PICTURES IN DIGESTIVE PATHOLOGY

 

Successful balloon overtube-guided colorectal endoscopic submucosal dissection by a gastroscope

 

 

Enrique Pérez-Cuadrado-Robles¹, Masayoshi Yamada² and Yutaka Saito²

¹ Small Bowel Unit. Department of Gastroenterology. Hospital Morales Meseguer. Murcia, Spain.
² Endoscopy Division. National Cancer Center Hospital. Tokyo, Japan

 

 

Case Report

An 80-year-old woman was diagnosed of a 10 cm colorectal laterally spreading tumor granular-type in the splenic flexure (Fig. 1). Endoscopic submucosal dissection (ESD) was performed but pediatric colonoscope approach (PCF-Q260JI, Olympus, Japan) was technically difficult due to the narrow transverse colon working space. Then, single-balloon endoscopy system using a 3.2 mm channel gastroscope (GIF-Q260J, Olympus, Japan) (total length: 1,350 mm, outer diameter: 9.9 mm) and a 770 mm balloon overtube (outer/inner diameter: 16.2/13.8 mm) (ST-CB1, Olympus, Japan) was carried out. The balloon was inflated near the distal tumor location and a traction clip attached by a nylon line was effectively used. Finally, en-bloc resection with tumor-free lateral/vertical margins was successfully achieved in 150 minutes without complication (Fig. 2). Histopathological examination confirmed intramucosal well-differentiated tubular adenocarcinoma without angiolymphatic invasion.

 

 

 

Discussion

Colorectal ESD can achieve en-bloc resection (1). However, cecum, hepatic and splenic flexures are difficult locations because of unstable scope maneuvers and narrow working space. In these cases, balloon overtube-guided ESD may confer a better approach, improving the access to the lesion and scope manoeuvres (2). This overtube has a large outer diameter and enables the use of a therapeutic gastroscope. The procedure can also facilitate traction-assisted techniques allowing a high-rate of en-bloc resections (3). In addition, large specimens can be easily retrieved through (4).

Thus, several combinations with different scopes and balloon overtubes for colorectal ESD have been described to date (5). In addition, a 3.2 mm double-balloon colonoscope may be other option for deep colon ESD but this scope is rarely accessible in Western countries. Outer/inner diameter, overtube length, tumor characteristics and local experience are decisive factors to choose the endoscopic approach. However, enteroscopy overtubes are too long and not suitable for most ESD procedures. Then, in our opinion, a balloon-guided therapeutic gastroscope is a good choice for ESD, particularly in deep colon. A short overtube specifically designed is necessary.

 

References

1. Saito Y, Uraoka T, Yamaguchi Y, et al. A prospective, multicenter study of 1,111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 2010;72:1217-25. DOI: 10.1016/j.gie.2010.08.004.         [ Links ]

2. Ohya T, Ohata K, Sumiyama K, et al. Balloon overtube-guided colorectal endoscopic submucosal dissection. World J Gastroenterol 2009;28;15:6086-90. DOI: 10.3748/wjg.15.6086.         [ Links ]

3. Okamoto K, Muguruma N, Kitamura S, et al. A new large-diameter overtube for endoscopic submucosal dissection in the colon. Endoscopy 2012;44:E395-E396. DOI: 10.1055/s-0032-1310249.         [ Links ]

4. Ikehara H, Saito Y, Uraoka T, et al. Specimen retrieval method using a sliding overtube for large colorectal neoplasm following endoscopic submucosal dissection. Endoscopy 2015;47:E168-9. DOI: 10.1055/s-0034-1391496.         [ Links ]

5. Okamoto K, Muguruma N, Kitamura S, et al. Endoscopic submucosal dissection for large colorectal tumors using a cross-counter technique and a novel large-diameter balloon overtube. Dig Endosc 2012;24(Suppl. 1):96-9. DOI: 10.1111/j.1443-1661.2012.01264.x.         [ Links ]