Post written by Takashi Muramoto, MD, PhD, from the Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan.

We presented endoscopic submucosal dissection (ESD) for a tumor located completely within a colonic diverticulum using a traction device in the video. The lesion was a flat-elevated tumor completely located within a colonic diverticulum in the hepatic flexure, measuring 10 mm in diameter. Based on endoscopic evaluation, since we made it possible to invert the diverticulum into the colonic lumen by traction with forceps, we scheduled ESD using a traction device under general anesthesia. After reconfirming that the diverticulum could be inverted into the lumen with forceps, the first endoclip grasping a ring-thread made of dental floss was fixed on the mucosa in the diverticulum. Immediately after, a second endoclip was used to grasp the ring-thread and fixed to the opposite colonic wall. By insufflating the air, the lesion within the inverted diverticulum was pulled out of the diverticulum into the colonic lumen, establishing a good field of view for dissection. After local injection of hyaluronic acid, a circumferential incision and dissection were performed using DualKnife (Olympus, Tokyo, Japan), and the lesion was promptly removed en bloc. The wound was completely closed with endoclips along with the diverticulum. The total procedure time was 10 minutes, and there were no adverse events. Histological examination of the resected lesion revealed a low-grade adenoma, and curative resection had been achieved.

It is difficult to achieve en bloc resection of a lesion involving a colonic diverticulum by ESD without adverse events, except by very highly skilled endoscopists. Therefore, until recently, surgical treatment was the most commonly adopted treatment strategy for these lesions, even if the lesions would otherwise have been expected to be resectable endoscopically. However, in the present case, we used the traction technique first to invert the diverticulum into the colonic lumen, which allowed a good field of view to be established for easy recognition of the dissection line, and the lesion could be removed rapidly and safely. This is the first case in which ESD was performed after inverting the entire diverticulum into the lumen using the traction technique.

By first using a traction device to invert the diverticulum containing the lesion into the colonic lumen, the tumor completely located within the diverticula was successfully resected by ESD. Our technique has the potential to be one of the minimally invasive treatment options for a tumor located completely within a colonic diverticulum, for which endoscopic treatment is technically challenging.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.