Clin Endosc > Volume 55(3); 2022 > Article
Sasaki, Nishikawa, and Sakaida: Underwater cold forceps polypectomy for an adenoma within a cecal diverticulum
Endoscopic resection of a polyp involving a colonic diverticulum is challenging. As there is no muscularis propria within a diverticulum, the potential risk of perforation associated with endoscopic resection must be considered.1,2
A 72-year-old male patient underwent follow-up colonoscopy after surgery for rectal cancer. A sessile polyp, 3 mm in size, was found in a cecal diverticulum. The underwater method eliminated halation and expanded the diverticulum cavity, making it possible to observe the lesion stably (Fig. 1A, Supplementary Video 1). Subsequently, underwater cold forceps polypectomy (CFP) was performed using Radial Jaw4-Jumbo cold polypectomy forceps (Boston Scientific, Tokyo, Japan) (Fig. 1B, C). Observation using narrow-band imaging and continuous irrigation confirmed that there were no residual lesions or perforations (Fig. 1D), and the wound was closed using clips. The pathological result was a tubular adenoma (Fig. 2).
The underwater method made it possible to expand the diverticulum cavity and float the lesion, allowing CFP to be performed safely.3 Cold biopsy forceps polypectomy was performed to avoid the risk of delayed perforation associated with hot polypectomy.4 This technique may be useful for cold snare polypectomy of larger polyps extending into a diverticulum.5 However, it would not be safe for large polyps involving more than one-fourth of a diverticulum. To the best of our knowledge, this is the first reported case of underwater CFP for an adenoma within a colonic diverticulum.

Supplementary Material

Supplementary Video 1. Underwater cold forceps polypectomy for an adenoma within a cecal diverticulum (
Supplementary materials related to this article can be found online at


Conflicts of Interest
The authors have no potential conflicts of interest.
We express our gratitude to Dr. Shuji Wasaki (Wasaki Clinic, Tsuwano, Japan) for his careful endoscopy and detection of the lesion.
Author Contributions
Conceptualization: SS; Project administration: SS, JN; Supervision: IS; Writing-original draft: SS; Writing-review & editing: SS, JN, IS.

Fig. 1.
Underwater cold forceps polypectomy. (A) A sessile polyp 3 mm in size was found in a cecal diverticulum. The underwater method improved polyp visualization. Narrow-band imaging (NBI). (B, C) Underwater cold forceps polypectomy was performed. (D) Observation using NBI and continuous irrigation confirmed that there were no residual lesions or perforation.
Fig. 2.
Resected specimen (hematoxylin & eosin, ×10). Histopathological examination revealed a tubular adenoma.


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2. Carmo J, Marques S, Chapim I, et al. Elastic band ligation for the removal of a colonic tubular adenoma in a diverticulum. Endoscopy 2015;47 Suppl 1:E490–E491.
3. Binmoeller KF, Weilert F, Shah J, et al. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc 2012;75:1086–1091.
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4. Kubosawa Y, Nishizawa T, Kinoshita S, et al. Cold snare polypectomy for polyp adjacent to colonic diverticulum. VideoGIE 2018;3:85–86.
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5. Yanagisawa F, Inoki K, Katagiri A, et al. Cold snare polypectomy in combination with a traction device for resection of a colonic adenoma partially extending into a diverticulum. VideoGIE 2020;5:580–582.
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