The Mettle to Use the Petals: Using Over-the-Scope Rings to Optimize Endoscopic Submucosal Dissection
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STANFORD MULTIDISCIPLINARY SEMINARS
The Mettle to Use the Petals: Using Over‑the‑Scope Rings to Optimize Endoscopic Submucosal Dissection Mike T. Wei1,2 · George Triadafilopoulos1 · Shai Friedland1,2 Accepted: 28 August 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Keywords Endoscopic submucosal dissection · Colonoscope stabilization · Pleated rings · Colonoscope attachments Abbreviations AC Ascending colon AdenoCA Adenocarcinoma AO Appendiceal orifice BMI Body mass index DC Descending colon EMR Endoscopic mucosal resection ESD Endoscopic submucosal dissection FUSE Full spectrum endoscopy HF Hepatic flexure HGD High-grade dysplasia ICV Ileocecal valve IQR Interquartile range LGD Low-grade dysplasia sm1 First submucosal layer SSP Sessile serrated polyp TA Tubular adenoma VA Villous adenoma TC Transverse colon TI Terminal ileum
No financial support was given for this study. * Mike T. Wei [email protected] George Triadafilopoulos [email protected] Shai Friedland [email protected] 1
Division of Gastroenterology and Hepatology, Stanford University Medical Center, 300 Pasteur Drive, Palo Alto, CA 94305, USA
Veterans Affairs Palo Alto, Palo Alto, CA, USA
2
Case Presentation and Evolution A 62-year-old female with history of uncontrolled hypertension, diabetes, and chronic kidney disease was seen at an outpatient facility for screening colonoscopy. On review of systems, she denied abdominal pain, nausea or vomiting, change in bowel habits, or weight changes. She mentioned a family history of colorectal cancer in her paternal grandmother, though we do not have the age at diagnosis. During the initial colonoscopy, a 10-mm pedunculated ascending colon adenomatous polyp was identified and removed by hot snare. Moreover, there was also a depressed 20-mm lesion in the ascending colon that was not removed or biopsied in order to avoid inducing fibrosis. The patient was referred to Stanford for endoscopic treatment. Six weeks later, the patient underwent colonoscopy for consideration of endoscopic submucosal dissection (ESD). The patient received monitored anesthesia care and had perfect Boston Bowel Preparation Scale of 9. For the procedure, a pleated ring was placed at the 15cm mark of the Olympus PCF colonoscope (Fig. 1), and the other was placed at the distal tip of the colonoscope, just behind a transparent cap [1]. On examination, the cecum was normal. The 20-mm polyp was depressed, consistent with a Paris IIc classification [2]. The surface appearance was concerning for early cancer (classification 2B of Japan Narrow Band Imaging Expert Team) (Fig. 2). In preparation for ESD, 15mL of hetastarch combined with diluted indigo carmine and epinephrine was injected with modest lift of the lesion from the muscularis propria. A partial circumferential incision around the lesion into the submucosa was performed using a DualKnife-J™ (Olympus, Tokyo, Japan). The lesion was then dissected from the underlying deep layers with the electrocautery knife, and the mucosal incisio
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