, improving exposure of the cutting line (Video 1, available online at www.giejournal. org). Subsequently, submucosal dissection was done
www.giejournal.org
carefully with a hook knife until subperitoneal tissue was visualized at the bottom of the diverticulum (Fig. 1E). After en bloc resection, the artificial ulcer including the diverticulum was closed with clips. The postoperative course was uneventful, and pathologic examination revealed a tubular adenoma (Fig. 1F). DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Hideaki Ritsuno, MD, PhD, Naoto Sakamoto, MD, PhD, Taro Osada, MD, PhD, Shingo P. Goto, MD, PhD, Sumio Watanabe, MD, PhD, Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
http://dx.doi.org/10.1016/j.gie.2015.05.002
Volume
-,
No.
-
: 2015 GASTROINTESTINAL ENDOSCOPY 1
