A peripheral approach allowing successful endoscopic...
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PICTURES IN DIGESTIVE PATHOLOGY 1130-0108/2015/107/6/378-379 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS COPYRIGHT © 2015 ARÁN EDICIONES, S. L. REV ESP ENFERM DIG (Madrid Vol. 107, N.º 6, pp. 378-379, 2015 A peripheral approach allowing successful endoscopic submucosal dissection for early colorectal carcinoma near the diverticula Hideki Kobara 1 , Hirohito Mori 1 , Kazi Rafiq 2 , Shintaro Fujihara 1 and Tsutomu Masaki 1 1 Department of Gastroenterology and Neurology. 2 Department of Pharmacology. Faculty of Medicine. Kagawa University. Kagawa, Japan CASE REPORT An 86-year-old man presented with a positive fecal occult blood test. Colonoscopy revealed a 25-mm laterally spreading tumor near the diverticula located in the ascending colon (Fig. 1). Magnifying endoscopy indicated a carcinoma with adenoma, suggesting that en bloc resection by endoscopic submucosal dissection (ESD) would be optimal. In designing a strategy for this lesion, the most important issue was marginal cutting near the diverticula for complete resection without adverse events. Informed consent was received from the patient. Firstly, a small incision was made on the peripheral mucosa near the diverticula to clearly identify the submucosa, followed by submucosal injection of 0.4% hyaluronate sodium solution (MucoUp; Johnson & Johnson K.K., Tokyo, Japan) with a nee- dle knife (KD-441Q; Olympus, Tokyo, Japan). The mucosa nearest to diverticula was dissected using the needle knife from the peripheral mucosa toward the side of diverticula, resulting in safe and complete marginal cutting of the mucosa near the diverticula (Fig. 2), and followed by standard colorectal ESD. The entire dissected surface, including the diverticula, was sutured with hemoclips to prevent late complications. Histolog- ical examination revealed a curative resection of a carcinoma with adenoma. The patient was hospitalized for 1 week without associated complications and showed excellent postoperative outcomes. DISCUSSION ESD is a standard therapeutic procedure for early colorectal carcinoma (1). However, various factors make en bloc resection for colorectal tumors difficult or unsafe (2). Accordingly, it is unclear whether ESD is the appropriate treatment for early col- orectal carcinoma near or within the diverticula (3). Complete full-thickness dissection, a novel type of surgery using laparo- scopic and endoscopic techniques, may be adaptable for colorec- tal tumors within the diverticula (4). Our findings suggest that the peripheral approach is safe and effective for early colorectal carcinoma near the diverticula. Fig. 1. Endoscopic finding revealing a 25-mm laterally spreading tumor near the diverticula. Fig. 2. First step of a peripheral approach: A small incision was made on the peripheral mucosa near the diverticula to clearly identify the submucosa. Fig. 3. Second step of a peripheral approach: The mucosa nearest to the diverticula (red arrows) was dissected using the needle knife from the peripheral mucosa toward the side of diverticula (blue arrow).
Transcript of A peripheral approach allowing successful endoscopic...
PICTURES IN DIGESTIVE PATHOLOGY
1130-0108/2015/107/6/378-379Revista española de enfeRmedades digestivasCopyRight © 2015 aRán ediCiones, s. l.
Rev esp enfeRm dig (MadridVol. 107, N.º 6, pp. 378-379, 2015
A peripheral approach allowing successful endoscopic submucosal dissection for early colorectal carcinoma near the diverticulaHideki Kobara1, Hirohito Mori1, Kazi Rafiq2, Shintaro Fujihara1 and Tsutomu Masaki1
1Department of Gastroenterology and Neurology. 2Department of Pharmacology. Faculty of Medicine. Kagawa University. Kagawa, Japan
CASE REPORT
An 86-year-old man presented with a positive fecal occult blood test. Colonoscopy revealed a 25-mm laterally spreading tumor near the diverticula located in the ascending colon (Fig. 1). Magnifying endoscopy indicated a carcinoma with adenoma, suggesting that en bloc resection by endoscopic submucosal dissection (ESD) would be optimal. In designing a strategy for this lesion, the most important issue was marginal cutting near the diverticula for complete resection without adverse events. Informed consent was received from the patient.
Firstly, a small incision was made on the peripheral mucosa near the diverticula to clearly identify the submucosa, followed by submucosal injection of 0.4% hyaluronate sodium solution (MucoUp; Johnson & Johnson K.K., Tokyo, Japan) with a nee-dle knife (KD-441Q; Olympus, Tokyo, Japan). The mucosa nearest to diverticula was dissected using the needle knife from the peripheral mucosa toward the side of diverticula, resulting in safe and complete marginal cutting of the mucosa near the diverticula (Fig. 2), and followed by standard colorectal ESD.
The entire dissected surface, including the diverticula, was sutured with hemoclips to prevent late complications. Histolog-ical examination revealed a curative resection of a carcinoma with adenoma. The patient was hospitalized for 1 week without associated complications and showed excellent postoperative outcomes.
DISCUSSION
ESD is a standard therapeutic procedure for early colorectal carcinoma (1). However, various factors make en bloc resection for colorectal tumors difficult or unsafe (2). Accordingly, it is unclear whether ESD is the appropriate treatment for early col-orectal carcinoma near or within the diverticula (3). Complete full-thickness dissection, a novel type of surgery using laparo-scopic and endoscopic techniques, may be adaptable for colorec-tal tumors within the diverticula (4). Our findings suggest that the peripheral approach is safe and effective for early colorectal carcinoma near the diverticula.
Fig. 1. Endoscopic finding revealing a 25-mm laterally spreading tumor near the diverticula.
Fig. 2. First step of a peripheral approach: A small incision was made on the peripheral mucosa near the diverticula to clearly identify the submucosa.
Fig. 3. Second step of a peripheral approach: The mucosa nearest to the diverticula (red arrows) was dissected using the needle knife from the peripheral mucosa toward the side of diverticula (blue arrow).
Vol. 107, N.º 6, 2015 A PERIPHERAL APPROACH ALLOWING SUCCESSFUL ENDOSCOPIC SUBMUCOSAL DISSECTION 379 FOR EARLY COLORECTAL CARCINOMA NEAR THE DIVERTICULA
Rev esp enfeRm Dig 2015; 107 (6): 378-379
REFERENCES
1. Tanaka S, Tamegai Y, Tsuda S, et al. Multicenter questionnaire survey on the current situation of colorectal endoscopic submucosal dissection in Japan. Dig Endosc 2010;22:S2-8.
2. Takeda T, Murakami T, Sakamoto N, et al. Traction device to remove an adenoma in the appendiceal orifice by endoscopic submucosal dis-section. Endoscopy 2013;45:E239-40.
3. Gotoda T, Takenaka R, Inokuchi T, et al. Endoscopic submucosal dis-section for a superficial esophageal squamous cell carcinoma within the parabronchial diverticula. Dig Endosc 2013;25:91-2.
4. Fukunaga Y, Tamegai Y, Chino A, et al. New technique of en bloc resection of colorectal tumor using laparoscopy and endoscopy cooper-atively (laparoscopy and endoscopy cooperative surgery - colorectal). Dis Colon Rectum 2014;57:267-71.
Fig. 4. Endoscopic finding showing successful and safe dissection of the mucosa near the diverticula (blue arrow).
Fig. 5. Endoscopic finding showing the progress of standard colorectal endoscopic submucosal dissection.
Fig. 6. Macroscopic finding showing en bloc resection for the colorectal tumor, resulting in a curative resection of a carcinoma with adenoma.
