V. Zimmer and E. Eltze, Marienhausklinik St. Josef Kohlhof, Neunkirchen Germany, published a case report on a patient with complex neoplasia in the proximal colon, who underwent additional-working channel (AWC)-assisted resection, alternatively designated EMR+.

EMR+ is a novel technique to increase en bloc resection rates of various upper and lower GI tract lesions, including flat, larger-than-20 mm, difficult-to-access lesions as well as lesions suspicious for submucosal infiltration. EMR+ relies on bimanual triangulation within the operative field by use of an additional working channel (AWC).

The 90-year-old female patient presented with iron-deficiency anemia. Ileocolonoscopy revealed a 22 mm non-granular laterally spreading lesion with discrete areas of pseudo-depression (LSL-NG/PD; Paris IIa+IIc) in the proximal colon. The lesion emerged across a fold. Due to concerns of advanced neoplasia and known higher risks of incomplete resection with conventional EMR, the endoscopists decided for EMR+.

An AWC device was externally mounted onto the colonoscope’s tip with the external channel oriented contralaterally to the scope’s working channel for maximum triangulation. Next, a 25 mm snare was introduced through the scope’s working channel and an anchor through the AWC to lift up the lesion as a modified “grasp-and-snare” approach.
After mobilization of the lesion, judicious forward-pushing movements were performed combined with slow but finally tight snare closure. This “push-back” technique was performed in order to limit the risk of muscularis propria capture and perforation.

Finally, electrocautery was performed. Visualization of the resection area excluded deep mural injury or perforation. A full defect closure was performed involving three hemoclips to reduce the risk of delayed bleeding. Final pathology indicated an unexpectedly favorable result for the patient with low-grade intraepithelial neoplasia with confirmed R0 status.