Kenichiro Imai, MD, from the Division of Endoscopy, Shizuoka Cancer Center, in Shizuoka, Japan presents this video case, “Pre-cutting endoscopic mucosal resection for cecal tumors extending to the appendiceal orifice.”
We demonstrate a pre-cutting EMR technique for a cecal tumor extending to the appendiceal orifice (CTAO). A 65-year-old-woman was referred to our hospital because of previous endoscopic resection failure due to poor lifting of the lesion. Colonoscopy showed a sessile, 20mm cecal polyp extending to the orifice. By magnified endoscopy, we diagnosed it as an adenoma. Thus, EMR was indicated. The lesion margin at the orifice could be seen, however, complete en bloc removal by conventional snare EMR method considered difficult due to the narrow lumen at the orifice. Therefore, we decided to perform mucosal incision at the orifice to assure the appropriate resection margin.
A successful submucosal injection of glycerol solution enabled to expose the tumor margin. One-third circumferential mucosal incision around the orifice was completed with a snare tip using cut current. Snare tip was set into the mucosal incision at the nearest site to the appendix and snare was positioned around the lesion along the mucosal incision. EMR achieved complete R0 resection with no perforation. Histology revealed a tubular adenoma with high-grade dysplasia with negative margins.
Endoscopic resection for CTAOs is considered challenging because the narrow lumen hampers a clear observation of the tumor margin. In addition, salvage endoscopic treatment for residual adenomas at the appendiceal orifice may be more difficult due to the increased narrowing of the lumen by scarring after initial resection. When recurrences can not be controlled by repeated salvage endoscopic treatments, surgery is sometimes needed. Therefore, R0 resection is desirable at the initial resection. Pre-cutting technique with snare tip is convenient using common accessories and a potentially effective modification for improved R0 resection.
En bloc resection is essential for complete tumor removal. In general, the main cause of resection failure in conventional EMR method was uncertain resection line by possible snare slippage due to difficult location, large tumor size, or poor lifting. Pre-cutting EMR technique enables flexible setting of resection line during mucosal incision procedure under the direct vision, led to assure the appropriate resection margin. This case shows that pre-cutting technique is a potential solution for R0 resection for CTAOs.
CTAOs may be difficult for endoscopic resection due to characterized anatomical features; poor visualization by the narrow lumen, risk of perforation because of thin muscular layer, and possible poor lifting by obscure muscularis mucosa around the appendix. However, outcomes of endoscopic resection have not been reported. To determine the indications and limitations of endoscopic treatments for CTAOs is crucial for development of further advanced techniques.
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