Endoscopic submucosal dissection of a rectal lesion using a new flower-shaped multiband traction system

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.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Nagata M. Advances in traction methods for endoscopic submucosal dissection: what is the best traction method and traction direction?. World J Gastroenterol 2022; 28: 1-22
• 2 Abe S, Wu SYS, Ego M. et al. Efficacy of current traction techniques for endoscopic submucosal dissection. Gut Liver 2020; 14: 673-684
• 3 Yahagi N. Is a traction device an almighty tool for overcoming the difficulties of endoscopic submucosal dissection?. Endoscopy 2024; 56: 212-213

Publikationsverlauf

Artikel online veröffentlicht:
03. April 2025