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case_images: Colonoscopy findings (a) White-light endoscopy revealed a 50 mm-sized aggregation of a superficial elevated granular tumor with a semi-pedunculated nodule in the ascending colon. (b) Magnified narrow-band imaging at the nodule lesion revealed a Japan narrow-band imaging classification of type 2A. (c) Kudo's pit pattern classification after crystal violet staining showed a type IIIL pit pattern in the superficial elevated granular lesion. (d) Kudo's pit pattern classification after crystal violet staining showed a type IV pit pattern in the nodular lesion.
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case_images: Co., Tokyo, Japan) by an endoscopist with 14 years of experience, and cecal intubation was performed for 10 min. Colonoscopy revealed a 50 mm-sized lesion in the ascending colon (Figure 1a). According to the Japan narrow-band imaging classification, this lesion showed a type 2A pattern (Figure 1b), and Kudo's pit pattern classification after crystal violet staining showed types IIIL and IV pit patterns (Figure 1c,d).
case_images: A long colonoscope and guidewire technique under X-ray image. (a) Cecal intubation was successful using a long colonoscope. (b) After inserting the tip of the long colonoscope into the terminal ileum as deeply as possible, the loop of the transverse (c) Colon was reduced. A guidewire was inserted into the terminal ileum protectively and slowly through a colonoscopic biopsy channel while confirming the flow of the oral intestinal gas under X-ray imaging. (d) To fix the tip of the guidewire retained in the ileum, the assistant inserted the guidewire while the endoscopist withdrew the colonoscope under X-ray imaging.
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case_images: The therapeutic colonoscopy and overtube were subsequently removed and replaced with a long colonoscope (PCF-H290ZL; Olympus Co.), and the cecal intubation was successful (Figure 2a), and the transverse colon loop was reduced. A guidewire (VisiGlide2, 0.035Type; Olympus Co.) was inserted (Figure 2b), and the colonoscope was removed with the tip of the guidewire retained (Figure 2c).
case_images: Balloon-assisted endoscopy (BAE) using therapeutic colonoscope and overtube. (a) Biopsy forceps were inserted through the biopsy channel of the therapeutic colonoscope attached to an overtube, and grasped at the guidewire's anal end. (b) The guidewire was pulled out of the biopsy channel at the tip. (c) A therapeutic colonoscope with an overtube was then inserted without loop reformation around the guidewire, the entire overtube was inserted, and the balloon was fixed in the ascending colon.
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case_images: Tokyo, Japan) were inserted, and the guidewire was grasped and pulled out through the biopsy channel (Figure 3a,b). The cecal intubation was successful without intestinal loop reformation, and an overtube was inserted into the ascending colon. (Figure 3c).
case_images: Specimen and histopathological findings. (a) Endoscopic submucosal dissection with good maneuverability, and en bloc resection were performed. (b) Histopathology showed an intramucosal tubular adenocarcinoma with negative horizontal and vertical margins. (c) There was no lymphovascular invasion in the high magnification.
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case_images: The procedural time from the insertion of the long colonoscope to the initiation of BA-ESD with a therapeutic colonoscope with an overtube took 25 min. The excellent maneuverability of the endoscope allowed safe ESD, and the lesion was resected en bloc without complications (Figure 4a). The resected specimen had a diameter of 77 x 48 mm, and histopathology revealed intramucosal tubular adenocarcinoma with negative horizontal and vertical margins and no lymphovascular invasion (Figure 4b,c).