Endoscopic submucosal resection with adaptative traction device: a new strategy to facilitate resection in patient with inflammatory bowel disease

Endoscopic submucosal dissection (ESD) is well described in non-IBD (inflammatory bowel disease) patients to remove non-invasive neoplastic lesions in the colon. Data are still limited in IBD patients. One of the limited factors for the resection by ESD of dysplasia in IBD is fibrosis, which leads to an increased risk of complication such as perforation.

We report a case of a 63-year-old man with a history of long-standing ulcerative colitis and multiple endoscopic mucosal resections of low-grade dysplasia in the sigmoid colon. He was referred after a new follow-up colonoscopy that revealed a non-polypoid lesion of 3 cm in the rectosigmoid junction ([Fig. 1]). The rest of the colon was free of inflammatory activity. An ESD was decided with a traction-assisted strategy to achieve R0 resection. After marking the lesion, a circumferential incision was made and a new adaptive multi-traction device (A-TRACT-2) was fixed at the two edges of the lesion ([Video 1], [Fig. 2]) and attached to the opposite colonic wall to optimize submucosal exposure. Depending on the level of insufflation, the degree of traction was modulated, and during dissection traction was gradually decreased. When submucosa exposure became incorrect owing to a lack of traction, a forceps was used to tighten the device, bringing all clips closer together to create additional traction ([Fig. 3]). The pathology report revealed a complete en bloc and R0 resection of a high-grade dysplasia with focal intramucosal adenocarcinoma.

Fig. 1 Non-polypoid lesion in the rectosigmoid junction.

Video 1 Endoscopic submucosal resection with adaptative traction device: a new strategy to facilitate resection in patient with inflammatory bowel disease.

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Fig. 2 Schematic view of the A-TRACT device.

Fig. 3 Tightening of the device.

ESD is feasible in IBD patients even in a fibrotic area, but conventional strategies are often defeated. Traction strategies can help for this kind of resection. This new handmade device has the advantage of being adaptive during the procedure to maintain the best exposure of the submucosa and minimize the risk of complications.

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