Clin Endosc.  2021 May;54(3):436-440. 10.5946/ce.2020.168.

Underwater Endoscopic Mucosal Resection without Submucosal Injection Facilitates En bloc Resection of Colon Adenomas Extending into a Diverticulum

• Hayashi Y
• Okada M
• Morikawa T
• Nomura T
• Fukuda H
• Takezawa T
• Lefor AK
• Yamamoto H

• KMID: 2516326
• DOI: http://doi.org/10.5946/ce.2020.168

Abstract

Superficial colonic neoplasms sometimes extend into a diverticulum. Conventional endoscopic mucosal resection of these lesions is considered challenging because colonic diverticula do not have a muscularis propria and are deeply inverted. Even if the solution is carefully injected below the mucosa at the bottom of the diverticulum, the mucosa is rarely elevated from the diverticular orifice, and it is usually just narrowed. Although endoscopic submucosal dissection or full-thickness resection with an over-the-scope clip device enables the complete resection of these lesions, it is still challenging, time consuming and expensive. Underwater endoscopic mucosal resection without submucosal injection (UEMR) is an innovative technique enabling en bloc resection of superficial colon lesions. We report three patients with colon adenomas extending into a diverticulum treated with successful UEMR. UEMR enabled rapid and safe en bloc resection of colon lesions extending into a diverticulum.

Keyword

Colonic diverticulum; Colonic neoplasm; Underwater endoscopic mucosal resection

Figure

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  Fig. 1. Underwater endoscopic mucosal resection without submucosal injection of a lesion in the cecum. (A) A 1.5-cm flat lesion in the cecum. (B) This lesion extended into a diverticulum. (C) The border of the lesion in the diverticulum was identified using water immersion. (D) The snare tip was anchored outside the lesion in the diverticulum. (E) The entire lesion was snared and cut using pure-cut mode diathermy. (F) The mucosal defect without any residual lesion was closed with hemoclips. Histology of the resected specimen showed an adenoma with negative resection margins.

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  Fig. 2. Underwater endoscopic mucosal resection without submucosal injection of the lesion in the ascending colon. (A) A 1.5-cm flat lesion in the ascending colon. (B) This lesion extended into a diverticulum. (C) Lesion demarcation in the diverticulum was done after everting the lesion with edge of a distal cap after water immersion. (D) The snare tip was placed outside the lesion in the diverticulum. (E) The entire lesion was snared and cut using pure-cut mode diathermy. (F) The mucosal defect without any residual lesion was closed using a reopenable clip with an 11-mm opening width (SureClip; Micro-Tech, Nanjing, China). Histology of the resected specimen showed an adenoma with negative resection margins.

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  Fig. 3. Underwater endoscopic mucosal resection without submucosal injection of the lesion in the ascending colon. (A) A 2-cm flat lesion in the ascending colon. (B) This lesion extended into a diverticulum. (C) Lesion demarcation in the diverticulum was done after water immersion. (D) The snare tip was placed outside the lesion in the diverticulum. The entire lesion was snared and cut using pure-cut mode diathermy. (E) The mucosal defect without any residual lesion. (F) The defect was completely closed with hemoclips while maintaining water immersion. Histology of the resected specimen showed an adenoma with negative resection margins.

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