Colorectal endoscopic submucosal dissection using the water pressure method for diverticulum-associated lesions: A case series study (with video)

Abstract

Background and study aims Colorectal endoscopic submucosal dissection (ESD) of diverticulum-associated lesions is challenging because these lesions require precise excision in narrow spaces. The water pressure method (WPM) uses active water pressure by the waterjet function under saline solution-filled conditions. This study aimed to determine the feasibility of WPM for resection of diverticulum-associated lesions.

Patients and methods This was a retrospective, observational case series study. We reviewed diverticulum-associated lesions treated by ESD with WPM at our institution between June 2017 and July 2021. Diverticulum-associated lesions were classified as follows: type 1, lesions in contact with or within 3 mm of the edge of a diverticulum; type 2, lesions that partially infiltrated the interior of a diverticulum; and type 3, lesions that infiltrated the interior of and completely covered the diverticulum. We collected data on the clinical characteristics and outcomes of the lesions.

Results Seven diverticulum-associated lesions were treated with ESD using WPM. The median lesion size was 37 mm (interquartile range: 25–54 mm). There were three cases of type 1, three cases of type 2, and one case of type 3. Three lesions were resected circumventing the diverticulum, and four lesions involved resection of the diverticulum. The en bloc resection and R0 resection rates were 86 %. One patient had severe fibrosis, which caused perforation, and in another patient, the diverticulum was too deep and narrow to be completely isolated.

Conclusions WPM allowed for precise procedures in the diverticulum. The feasibility of WPM has been suggested for diverticulum-associated lesions, although cases have been complex.

• References

• 1 Tanaka S, Kashida H, Saito Y. et al. Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2020; 32: 219-239
• 2 Camilleri M, Sandler RS, Peery AF. Etiopathogenetic mechanisms in diverticular disease of the colon. Cell Mol Gastroenterol Hepatol 2020; 9: 15-32
• 3 Yahagi N, Nishizawa T, Sasaki M. et al. Water pressure method for duodenal endoscopic submucosal dissection. Endoscopy 2017; 49: E227-E228
• 4 Yoshii S, Hayashi Y, Matsui T. et al. “Underwater” endoscopic submucosal dissection: a novel technique for complete resection of a rectal neuroendocrine tumor. Endoscopy 2016; 48: E67-E68
• 5 Kato M, Takatori Y, Sasaki M. et al. Water pressure method for duodenal endoscopic submucosal dissection (with video). Gastrointest Endosc 2021; 93: 942-949
• 6 Masunaga T, Kato M, Yahagi N. Successful endoscopic submucosal dissection using the water pressure method for cervical esophageal cancer. Dig Endosc 2021;
• 7 Jimenez-Garcia VA, Yamada M, Ikematsu H. et al. Endoscopic submucosal dissection in management of colorectal tumors near or involving a diverticulum: a retrospective case series. Endosc Int Open 2019; 7: E664-E671
• 8 Muramoto T, Ohata K, Sakai E. et al. Endoscopic submucosal dissection for colorectal neoplasms in proximity or extending to a diverticulum. Surg Endosc 2021; 35: 3479-3487
• 9 Watanabe T, Muro K, Ajioka Y. et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2016 for the treatment of colorectal cancer. Int J Clin Oncol 2018; 23: 1-34
• 10 Bosman FTCF, Hruban RH, Theise ND. WHO classification of tumours of the digestive system. 4th edn. Lyon: IARC Press; 2010
• 11 Matsumoto A, Tanaka S, Oba S. et al. Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scand J Gastroenterol 2010; 45: 1329-1337
• 12 Nomura S, Shimura T, Katano T. et al. A multicenter, single-blind randomized controlled trial of endoscopic clipping closure for preventing coagulation syndrome after colorectal endoscopic submucosal dissection. Gastrointest Endosc 2020; 91: 859-867.e851
• 13 Nagata N, Niikura R, Aoki T. et al. Increase in colonic diverticulosis and diverticular hemorrhage in an aging society: lessons from a 9-year colonoscopic study of 28,192 patients in Japan. Int J Colorectal Dis 2014; 29: 379-385
• 14 Yamamichi N, Shimamoto T, Takahashi Y. et al. Trend and risk factors of diverticulosis in Japan: age, gender, and lifestyle/metabolic-related factors may cooperatively affect on the colorectal diverticula formation. PLoS One 2015; 10: e0123688
• 15 Fu KI, Hamahata Y, Tsujinaka Y. Early colon cancer within a diverticulum treated by magnifying chromoendoscopy and laparoscopy. World J Gastroenterol 2010; 16: 1545-1547
• 16 Valli PV, Kaufmann M, Vrugt B. et al. Endoscopic resection of a diverticulum-arisen colonic adenoma using a full-thickness resection device. Gastroenterology 2014; 147: 969-971
• 17 Schmidt A, Bauerfeind P, Gubler C. et al. Endoscopic full-thickness resection in the colorectum with a novel over-the-scope device: first experience. Endoscopy 2015; 47: 719-725
• 18 Shakhatreh MH, Hair C, Shaib YH. et al. Removal of a colonic polyp in a diverticulum: a novel use of the over-the-scope clip device. Gastrointest Endosc 2015; 81: 756
• 19 Andrisani G, Pizzicannella M, Martino M. et al. Endoscopic full-thickness resection of superficial colorectal neoplasms using a new over-the-scope clip system: A single-centre study. Dig Liver Dis 2017; 49: 1009-1013
• 20 Schmidt A, Beyna T, Schumacher B. et al. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut 2018; 67: 1280-1289
• 21 Hawa F, Al Hillan A, Catanzaro AT. et al. Endoscopic management of a tubulovillous adenoma within a diverticulum: report of a case and review of literature. Cureus 2020; 12: e8668
• 22 Boger P, Rahman I, Hu M. et al. Endoscopic full thickness resection in the colo-rectum: outcomes from the UK Registry. Eur J Gastroenterol Hepatol 2021; 33: 852-858
• 23 Okimoto K, Matsumura T, Akizue N. et al. Endoscopic band ligation for the removal of colonic polyp invading the diverticulum. Endoscopy 2022;
• 24 Iwatsubo T, Uedo N, Yamasaki Y. et al. Traction-assisted colorectal endoscopic submucosal dissection by use of clip and line for a neoplasm involving colonic diverticulum. VideoGIE 2017; 2: 337-338
• 25 Shichijo S, Yamasaki Y, Takeuchi Y. Case of colonic adenoma involving a diverticulum resected by a traction-assisted endoscopic submucosal dissection technique. Dig Endosc 2017; 29: 729-730
• 26 Yamaguchi H, Fukuzawa M, Kawai T. et al. “Pulley type” countertraction for colonic endoscopic submucosal dissection of laterally spreading tumors involving a diverticulum. Endosc Int Open 2020; 8: E1183-E1184
• 27 Chou CK, Wu CC, Chang MC. et al. Rubber band-clip traction can facilitate colonic endoscopic submucosal dissection of a laterally spreading tumour involving the caecal diverticulum – a video vignette. Colorectal Dis 2021; 23: 2203
• 28 Yoshikawa T, Yamauchi A, Yazumi S. Successful endoscopic submucosal dissection of a laterally spreading tumor involving a diverticulum assisted by a traction device. Dig Endosc 2021; 34: e15-e16
• 29 Lambin T, Jacques J, Rivory J. et al. Endoscopic submucosal dissection of a laterally spreading tumor involving a colonic diverticulum using the counter-traction technique. Endoscopy 2022; 54: E34-E35
• 30 Masunaga T, Kato M, Sasaki M. et al. Feasibility of endoscopic resection for large pedunculated duodenal lesions (with video). Surg Endosc 2022; 36: 3637-3644
• 31 Harada H, Nakahara R, Murakami D. et al. Saline-pocket endoscopic submucosal dissection for superficial colorectal neoplasms: a randomized controlled trial (with video). Gastrointest Endosc 2019; 90: 278-287
• 32 Tamegai Y, Fukunaga Y, Suzuki S. et al. Laparoscopic and endoscopic cooperative surgery (LECS) to overcome the limitations of endoscopic resection for colorectal tumors. Endosc Int Open 2018; 6: E1477-E1485