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A novel technique of endoscopic submucosal dissection for circumferential ileocecal valve adenomas with terminal ileum involvement: the “doughnut resection” (with videos)

  • Krishna C. Gurram
  • Erin Ly
  • Xiaocen Zhang
  • Rani Modayil
  • Kanak Das
  • Daryl Ramai
  • Sagarika Nithyanand
  • Shriya Bhumi
  • Sivaram Neppala
  • Harika Boinpally
  • Stavros StavropoulosEmail author
Dynamic Manuscript
  • 36 Downloads

Abstract

Background

Ileocecal valve (ICV) lesions are difficult to resect endoscopically and patients are often referred for laparoscopic colectomy. ICV involvement has been shown to be related to technical failure and tumor recurrence after endoscopic mucosal resection (EMR) and represents a challenge for endoscopic submucosal dissection (ESD). Few publications have focused specifically on endoscopic management of ICV lesions.

Methods

We developed a novel ESD technique, the “doughnut resection,” for circumferential ICV adenomas with terminal ileum involvement. Two circumferential mucosal incisions are performed, one in the ileum and the other in the cecum, followed by submucosal dissection of the disk of tissue between the two incisions around a guiding stent placed across the valve that helps guide the dissection as it crosses the valve orifice. The lesion is removed en bloc in the shape of a “doughnut” with two concentric assessable lateral margins. The underwater ESD technique and a gastroscope were used to facilitate the resection.

Results

Seven patients received the doughnut resection. The median patient age was 67 years. All patients had prior biopsy and three had prior endoscopic resection (1–6 times). The median specimen diameter was 4.5 cm (range 3–8). All resections were en bloc and R0. There was no perforation, delayed bleeding, or other clinically significant adverse events. After a median follow-up of 21 months (range 12–32), there was no tumor recurrence.

Conclusion

The “doughnut resection” is a feasible, safe, and effective method to remove circumferential ICV lesions endoscopically even for patients with multiple prior tumor manipulations.

Keywords

Endoscopic submucosal dissection Endoscopic mucosal resection Colon adenoma Ileocecal valve 

Abbreviations

ESD

Endoscopic submucosal dissection

EMR

Endoscopic mucosal resection

ICV

Ileocecal valve

TI

Terminal ileum

Notes

Compliance with ethical standards

Disclosures

Dr. Stavros Stavropoulos is a consultant for Boston Scientific and Olympus and receives an honorarium from ERBE USA. Dr. Krishna C. Gurram, Erin Ly, Xiaocen Zhang, Rani Modayil, Kanak Das, Daryl Ramai, Sagarika Nithyanand, Shriya Bhumi, Sivaram Neppala, and Harika Boinpally have no conflicts of interest or financial ties to disclose.

Supplementary material

464_2019_7202_MOESM1_ESM.mpg (186.5 mb)
Supplementary material 1 (MPG 190994 kb)Below is the link to the electronic supplementary material

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Krishna C. Gurram
    • 1
    • 2
  • Erin Ly
    • 1
  • Xiaocen Zhang
    • 1
    • 3
  • Rani Modayil
    • 1
  • Kanak Das
    • 1
  • Daryl Ramai
    • 2
  • Sagarika Nithyanand
    • 1
  • Shriya Bhumi
    • 1
  • Sivaram Neppala
    • 1
  • Harika Boinpally
    • 1
  • Stavros Stavropoulos
    • 1
    Email author
  1. 1.Division of Gastroenterology Hepatology and NutritionNYU Winthrop HospitalMineolaUSA
  2. 2.Division of Gastroenterology and HepatologyBrooklyn Hospital CenterNew YorkUSA
  3. 3.Mount Sinai St. Luke’s-West Hospital CenterNew YorkUSA

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