The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection

Swan, Michael P.; Bourke, Michael J.; Moss, Alan; Williams, Stephen J.; Hopper, Andrew D; Metz, Andrew J.

doi:10.1016/j.gie.2010.07.003

Cited by 144 publications

(88 citation statements)

References 23 publications

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“…Caputi et al (5) reported in their series 2.3% of perforation after EMR (all polypoid carcinomas). Swan et al (45) described a target sign as a marker of muscularis propria resection and, therefore, potential perforation during EMR of colorectal lesions, with an incidence of 3.8% for en bloc resection and 1.6% for piecemeal resection (P = 0.16). Prompt recognition of this sign allows immediate closure with endoscopic clips.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas

Santos¹,

Malaman²,

Pereira-Lima

2011

Arq. Gastroenterol.

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-Context -Endoscopic mucosal resection is a minimally invasive technique used in the treatment of colorectal neoplasms, including early carcinomas of different size and morphology. Objectives -To evaluate procedure safety, efficacy, outcomes, and recurrence rate in endoscopic mucosal resection of colorectal lesions. Methods -A total of 172 lesions in 156 patients were analyzed between May 2003 and May 2009. All lesions showed pit pattern suggestive of neoplasia (Kudo types III-V) at high-magnification chromocolonoscopy with indigo carmine. The lesions were evaluated for macroscopic classification, size, location, and histopathology. Lesions 20 mm or smaller were resected en bloc and lesions larger than 20 mm were removed using the piecemeal technique.Complications and recurrence were analyzed. Patients were followed up for 18 months. Results -There were 83 (48.2%) superficial lesions, 57 (33.1%) depressed lesions, 44 (25.6%) laterally spreading tumors, and 45 (26.2%) protruding lesions. Mean lesion size was 11.5 mm ± 9.6 mm (2 mm-60 mm). Patients' mean age was 61.6 ± 12.5 years (34-93 years). Regarding lesion site, 24 (14.0%) lesions were located in the rectum, 68 (39.5%) in the left colon, and 80 (46.5%) in the right colon (transverse, ascending, and cecum). There were 167 (97.1%) neoplasms: 142 (82.5%) adenomatous lesions, 24 (14.0%) intramucosal carcinomas, and 1 (0.6%) invasive carcinoma. En bloc resection was performed in 158 (91.9%) cases and piecemeal resection in 14 (8.1%). Bleeding occurred in 5 (2.9%) cases. Recurrence was observed in 4.1% (5/122) of cases and was associated with lesions larger than 20 mm (P<0.01), piecemeal resection (P<0.01), advanced neoplasm (P = 0.01), and carcinoma compared to adenoma (P = 0.04). Conclusions -Endoscopic mucosal resection of colorectal lesions is a safe and effective procedure, with low complication and local recurrence rates. Recurrence is associated with lesions larger than 20 mm and carcinomas.

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Section: Discussionmentioning

confidence: 99%

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas

Santos¹,

Malaman²,

Pereira-Lima

2011

Arq. Gastroenterol.

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“…Initially, we did not realize that the whole layer had been resected, as the resection defect was blue in color. However, as a few whitish bundles mimicking the MP were detected above the blue layer, we carefully studied the underside of the resected specimen immediately and found the so-called target sign that suggested MP resection and potential perforation [4]. Therefore, we concluded that the blue layer below the MP (''mirror target sign'') had been created by unplanned injection of solution into the serosal rather than the submucosal layer.…”

Section: Discussionmentioning

confidence: 98%

Endoscopic full-thickness resection of a lateral spreading rectal tumor after unplanned injection of dilute hyaluronic acid into the subserosal layer (with video)

Kaneko

Konuma

et al. 2012

Tech Coloproctol

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A 74-year-old woman underwent colonoscopy for investigation of a liver tumor. A lateral spreading tumor of the non-granular type (LST-NG), 25 mm in diameter, was detected at the rectosigmoid junction. As magnifying image-enhanced colonoscopy suggested a tubulovillous adenoma, endoscopic mucosal resection (EMR) was chosen for removal of the LST-NG. The lesion was effectively and evenly lifted after injection of 0.4% hyaluronic acid diluted with glycerol in the ratio of 1:1. A small amount of indigo-carmine dye was also added for coloration of the plane of resection. The lesion was completely removed en bloc. Although a blue-colored layer was identified in the resection defect, a small amount of a whitish layer was detected above the blue layer. The muscle layer was clearly located on the underside of the resected polyp. A total of 14 endoclips were used to close the defect completely. The patient was successfully treated conservatively without surgery. Histology of the resected specimen showed that it contained a tubulovillous adenoma with the submucosal layer and both layers of the muscularis propria. The surgical margin was free of neoplastic change horizontally and vertically. To the best of our knowledge, this is the first case report of full-thickness resection associated with EMR after unplanned injection of dilute hyaluronic acid into the subserosal layer rather than the intended submucosal layer. We describe how to promptly recognize this complication during colonoscopy, in order to achieve immediate closure of the defect, with the identification of a "mirror target sign" on the colonic wall.

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“…Perforation after EMR of colonic lesions is also rare (<1%) [16,17,87,88]. A perforation can be identified by carefully examining the resection defect.…”

Section: Complicationsmentioning

confidence: 99%

“…A perforation can be identified by carefully examining the resection defect. Small perforations recognized during the procedure can be successfully sealed by using endoscopic clips [88,89]. Larger perforations may require urgent salvage surgery to prevent peritonitis.…”

Section: Complicationsmentioning

confidence: 99%

Endoscopic Resection Techniques

Hoffman¹,

Heesen²,

Kollmar³

et al. 2017

Visc Med

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The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection

Cited by 144 publications

References 23 publications

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas

Endoscopic full-thickness resection of a lateral spreading rectal tumor after unplanned injection of dilute hyaluronic acid into the subserosal layer (with video)

Endoscopic Resection Techniques

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