ENDOSCOPIC EN BLOC MUCOSAL RESECTION OF LARGE FLAT CAECAL ADENOMA

Aim:

Videocase describes a 61-year-old woman with granular homogenous laterally spreading caecal tumor (LST-GH), size 40 × 30 mm, which was curatively treated by en bloc endoscopic mucosal resection (EMR) technique. Is not primarily designed technique for such large lesions.

Methods:

Colonoscope CF-HQ190L (Olympus Europe, Hamburg, Germany) was used. The patient underwent a standard preparation (Vistaprep, Tillots Pharma) in split dosing. Procedure was performed in analgosedation. White light and narrow band imaging (NBI) were used to evaluate the lesion, which belonged to the NICE type 2 (NBI-International-Colorectal-Endoscopic) classification. The en bloc EMR was performed by the lift and cut technique. A solution of patent blue diluted with adrenaline (1:20.000) was used for the submucosal injection. The lesion was removed with a SnareMaster SD-230U polypectomic snare by using an ESG-100 electrocoagulation unit (Olympus) in the Pulse Cut Slow Level 120 W.

Results:

We performed an en bloc endoscopic mucosal resection of large LST (40 × 30 mm). Resulting histology was the adenoma with low grade intraepitelial neoplasia (LGIN). Despite of its size, the lesion was resected curatively (R0 resection) without peri- or postprocedural complication and without local residual neoplasia 3 moths after the procedure.

Conclusion:

It is generally assumed that flat lesions ≤20 mm should be removed en bloc by endoscopic mucosal resection technique. For lesions > 20 mm, piecemeal EMR (EPMR) or endoscopic submucosal dissection (ESD) is recommended. However, our case shows that even lesions of 40 mm size can be also curatively resected en bloc. After using methylene blue and diluted adrenaline for injection the lesion becomes blue. Adrenaline causes fading of surrounding tissue and the edges of the lesion are much better visible than without adrenaline. Mucosal fading is more appropriate than labeling the lesion edges with coagulation markers. The whole lesion can be better captured inside the snare.