Endoscopic techniques for diverticular colon polyp resection, a case presentation and educational overview. These are our disclosures. Colorectal polyps within diverticula represent a unique clinical challenge due to the increased risk of complications. Lack of a muscle layer within the diverticula lead to thin, fragile walls heightening perforation risk. Confined space within diverticula limits instrument maneuverability and assessment of polyp size and margins. Various techniques have been described for diverticular polyp resection. Polyp eversion technique. This is one of the most commonly employed techniques where polyps are everted using injection lift or forceps before snare resection. This is typically used for smaller, sessile polyps. Band ligation without resection. This method utilizes the ligate and let go technique using endogroup or band ligator. It is primarily used for pedunculated polyps and in locations where traditional snaring is risky. The downside is a lack of tissue for histopathological analysis. Underwater endoscopic mucosal resection. Water submersion during underwater EMR lifts the polyp out of the diverticulum facilitating resection. Underwater EMR is described as safer than conventional EMR due to reduced risks of perforation. However, closure is mandatory within the diverticulum. It is said to be more effective in removing medium to larger sized polyps. Endoscopic submucosal dissection. Historically, this was considered a contraindication for diverticular lesions due to absence of an underlying muscle layer. However, ESD techniques utilizing both traction and non-traction have since been described in literature. It requires careful dissection of the submucosa just above the serosa outside of the diverticulum. It has a higher risk of perforation, underscoring need for ESD expertise and can be a time-intensive procedure. A retrospective study evaluated the safety and feasibility of ESD for superficial polyps near or involving a diverticulum. The study demonstrated a 67% total on-block resection rate, which was 100% for tumors near and only 33% for tumors involving a diverticulum. Tumors involving the diverticulum also showed polyp recurrence and adverse events. ESD was deemed safe for tumors near a diverticulum. However, suitability for tumors involved in diverticula is unclear. The full thickness resection device for diverticular polyps ensures complete capture of the lesion and reception of all layers of the bowel wall. It is effective for polyps contained fully within the diverticulum and the over-the-scope clip effectively reduces the risk of post-reception leakage. Due to its size, the FTRD does require careful maneuvering through the colon to reach its target and is suitable only for polyps that can fit within its cap. We present a case of a 46-year-old female who underwent a routine screening colonoscopy. She was found to have a 15-millimeter flat, carpet-like lesion in the sigmoid colon situated 30 centimeters from the anal verge. The lesion was located completely within the diverticulum and the biopsy was consistent with a tubular villus adenoma. We utilized a therapeutic gastroscope for this procedure, first focusing on evaluating the polyp that was found to be completely within the diverticulum in the sigmoid colon. The diverticulum's thin wall around the polyp was evident, signifying a lack of an underlying muscle layer. The polyp was examined under narrowband imaging, confirming the nice type II and likely KUDO pit pattern form consistent with the pathological diagnosis. A marking probe set to soft coagulation mode was used to delineate the lesion and to mark the diverticulum's opening. This demarcates the area devoid of muscularis propria. Such marking aids in identifying the lesion during resection and enables precise placement of the over-the-scope clip on the normal wall that includes the muscularis propria. The full-thickness resection device system is then mounted onto the scope and gently advanced to the polyp. A grasping forceps was then used to secure the polyp into the cap of the full-thickness resection device. The grasping forceps also aids in retrieval of the specimen after resection. Gentle suction was applied intermittently in order to fully draw the lesion into the cap. It is crucial to avoid applying full or continuous suction as this may result in the entrapment of extra-luminal structures within the cap. After fully encompassing the lesion, the clip was deployed, followed by resection using the integrated snare with pure-cut current. The retrieved specimen, showing yellow adipose tissue, confirmed a full-thickness resection. Markings on the surface validated complete lesion excision with negative margins. Immediately after resection, another endoscope was inserted and the site was re-examined. The clip is seen effectively grasping all layers of the colon wall with central yellow tissue representing the perichelonic adipose tissue. A meticulous inspection confirmed the absence of perforation or any residual polypoid tissue. The post-procedure recovery was unremarkable and the patient did not experience any pain or bleeding. Her diet was resumed on the same day. Pathology confirmed tubulobulus adenoma that was negative for high-grade dysplasia with an observed lack of muscularis propria indicative of its diverticular origin. She is scheduled for a repeat colonoscopy in one year. Polyps located within diverticula present a unique challenge due to the delicate structure of the diverticular wall and its propensity for complications. Historically, these polyps are managed surgically, however now can be addressed with advanced endoscopic methods. Techniques such as polyp eversion, band ligation, and ESD have been devised for safe removal. FTRD may offer a targeted approach for medium-sized lesions to ensure complete resection while providing secure closure.

colorectal polyps

diverticula

endoscopic techniques

Full-Thickness Resection Device (FTRD)

tubular villus adenoma