Underwater endoscopic mucosal resection for complete R0 removal of a residual adenoma at a perforated scar in a patient with colostomy

Abstract

Endoscopic mucosal resection (EMR) of residual polyps is technically challenging, as submucosal fibrosis from the initial resection makes it difficult to lift the lesion during submucosal injection and to snare the entire tumor [1]. Endoscopic submucosal dissection (ESD) enables complete removal of such residual polyps [2] but presents some technical difficulties and is time-consuming [3]. An 82-year-old man with permanent sigmoidostomy was referred to our unit because of a residual polyp in the descending colon, seen at the 18-month surveillance test after EMR at another hospital. Perforation had occurred during EMR, and clip closure had been performed. Colonoscopy through the sigmoidostomy showed a 12-mm polyp surrounded by multiple widespread scars on the dorsal side 20 cm proximal to the colostomy (▶ Fig. 1). The lesion was diagnosed as an adenoma (▶ Fig. 2 a, b). Complete removal by ESD was considered difficult [4]. First, there was the possibility of severe and widespread submucosal fibrosis because of multiple deep ulcer scars. Second, traction would have to be limited, since it is difficult to change the po-E122 Hosotani Kazuya et al. Underwater EMR for R0 removal of a residual adenoma at a perforated scar … Endoscopy 2017; 49: E121-E122 E-Videos This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Underwater endoscopic mucosal resection for complete R0 removal of colorectal polyp in a patient with ulcerative colitis

“…However, UEMR eliminates the need for submucosal injection. The "floating" and "heat-sink" effects facilitate the grasping and removal of large or scarred polyps [5]. This is the first case to demonstrate the usefulness of UEMR for the management of superficial colorectal neoplasia in patients with ulcerative colitis.…”

Quality of endoscopy reporting at index colonoscopy significantly impacts outcome of subsequent EMR in patients with > 20 mm colon polyps

“…EMR was abandoned in 21 patients with benign polyps owing to extensive polyp tethering 21 . Although novel techniques such as two-stage resection, endoscopic submucosal dissection (ESD), underwater EMR, and full-thickness colon resection may serve as options for managing patients with polyps tethered to the colon wall, submucosal fibrosis increases complications and failure rate 22 23 24 25 26 27 28 29 30 . In our own practice, we are able to remove polyps that have limited tethering to the underlying wall using a combination of underwater EMR and hot biopsy avulsion, but could not remove polyps with extensive and deep tethering.…”

Underwater endoscopic mucosal resection for colorectal lesions: Can it be an “Underwater” revolution?

“…Four case reports described UEMR for lesions accompanied by a scar. 51 , 52 , 53 , 54 Although this advantage of UEMR was already described in retrospective analyses, the technique and efficacy are worthy of publication as case reports for provision of information because these lesions are difficult to remove using conventional procedures like CEMR or ESD. Two other case reports described UEMR in patients with ulcerative colitis.…”