Endoscopic submucosal dissection in management of colorectal tumors near or involving a diverticulum: a retrospective case series

Abstract

Background and study aims Surgery is the standard treatment for colon tumors associated with diverticulum. Use of endoscopic submucosal dissection (ESD) to treat such tumors is controversial. The aim of this study was to assess the safety and feasibility of ESD in treating superficial colorectal tumors situated near or involving diverticulum. Patients and methods Consecutive patients from two referral centers who had colorectal tumors near or involving diverticulum treated by ESD were retrospectively studied. Clinicopathological characteristics and clinical outcomes were analyzed. Results Of the 12 patients studied, six had tumors near diverticulum and six had tumors involving diverticulum. The overall en-bloc R0 resection rate, median tumor size and procedure time were 67 %, 26.5 mm (range, 15 – 80 mm) and 110 minutes (range, 50 – 220 minutes), respectively. For tumors near diverticulum group, the en-bloc R0 resection rate was 100 % and no adverse events (AEs) or residual/recurrent tumors were observed. In contrast, for intradiverticular tumors group, the en-bloc R0 resection rate was low at 33 %, and one AE (perforation) was observed. The diverticula were ≥ 6 mm in diameter in the patients with incomplete resection. However, all but one diverticulum was unrecognized before ESD. Two residual tumors were detected at the 12-month surveillance and one required surgery. Conclusions This case series indicates that ESD is safe and feasible for treating colorectal tumors near a diverticulum and might be feasible for tumors involving a diverticulum smaller than 6 mm. Selection for smaller diverticulum size may contribute to higher en-bloc R0 resection rates.

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

“…In our opinion, accidental intramuscular injection may also allow snaring of the muscularis propria of the lesion even with water immersion. Although ESD or endoscopic full-thickness resection with an over-the-scope clip device [ 11 , 12 ] enables complete resection of superficial colonic lesions extending into a diverticulum, it is still challenging, time consuming and expensive. Some recently introduced traction devices facilitate ESD of the lesions [ 13 - 15 ].…”

Endoscopic Management of a Tubulovillous Adenoma Within a Diverticulum: Report of a Case and Review of Literature

“…Generally, EMR and endoscopic resection of banded tissues are considered challenging in cases of diverticula-associated CRN due to the increased risk of perforation secondary to the lack of a muscular layer [4,11,12]. On the other hand, ESD safety and feasibility has been demonstrated for these particular lesions in a more recent retrospective case series by Jimenez-Garcia et al with better en block resection rates for tumors located near a diverticulum than those extending into the diverticulum [7].…”

“…These lesions pose a technical challenge for endoscopic management given their difficult location inside the diverticulum and the greater risk of perforation upon endoscopic resection owing to the lack of the muscular layer within the diverticulum [ 4 - 6 ]. Therefore, surgery is considered the standard treatment for colorectal neoplasia (CRN) associated with a diverticulum [ 7 ].…”

“…Endoscopic techniques for resection of tumors arising in a diverticulum have been proposed in the literature as less-invasive approaches [ 7 - 9 ]. However, the evidence supporting this approach remains modest and controversial.…”

Successful endoscopic submucosal dissection for a tumor located completely within a colonic diverticulum after inversion of the diverticulum using a traction device

“…Safely performing ESD for lesions involving a diverticulum is technically very challenging, not least because of the high risk of perforation owing to the absence of a muscle layer in a diverticulum. 2 , 3 In addition, it is difficult to recognize the dissection line in the deeper parts of a diverticulum, which often results in incomplete resection. Therefore, it is difficult to achieve en bloc resection of a lesion involving a colonic diverticulum by ESD without adverse events, unless performed by very highly skilled endoscopists; therefore, until recently, surgical treatment was the most commonly adopted treatment strategy for these lesions, even if the lesions would otherwise have been expected to be resectable endoscopically.…”