1886 Endoscopic Management of Tubulovillous Adenoma Within a Diverticulum: Report of a Case and Review of Literature

Abstract

INTRODUCTION: Colonic polyps within a diverticulum are technically challenging to resect as the polyp might be difficult to access if it is buried within the diverticulum. There is also an increased risk of perforation upon endoscopic resection owing to the lack of muscularis propria in the wall of the diverticulum. We describe an endoscopic technique for management of a rare case of tubulovillous adenoma within a diverticulum with review of literature. CASE DESCRIPTION/METHODS: A 74-year-old male underwent screening colonoscopy which identified a 15 mm polyp within a sigmoid colon diverticulum. Attempted resection was unsuccessful despite sub-mucosal injection with saline and the use of multiple snares. Therefore, the endoscopist elected to use a variceal band ligator. The polyp was then suctioned into the band ligator cap and 2 bands were deployed which exposed a clearly defined 15 mm polyp. This was followed by endoscopic resection using hot snare polypectomy. Histopathology revealed a tubulovillous adenoma. Inspection of the resection site demonstrated a 3 mm perforation which was closed using 4 endoscopic clips. The patient was admitted overnight for observation and was discharged the following day without complications. DISCUSSION: Colonic polyps within a diverticulum are technically challenging to resect given that the majority of the polyp might be buried within the diverticulum. Suction over the polyp using a variceal banding device and deploying bands across the base was an effective method for exposing and resecting the entire polyp in this case. However, it was complicated by a small iatrogenic perforation likely due to the lack of a muscularis propria within the wall of the diverticulum. Review of literature revealed three other cases which reported endoscopic management of colonic polyps within a diverticulum. Two of the cases utilized an over the scope clip at the base of the suctioned polyp prior to resection with a hot snare to reduce the risk of iatrogenic perforation. The third case allowed for natural sloughing of the polyp to occur without tissue retrieval as a result of tissue ischemia from the band. In conclusion, colonic polyps within a diverticulum can be successfully removed by using a band ligator and/or over the scope clip to isolate the polyp. The polyp can then be resected using hot snare polypectomy to ensure tissue retrieval. However, an over the scope clip should be used prophylactically to prevent a perforation or a perforation can be closed with endoscopic clips.