Endoscopic submucosal dissection (ESD) is the preferred treatment for en bloc resection
of tumors of the superficial gastrointestinal tract. This complex technique carries
a high risk of complications and is time consuming. Maintaining a firm submucosal
space through tissue traction is key for a precise and safe dissection [1]. There is a growing interest in the development of new traction devices to facilitate
ESD procedures [2]
[3].
We designed a novel traction technique using five elastic bands. Four of these are
attached to a central band with a thread knot, creating a flower-like appearance.
A crossed thread over the central band provides a handle for the entire piece ([Fig. 1]).
Fig. 1 The flower-shaped multiband traction system.
A 64-year-old woman with a 50-mm laterally spreading tumor (LST)-granular nodular
mixed type, located in the rectum (JNET type 2B) ([Fig. 2]), was referred for endoscopic resection. After submucosal injection of succinylated
gelatin mixed with indigo carmine, we performed ESD with a DualKnife-J (Olympus, Tokyo,
Japan) ([Video 1]). Once the initial circumferential incision and trimming was completed, each peripheral
band was anchored with a clip to the four quadrants of the flap ([Fig. 3]). This first step improved the dissection plane through centripetal traction. When
tension was lost, the central band was anchored with a clip through the thread to
the contralateral wall of the rectum. This second step enabled dynamic traction, enhancing
the endoscopic view and allowing dissection to be completed ([Fig. 4], [Fig. 5]). The procedure was performed without complications, and the patient was discharged
the next day.
Fig. 2 White-light imaging of a 50-mm rectal lesion (0-IIa+Is, laterally spreading tumor-granular
nodular mixed type).
Fig. 3 The multiband traction system creates an initial centripetal traction.
Fig. 4 Macroscopic view of the resected lesion.
Fig. 5 Illustration of the use of the traction device. a The flower-shaped multiband traction system is inserted after circumferential incision
of the lesion. b The four bands are anchored with clips onto the flap, creating centripetal tension.
c When tension is lost, the crossed thread over the central band is anchored by another
clip attached to the contralateral wall of the rectum. d This provides global traction for the entire piece, enhancing the endoscopic view
and facilitating the completion of the dissection.
Endoscopic submucosal dissection of a rectal lesion assisted by a flower-shaped multiband
traction system.Video 1
Pathological examination revealed a pT1 adenocarcinoma with no risk factors. Following
a multidisciplinary decision, this was considered a curative resection.
In conclusion, the flower-shaped multiband traction system is a simple traction technique
that could optimize the safety and duration of ESD. This strategy seems feasible for
LSTs with no bulky component and good maneuverability. Further studies are needed.
Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AD
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