Removing inflammatory bowel disease-associated dysplastic lesions with benign negative lift sign with cap-assisted EMR: a video tutorial for practicing gastroenterologists.

BACKGROUND AND AIMS

Colon polyps associated with long-standing inflammation from inflammatory bowel disease (IBD) are prone to develop submucosal fibrosis. This underlying fibrosis from chronic inflammation can make dysplastic mass lesions difficult to resect. Using a distal cap attachment when performing EMR for removal of these fibrotic and scarred-down lesions can be advantageous.

METHODS

Three representative cases of dysplastic, IBD-associated, colon mass lesions resected by cap-assisted EMR were selected from a previously reported case series for demonstration purposes. Lesions are first evaluated for malignant features, and if none are present, lifting is attempted but often fails to lift the lesion. The cold or hot snare is placed over the lesion, and suction is used to bring the target tissue through the snare and into the clear distal cap attachment. The snare is blindly closed, suction released, and the amount of tissue captured is evaluated. If appropriate, the snare is slightly lifted away from the wall to limit the amount of thermal exposure to the muscularis propria and then subsequently transects the tissue. This process is completed until the lesion is completely removed. Thermal treatment is performed to the lesion edges and any nodularity.

RESULTS

Three cases are presented demonstrating cap-assisted EMR for adherent dysplastic lesions in patients with IBD, with a fourth case included as an example of a type IV muscle injury occurring and treated during cap-assisted EMR.

CONCLUSIONS

Distal cap-assisted EMR is a safe and effective technique that can be used in patients with IBD with tacked-down, fibrotic, dysplastic lesions attributable to submucosal fibrosis. However, it is important for endoscopists to be comfortable with lesion recognition as well as recognizing and managing related muscle injuries with a low-threshold for closure of the resection site.