Underwater endoscopic submucosal dissection of a non-granular laterally spreading tumor of the hepatic flexure

A 68-year-old man was referred to our hospital for endoscopic treatment of a nongranular pseudodepressed laterally spreading tumor (LST) of the hepatic flexure with a histological diagnosis of adenocarcinoma discovered in another center and for which he refused surgery.

At the endoscopic examination, using blue light imaging and linked color imaging (Fujifilm, Valhalla, New York, USA), we observed a nongranular LST with features suggestive of deep submucosal invasion (central depression and Vi pattern according to Kudo classification) ([Fig. 1]). An underwater endoscopic submucosal dissection was performed ([Video 1]).

Fig. 1 Nongranular laterally spreading tumor of the hepatic flexure.

Video 1 Underwater endoscopic submucosal dissection of a nongranular laterally spreading tumor of the hepatic flexure.

The procedure was carried out using a T-type HybridKnife (Erbe, Tübingen, Germany). To start, an incision was made on the anal side; then the colon was filled with saline, and an underwater submucosal pocket was created under the lesion ([Fig. 2]). Finally, the circumferential incision was complete and the tumor was removed en bloc. In the end, the muscular layer was clear, without any defects or exposed vessels ([Fig. 3]). The procedure was completed without any adverse events and the patient was discharged the day after.

Fig. 2 Submucosal layer exposed during underwater dissection.

Fig. 3 Result of the resection.

The resected specimen ([Fig. 4]) showed an adenocarcinoma arising in a tubulovillous adenoma, 35 × 30 mm in size, with poorly differentiated clusters, infiltration of the submucosa layer (2200 microns), clear margins, aspects of lymphovascular invasion, and low-grade budding. To check for high-risk features of metastatic disease, an abdominal computed tomography was performed and did not show any metastasis. The patient was resent to surgery, which he again refused.

Fig. 4 Resected specimen of the nongranular laterally spreading tumor.

Our case shows that underwater submucosal dissection is safe and effective for complete resection of colic neoplasia [1] [2] even when the submucosal layer is involved.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Nagata M. Usefulness of underwater endoscopic submucosal dissection in saline solution with a monopolar knife for colorectal tumors (with videos). Gastrointest Endosc 2018; 87: 1345-1353
• 2 Yoshii S, Akasaka T, Hayashi Y. et al. “Underwater” endoscopic submucosal dissection: a novel method for resection in saline with a bipolar needle knife for colorectal epithelial neoplasia. Surg Endosc 2018; 32: 5031-5036

Publication History

Article published online:
06 May 2020