Colorectal endoscopic submucosal dissection using a clip-on-clip traction method

To safely and efficiently perform colorectal endoscopic submucosal dissection (ESD), clear visualization of the submucosal layer is important. Therefore, various traction methods have been developed to date [1] [2] [3]. However, there are few reports of using special devices other than clips, and traction methods that are generally used have not been reported. Recently, we developed a new clip-on-clip closure method to close the mucosal defect after ESD using clips only [4]. Here, we describe a new traction method: clip-on-clip traction method (CCTM).

The colorectal ESD method using CCTM is shown in [Video 1]. The patient had a nongranular laterally spreading tumor, 20 mm in size, in the rectosigmoid. Marking was done around the lesion and a full-circumference incision was made. First, a clip was placed on the mucous membrane on the lesion side ([Fig. 1 a]). Then, a second clip was placed on the handle of the first clip ([Fig. 1 b]). Next, the teeth of a third clip were passed through the gap between the teeth of the second clip, which served as an anchor, and then fixed to the contralateral normal colorectal mucosa ([Fig. 1 c]). In the current case, the third clip did not fix to the contralateral colorectal mucosa. However, there was adequate space between the teeth of the second clip for a fourth clip to be added. This ensured a strong traction.

Video 1 Colorectal endoscopic submucosal dissection and troubleshooting using the clip-on-clip traction method.

Fig. 1 Colorectal endoscopic submucosal dissection schema using the clip-on-clip traction method. a After full-circumference incision of the lesion, the first clip was placed on the mucous membrane on the lesion side. b A second clip was placed on the handle of the first clip. The gap between the teeth of the second clip (red area) was used as an anchor. c The teeth of a third clip (green) were passed through the gap, and then fixed to the contralateral normal mucosa.

Because the submucosa could be viewed properly using CCTM, colorectal ESD could be performed safely without any intraoperative adverse event. As the resected lesion was fixed with a clip to the contralateral side, the lesion could be removed from the mucosa with a grasping forceps.

CCTM is simple, and is a novel method that can be applied safely to achieve effective traction even in a narrow intestinal tract, such as the rectosigmoid or sigmoid colon.

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• References

• 1 Osada T, Sakamoto N, Shibuya T. et al. “Loops-attached rubber band” facilitation of endoscopic submucosal dissection of superficial colorectal neoplasm. Endoscopy 2008; 40 (Suppl. 02) E101-E102
• 2 Matsuzaki I, Isobe S, Hirose K. et al. Magnetic anchor-guided endoscopic submucosal dissection for colonic tumor. VideoGIE 2017; 2: 74-75
• 3 Nomura T, Kamei A, Sugimoto S. et al. Colorectal endoscopic submucosal dissection using the “dental floss with rubber band method”. Endoscopy 2018; 50: E78-E80
• 4 Nomura T, Kamei A, Sugimoto S. et al. New closure method for a mucosal defect after endoscopic submucosal dissection: the clip-on-clip closure method. Endoscopy 2018; DOI: 10.1055/s-0044-100486.