1130-0108/2016/108/5/280-281Revista española de enfeRmedades digestivasCopyRight © 2016 aRán ediCiones, s. l.

Rev esp enfeRm dig (Madrid)Vol. 108, N.º 5, pp. 280-281, 2016

PICTURES IN DIGESTIVE PATHOLOGYPICTURES IN DIGESTIVE PATHOLOGY

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 dissec-tion (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,

Successful balloon overtube-guided colorectal endoscopic submucosal dissection by a gastroscopeEnrique Pérez-Cuadrado-Robles1, Masayoshi Yamada2 and Yutaka Saito2

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

Fig. 1. A. CT-colonography image of a colorectal tumor in the splenic flexure. B. A 10 cm lateral spreading granular-type tumor was detec-ted by white light colonoscopy (white arrows define the lesion limits). C. Image after spraying with indigo carmine dye. The lesion involved three-quarters of the circumference. D. Magnifying chromoendoscopy with crystal violet confirmed Kudo’s type IV pit pattern indicating intra-mucosal neoplasm.

Fig. 2. A gastroscope preloaded into the ST-CB1 balloon overtube. B. The scope with short-type ST hood (Fuji Film, Japan) is loaded into the overtube. The hood, the overtube and the tumor are indicated by arrows from right to left. C. Post-ESD scar after en-bloc resection. D. The resec-ted specimen was divided into 40 sections and the final pathological diagnosis was intramucosal cancer with free margins.

en-bloc resection with tumor-free lateral/vertical margins was successfully achieved in 150 minutes without compli-cation (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-as-

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Vol. 108, N.º 5, 2016 SUCCESSFUL BALLOON OVERTUBE-GUIDED COLORECTAL ENDOSCOPIC SUBMUCOSAL DISSECTION BY A GASTROSCOPE 281

Rev esp enfeRm Dig 2016; 108 (5): 280-281

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

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

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

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

5. Okamoto K, Muguruma N, Kitamura S, et al. Endoscopic submu-cosal 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

sisted 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 colono-scope 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.