New inversion method: endoscopic submucosal dissection of a neoplasm extending into a colonic diverticulum Article Swipe

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Jun Arimoto , Hideyuki Chiba , Jun Tachikawa , Tohru Goto , Atsushi Nakajima · YOU? · · 2019 · Open Access · · DOI: https://doi.org/10.1016/j.vgie.2019.01.006

Endoscopic submucosal dissection (ESD) is an excellent treatment for superficial colorectal neoplasms because it allows en bloc resection, regardless of the lesion size.1Tamegai Y. Saito Y. Masaki N. et al.Endoscopic submucosal dissection: a safe technique for colorectal tumors.Endoscopy. 2007; 39: 418-422Crossref PubMed Scopus (221) Google Scholar, 2Tanaka S. Terasaki M. Hayashi N. et al.Warning for unprincipled colorectal endoscopic submucosal dissection: accurate diagnosis and reasonable treatment strategy.Dig Endosc. 2013; 25: 107-116Crossref PubMed Scopus (73) Google Scholar However, conventional ESD of a neoplasm involving a colonic diverticulum is difficult because the diverticular wall lacks a muscularis propria. We sometimes observe inversion of a diverticulum because of the effect of suction during colonoscopy. Therefore, we have developed a new technique, inversion ESD (ivESD), for lesions extending into a diverticulum. A 76-year-old man had a 20-mm neoplasm in the ascending colon that extended into a diverticulum (Fig. 1). The procedure was performed with the patient under general anesthesia with a PCF-290HT (Olympus, Tokyo, Japan), and the tissue dissection was performed with a Dual knife (Olympus). First, we performed multiple suctions in the area of the diverticulum until all of the lesion was completely inverted (Video 1, available online at www.VideoGIE.org). After injection of the solution (a mixture of 0.4% sodium hyaluronate [Muco UpR; Boston Scientific Japan, Tokyo, Japan] and indigo carmine with diluted epinephrine) into the submucosa of the diverticulum, a mucosal incision was started at the diverticulum side (proximal side). The diverticulum inversion enabled good visibility of the entire lesion. The lesion was resected en bloc within 14 minutes without adverse events (Fig. 2). Oral feeding was started on day 2, and the patient was discharged on day 5. Histologic examination revealed a carcinoma-in-adenoma (tub 1, pTis, ly0, v0, pHM0, pVM0) and curative resection.Figure 2Inversion of the diverticulum allowed good visibility of the entire lesion. A, Mucosal incision was started at the diverticulum side (proximal side). B, Wound after endoscopic submucosal dissection, showing a defect in the muscularis propria at the diverticulum (black arrows). C, The wound, including the defect in the muscularis propria, was completely closed with clips.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Some reports have been published on traction-assisted ESD for lesions extending into a diverticulum3Satoki S. Yamasaki Y. Takeuchi Y. Case of colonic adenoma involving a diverticulum resected by a traction-assisted endoscopic submucosal dissection technique.Dig Endosc. 2017; 29: 729-730Crossref PubMed Scopus (17) Google Scholar, 4Iwatsubo T. Uedo N. Yamasaki Y. et al.Traction-assisted colorectal endoscopic submucosal dissection by use of clip and line for a neoplasm involving colonic diverticulum.VideoGIE. 2017; 2: 337Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar; however, the traction method is sometimes complicated, and the attachment of clips takes time. The ivESD requires only a small amount of suction and is very simple; therefore, ESD was completed within a short time. This is the first report of ivESD. It may not be possible to invert all diverticula, and traction-assisted ESD may also be attempted in such cases. However, it may be desirable to attempt ivESD whether or not inversion of the diverticulum is possible. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3NGEwMWQ2MjIyYTkzY2U1N2ZlYTMxZWE3NDBkMjQ4MSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NTgwMzU4fQ.lqqoPAI2w3xN6ah2ldAauQoOCEwVlrC0rS9m0CqzyITYl8laVcGUJquP0LGmre3ic-3M6xI5eJWlLGlgKczbR7hFA4alkW559PGhjPJ5sXQkCgVfcb2gmwYGHtm44MBWCfuVo7IfTaoczGY4HTzdVaLApv5wnoWerdxm2qox4fCewOFqAZqSw7_Uiv7Yv97HeOQMlWpcZIcph06B4gOL1af5r_FzSWN0iul-r9tFz0P6_VoYV2bXfPl1G_V_o9BFlDkTQvREFYqSCTbmPvcuvRmg70giLgjxM_j-oUgYAPkmsRkfvU_XXId15iLBMX6Bs-MMqlLqWvqnMzmgszi9rg Download .mp4 (49.19 MB) Help with .mp4 files Video 1We inverted the diverticulum by colonoscopic suction. Inversion of the diverticulum allowed good visibility of the entire lesion. The specimen was resected en bloc without adverse events.

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en

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https://doi.org/10.1016/j.vgie.2019.01.006

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https://doi.org/10.1016/j.vgie.2019.01.006

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New inversion method: endoscopic submucosal dissection of a neoplasm extending into a colonic diverticulum

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article

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en

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2019

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2019-03-12

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Jun Arimoto, Hideyuki Chiba, Jun Tachikawa, Tohru Goto, Atsushi Nakajima

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https://doi.org/10.1016/j.vgie.2019.01.006

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https://www.videogie.org/article/S2468448119300190/pdf

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Medicine, Ascending colon, Submucosa, Colonoscopy, Diverticulum (mollusc), Dissection (medical), Radiology, Surgery, Colorectal cancer, Internal medicine, Cancer

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3

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