Feasibility and safety of endoscopic submucosal dissection for lesions in proximity to a colonic diverticulum

Abstract

Background/aims: Endoscopic submucosal dissection (ESD) for diverticulum-associated colorectal lesions is generally contraindicated because of the high risk of perforation. Several studies on patients with such lesions treated with ESD have been reported recently. However, the feasibility and safety of ESD for lesions in proximity to a colonic diverticulum (D-ESD) have not been fully clarified. The aim of this study was to evaluate the feasibility and safety of D-ESD.

Methods: D-ESD was defined as ESD for lesions within approximately 3 mm of a diverticulum. Twenty-six consecutive patients who underwent D-ESD were included. Two strategic approaches were used depending on whether submucosal dissection of the diverticulum-related part was required (strategy B) or not (strategy A). Treatment outcomes and adverse events associated with each strategy were analyzed.

Results: The en bloc resection rate was 96.2%. The rates of R0 and curative resection in strategies A and B were 80.8%, 73.1%, 84.6%, and 70.6%, respectively. Two cases of intraoperative perforation and one case of delayed perforation occurred. The delayed perforation case required emergency surgery, but the other cases were managed conservatively.

Conclusion: D-ESD may be a feasible treatment option. However, it should be performed in a high-volume center by expert hands because it requires highly skilled endoscopic techniques.

Keywords: Colonic diverticulum; Colorectal neoplasms; Endoscopic submucosal dissection; Feasibility; Pocket creation method.

Fig. 1.

Classification according to the association between a lesion and a diverticulum. (A) Type 0: a lesion within 3 mm of the diverticulum border. However, a normal mucosa intervens between the diverticulum and the lesion. (B) Type 1: a lesion reaches the border of the diverticulum but does not involve the orifice of the diverticulum. (C) Type 2: a lesion reaches and partially involves the orifice of the diverticulum. (D) Type 3: a lesion completely covers the orifice of the diverticulum. In some cases, the presence of a diverticulum cannot be recognized preoperatively.

Fig. 2.

Strategic approach for endoscopic submucosal dissection of lesions in proximity to a colonic diverticulum. Strategy A for type 0 and some type 1 and type 3 lesions. (1) A semi-circumferential mucosal incision was made between the lesion and the diverticulum or from the anal side of the lesion. (2) Submucosal dissection was performed on the anal side towards the oral side. (3) A circumferential incision and submucosal dissection were performed in the remaining parts. Dot circle, diverticulum; red line, mucosal incision; blue arrow, submucosal dissection.

Fig. 3.

Strategic approach for endoscopic submucosal dissection of lesions in proximity to a colonic diverticulum. Strategy B for type 2 lesions and some type 1 and type 3 lesions. (1) A semi-circumferential mucosal incision was made from the anal side of the lesion. (2) Submucosal dissection was performed, and double pockets were made on both sides of the diverticulum towards the oral side. (3) Submucosal dissection around the diverticulum was performed maximally to expose the diverticulum under the lesion. Mucosae on both lateral sides were left at this time (yellow line). (4) Dissection of the diverticulum was performed carefully using the tapping technique, and the remaining mucosal incision was then completed. Dot circle, diverticulum; red line, mucosal incision; blue arrow, submucosal dissection.