Gastrointestinal: Additional working channel-assisted endoscopic mucosal resection (EMR+): A novel tool for en bloc resection of colorectal lesions

Abstract

A 75-year-old patient was referred for resection of tattoo-marked colorectal lesions. For an obvious massively submucosally invasive sigmoid lesion, surgery was recommended (operative pathology confirmed sm3-invasion). The transverse colon lesion was characterized as a laterally spreading tumor of non-granular type with pseudodepression (LST-NG/PD) estimated at 20 mm (Fig. 1a). With high rates of advanced neoplasia, en bloc resection is generally recommended owing to high inherent risks of technical piecemeal and incomplete resections related to endoscopic mucosal resection. To this end, we mounted a novel accessory endoscopic resection device, the Additional Working Channel (AWC, Ovesco, Tübingen, Germany), onto the scope's tip to perform what has been designated endoscopic mucosal resection plus (EMR+). A 30-mm snare was introduced through the working channel after standard submucosal injection and an anchor through the AWC instrumental for triangulation within the operative field (Fig. 1b). Next, the lesion was snared after mobilization and confirmation of adequate margins (Fig. 1c). Reassuringly enough and unexpectedly, final pathology revealed only low-grade intraepithelial neoplasia with wide R0 margin status. While piecemeal endoscopic mucosal resections are still considered standard in the resection of colorectal lesions in most Western endoscopy services, technological and technical advancements in endoscopy such as EMR+ to safely perform rapid and easy-to-achieve en bloc resections represent a definitive future goal to this end.