Underwater EMR of a colonic adenoma surrounded by diverticula.

Abstract

An 83-year-old man with positive fecal occult blood test results underwent colonoscopy, which revealed a 15-mm-diameter laterally spreading tumor surrounded by multiple diverticula at the ascending colon (Figs. 1 and 2). The lesion was a nongranular-type laterally spreading tumor, and the Japanese Narrow-Band Imaging Expert Team classification was type 2A, meaning no evidence of invasion; therefore, we performed endoscopic resection instead of surgery.Figure 2Endoscopic image showing the tumor well demarcated with indigo carmine.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Conventional EMR of the tumor surrounded by diverticula with the use of submucosal saline solution injection would have been difficult because the appropriate lifting up by submucosal injection is difficult, and snaring including adjacent diverticula would have resulted in perforations. Furthermore, endoscopic submucosal dissection (ESD) for tumors adjacent to diverticula carries a high risk of perforation, and performing ESD on such lesions demands highly advanced skills, although we have reported success with the use of ESD for colonic polyps involving a diverticulum.1Shichijo S. Matsuno K. Takeuchi Y. et al.Pulley traction-assisted colonic endoscopic submucosal dissection affords good visibility of submucosal layer.VideoGIE. 2018; 3: 358-360Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,2Shichijo 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 Underwater EMR was developed and described by Binmoeller et al3Binmoeller K.F. Weilert F. Shah J. et al."Underwater" EMR without submucosal injection for large sessile colorectal polyps (with video).Gastrointest Endosc. 2012; 75: 1086-1091Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar in 2012. We previously reported the usefulness of this procedure with a high en bloc resection rate for intermediate-sized colorectal polyps4Yamashina T. Uedo N. Akasaka T. et al.Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps.Gastroenterology. 2019; 157: 451-461.e2Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar; therefore, we performed underwater EMR for this lesion (Video 1, available online at www.VideoGIE.org). We here report the first case, to our knowledge, of a colonic adenoma surrounded by diverticula treated with underwater EMR. We used a magnifying colonoscope (Evis PCF-Q260ZAI; Olympus Medical Systems, Tokyo, Japan). Air was evacuated from the affected segment of the lumen and infused water until the lumen was completely full, after which we performed hot-snare polypectomy without submucosal injection, using a SnareMaster (15 mm; Olympus Medical Systems) (Fig. 3). A high-frequency electrical generator (Vio 300D; Erbe Elektromedizin, Tübingen, Germany) was used with the following settings: endocut Q mode: effect 3, duration 2, interval 4. We resected the lesion en bloc in 2 minutes without perforation and completely closed the mucosal defect with clips (Figs. 4 and 5). No adverse events occurred, and the patient experienced no postoperative abdominal pain or fever requiring antibiotics. On pathologic examination, the lesion was a tubular adenoma, high-grade in part, with negative margins (Fig. 6).Figure 4Endoscopic image showing completed underwater EMR.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Endoscopic image showing complete closure of the defect with clips.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Photograph of the specimen after it was resected en bloc in 2 minutes.View Large Image Figure ViewerDownload Hi-res image Download (PPT) All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjOWE4NzBhZThjMTAyNjRmNTMyMWUzMThjM2U0OTJhNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MDA4Njc1fQ.ojSWMYGdEpn8sb_Vue33TsVsQk4sx0xrnjsYhN0e_DMlvnvbvi5PS7yv2mRUWzp3aWHkwZ4DJoK_nBNhCPKTdkB4F-kWgbyJUoHLKX-Wmq3WgmsVAB7rESbsA-KJA1m88IGz7HnhNTBBdva_Y-l26Ngn1miP5yyC9XT5ZVGfCjWvecCVo_hEJW_mHgjtsoOZ7OPrY-u8tb-Xx4tDpXt02RazLx4tDvP4H2nsA00kITkefKFvNuW-xE7zwOvGY82EkSh-eF7LSqwaA-uLhLrVmQb-OqrnZzW2Nxnbn-qa2NBulHuER2Ie6ppmB_x4TSRdEXfxLjxmy7Soh5Bp0OQrOA Download .mp4 (31.25 MB) Help with .mp4 files Video 1Underwater EMR of the colonic adenoma surrounded by diverticula.