Endoscopic submucosal dissection of a large cecal polyp involving the ileocecal valve and the terminal ileum.

Abstract

An 83-year-old man with no significant medical history was referred for endoscopic submucosal dissection (ESD) of a large cecal polyp involving the ileocecal valve and the terminal ileum ([Fig. 1 a]). The strategy of dissection included the creation of a flap at the ileal side, clip and band countertraction [1], and creation of a pocket [2] ([Video 1]). The lesion was lifted with a mixture of hydroxyethyl starch and indigo carmine. An initial incision was performed inside the terminal ileum with a DualKnife 1.5 mm (Olympus, Japan) ([Fig. 1 b]). The presence of fat in this area slowed down the dissection speed and obscured visibility. Progressively a flap was created underneath the lesion. Countertraction was applied using clips and an attached rubber band ([Fig. 1 c]), providing further access to the dissection plane. Step by step, a tunnel was created along the axis of the polyp. The tunnel was then enlarged on both sides to create a pocket ([Fig. 1 d]). After half of the lesion had been dissected, additional counteraction was provided in a similar fashion to modify the axis of dissection. In addition, dissection with an IT knife (Olympus) under saline was performed in areas with suboptimal lifting from the muscularis propria [3]. The lesion was removed en bloc, after detachment with a loop cutter ([Fig. 1 e]). The procedure lasted 4 hours and was uneventful. Pathology revealed a 6-cm tubulovillous adenoma with low grade dysplasia, and confirmed an R0 resection.