Mucosal carcinoma arising in a colon diverticulum: endoscopic submucosal dissection using the novel “clip-band-tent” traction method
Year: 2025
Type: article
Study design: Case Report
Abstract: Endoscopic submucosal dissection (ESD) may be considered challenging for treating a colonic tumor involving a diverticulum [ 1 ] or having tattoo-induced fibrotic submucosal [ 2 ]. Here, we report a case of a laterally spreading tumor (LST) tattooed arising from a colonic diverticulum resected by saline immersion ESD ([ Video 1 ]). A 83-year-old woman with a previous left hemicolectomy for sigmoid adenocarcinoma was referred to our hospital for an organ-sparing approach. On endoscopic examination, in the ascending colon, a lesion with granular nodular mixed LST morphology was detected inside of a diverticulum which was completely involved ([ Fig. 1 ]). Surface pattern evaluation classified this lesion as JNET2A according to the Japan NBI Expert Team classification. We performed the technique with the following steps ([ Fig. 2 ]): circumferential mucosal incision using the ERBEJET hydrodissection system (Erbe), which allowed the diverticulum to be released from the tattoo-induced fibrotic wall ([ Fig. 3 ]); the “clip-band-tent” traction method was used as a variant of the clip-band technique [ 3 ] for the eversion of the diverticulum, stabilizing the submucosal layer view and providing adequate tension, which allowed better recognition of the dissection line ([ Fig. 4 ]); we easily identified the fibrotic submucosal layer using immersion in saline solution and the clip-flap traction method [ 4 ], which enabled precise dissection using the T-type HybridKnife in probe mode [ 5 ] and a VIO 3 unit set at preciseSECT mode (Erbe) with a narrow safety margin. En bloc resection was achieved without any adverse events ([ Fig. 5 ]) and the diverticular orifice and mucosal defect were closed using resolution clips (Boston Scientific). The patient was discharged 24 hours after ESD. Histopathological examination showed a well-differentiated adenocarcinoma confined to the mucosal layer and free lateral and vertical resection margins. Fig. 1 Endoscopic image showing a laterally spreading granular-type tumor in the ascending colon arising from the base of the diverticulum with evidence of a previous endoscopic tattoo around it. Surface pattern evaluation classified this lesion as JNET2A according to the Japan NBI Expert Team classification. Fig. 2 Graphical representation of endoscopic submucosal dissection with the “clip-band-tent” traction method for eversion of the diverticulum: a illustration of the laterally spreading granular-type tumor arising from the base of the diverticulum and endoscopic tattoo around it; b circumferential mucosal incision; c the “clip-band-tent” traction method is used as a variant of the clip-band technique for the eversion of diverticulum; d the clip-flap traction method is used facilitating submucosal layer visualization during saline immersion dissection. Fig. 3 a Endoscopic image showing a circumferential mucosal incision T-type Hybridknife using an ERBEJET hydrodissection system, which allowed the diverticulum to be released from the tattoo-induced fibrotic wall. b The defect of the muscularis propria at the diverticulum is indicated with yellow arrows. Fig. 4 Endoscopic image showing an optimal eversion of the diverticulum by the “clip-band-tent” traction method. Fig. 5 Macroscopic appearance of the resected specimen. Quality: mobile 360 480 720 Download Large superficial tumor of the colon involving a diverticulum removed by endoscopic submucosal dissection using the novel “clip-band-tent” traction method and T-type Hybridknife used in probe mode.Video 1 The “clip-band-tent” traction method could be a promising variant of traction-assisted ESD for lesions involving a diverticulum as it significantly facilitates the precision of the technique. Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AD Endoscopy E-Videos https://eref.thieme.de/e-videos E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos . Publication History Article published online: 06 May 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany
Source: Endoscopy
DOI: 10.1055/a-2584-1414
Institutions: Universidad San Pablo CEU, HM Hospitales
Language: English
Subfield: Oncology
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4410108996