Endoscopic submucosal dissection of lateral spreading polyps involving the ileocecal valve, transcecal IC valve mucosal resection and remodeling. In collaboration with my co-authors, we present three successful cases to demonstrate this technique. Resection of circumferential polyps involving the IC valve could be challenging due to its unique anatomical configuration and limited scope maneuverability. EMR is associated with higher incomplete resection rate and recurrence rate comparing to ESD. Endoscopic transcecal IC valve mucosal resection would ensure end-block removal of such polyp from both clonic and ileal sites. This is a brief description of our endoscopic method. The procedure starts with circumferential marking and incision around the lesion in the base of the sacrum. Submucosal dissection starts from the anal side till reaching the ileal mucosa. This step is then followed by expansion of submucosal dissection to both lateral margin. Applying traction would facilitate the next step of the procedure which is circumferential dissection of the ileal mucosa. The last step of the procedure is submucosal dissection of the oral side till the lesion is removed. In order to keep the patency of the IC valve, we advocate for IC valve remodeling. The ileal side of the resection bed is grabbed with a clip. The clip is then rotated and the other jaw is repositioned to grab the healthy clonic mucosa on the opposite side of the resection bed. The process is then repeated in a circumferential manner till complete IC valve remodeling is achieved. Our first case is a 77 year old male with a 50 millimeter granular lateral spreading polyp involving over 80% circumference of the IC valve. The procedure starts with careful examination of the polyp. In this case, the polyp is expanded over 80% circumference of the IC valve and extended superficially within the valve. Then we start with circumferential marking of the lesion within the ileal mucosa as well as around the lesion in the base of the cecum. The next step is circumferential injection around the lesion in the base of the cecum. After making a safe submucosal cushion within the anal side of the lesion, we start incision and dissection of the anal side of the lesion. It is important to remember abundance of fat within the submucosal layer of the IC valve which could affect conductivity of energy and dissection speed. The dissection is then continued till reaching the back side of the ileal mucosa. You can clearly differentiate the back side of the ileal mucosa and the clonic muscle layer. Next step is to complete dissection of both lateral margins till reaching the ileal mucosa. We recommend to apply traction after this step to improve visualization. In this video, we are using a rubber band clip traction method. We then proceed with circumferential dissection of the ileal mucosa at the base of the IC valve. After complete dissection of the ileal mucosa, the final step of the procedure is submucosal dissection of the oral side of the lesion till the lesion is removed. Using an over tube provides greater scope stability during each step of the procedure and expedite dissection. It is highly important to examine the ileal side of the lesion to ensure complete removal of the entire polyp. The final step is IC valve remodeling. Using a hemostatic clip, we approximated the normal ileal mucosa to the healthy colonic mucosa over the resection bed. This process is then repeated in a circumferential fashion till complete IC valve remodeling is achieved. Our second case is a 68-year-old female with a 50-millimeter non-granular lateral spreading polyps involving over 90% of the circumference. In this case, the basic endoscopic methods remain the same, except we are demonstrating a different method of traction with a snare traction via a double balloon over tube platform. After complete dissection of the ileal mucosa of the IC valve, the submucosal dissection of the oral side of the lesion was then performed, resulting in removing the polyp and block. IC valve remodeling was completed successfully with complete closure of the resection bed. Our third case is a 55-year-old female with a 60-millimeter non-granular lateral spreading polyp involving over 80% of the IC valve circumference. In this case, we use the same endoscopic dissection method with a different type of traction. Using a double balloon over tube platform, traction was applied via a flexible endoscopic grasper. This device provides dynamic multi-directional traction, facilitating dissection. As you can see, after dissection of one margin, the lesion is then pulled to the opposite side, providing better visualization of this margin. After complete removal of the lesion, it is clear that the polyp was removed and blocked from both colonic and ileal mucosa. In pathological evaluation, you can see the clear transition from colonic to ileal mucosa. This patient had a tubular adenoma involving the IC valve, which was removed R0, supported by normal colonic and ileal mucosa on both sides of the specimen. Historically complex IC valve polyps are managed by hemicolectomy and ileocolonic anastomosis. Loss of IC valve function after surgery is a known risk factor for bacterial overgrowth and diarrheal symptoms over time. Endoscopic transceical IC valve mucosal resection would ensure end block removal of the polyp from both colonic and ileoid side, eliminating the surgical need. IC valve remodeling is a crucial step to prevent future stricture formation and to maintain patency of the IC valve. In conclusion, endoscopic transceical mucosal IC valve resection is a safe and effective method for management of complex polyps involving the IC valve to ensure negative resected margin is achieved. IC valve remodeling would maintain valve function and limit stricture formation.

endoscopic submucosal dissection

transcecal mucosal resection

ileocecal valve

lateral spreading polyps

IC valve remodeling