With the progression of technology, endoscopic submucosal dissection (ESD) has been
increasingly applied in clinical practice. However, ESD still faces technical challenges
in certain cases. To reduce the difficulty of the procedure, shorten the operation
time, and decrease the incidence of complications, various traction devices have been
invented and employed clinically [1]
[2]
[3]. Additionally, owing to limitations of single-point traction, multipoint traction
techniques have been developed to achieve more efficient dissection. These multipoint
traction techniques represent technological improvements and innovations based on
traction devices [4]
[5]. Herein, we introduce a novel multipoint traction method that enhances traction
force, enabling rapid dissection of the lesion.
A 55-year-old woman underwent colonoscopy, during which a laterally spreading tumor
measuring approximately 2.2 × 1.8 cm was identified in the mid-transverse colon ([Fig. 1]
a). Subsequently, she underwent ESD ([Video 1]). ESD was considered challenging due to the lesion extending over intestinal folds
and being influenced by arterial pulsation. Therefore, we employed a novel multipoint
traction method to address these difficulties.
Fig. 1 Multipoint traction for the treatment of colonic laterally spreading tumor (LST).
a An LST measuring approximately 2.2 × 1.8 cm was identified in the mid-transverse
colon. b Following submucosal injection, a circumferential incision was made around the lesion.
c One loop of an “8”-shaped rubber ring was secured to the right side of the lesion
using a clip. d The opposite loop of the “8”-shaped rubber ring was anchored to the left side of
the lesion with another clip. e A third clip was employed to fix the central part of the rubber ring at the anal
side of the lesion. f A fourth clip was applied to secure the middle part of the rubber ring to the opposing
intestinal wall. g Complete dissection of the submucosal layer of the lesion was achieved. h Post-ESD appearance of the resected lesion.
Multipoint traction for the treatment of colonic laterally spreading tumor.Video 1
First, a circumferential mucosal incision was made using a mucosal cutting knife ([Fig. 1]
b). An elastic rubber ring was then knotted in the middle to form an “8” shape. One
loop of the rubber ring was secured to the right side of the lesion using a clip ([Fig. 1]
c). A second clip was used to anchor the opposite loop of the rubber ring to the left
side of the lesion ([Fig. 1]
d). The central part of the rubber ring was then fixed at the anal side of the lesion
with a third clip ([Fig. 1]
e). A fourth clip was applied to the middle of the rubber ring, securing it to the
opposite intestinal wall ([Fig. 1]
f). Following this traction technique, the submucosal layer was clearly exposed, transitioning
from point traction to surface traction. This increased the traction area and achieved
a converging effect. Benefiting from the tension generated by the traction device,
the endoscopist successfully completed the dissection of the entire submucosal layer
within 2 minutes ([Fig. 1]
g), without causing damage to the muscularis propria. The resected lesion measured
approximately 2.8 × 2.2 cm ([Fig. 1]
h). Postoperative pathology revealed a tubular adenoma with low grade dysplasia, with
no tumor tissue observed at the horizontal and basal margins.
This novel multipoint traction method not only converges the lesions from both sides
but also utilizes three traction points to pull the lesion toward the opposite side
of the intestinal lumen, creating a fan-like convergence. This approach offers two
primary advantages: it reduces the area of the lesion that needs to be dissected and
ensures consistent tension throughout the submucosal layer, facilitating rapid dissection.
However, we are considering whether an alternative setup with the third clip securing
both loops at the anal side of the lesion, or the fourth clip similarly securing both
loops on the opposite intestinal wall, might yield even better results. We will continue
to explore and study this possibility.
In summary, our new multipoint traction method provides valuable insights for endoscopists.
Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AD
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
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