Endoscopy 2021; 53(05): E177-E178
DOI: 10.1055/a-1216-1167
E-Videos

A novel technique for adjusting traction direction during colorectal endoscopic submucosal dissection using S-O clip

Yutaka Okagawa
1  Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
2  Department of Gastroenterology, Tonan Hospital, Sapporo, Japan
,
Seiichiro Abe
1  Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
,
Hiroyuki Takamaru
1  Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
,
Masau Sekiguchi
1  Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
3  Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan
,
Masayoshi Yamada
1  Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
,
Taku Sakamoto
1  Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
,
Yutaka Saito
1  Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
› Author Affiliations

A 67-year-old man had an elevated lesion with central shallow depression, approximately 20 mm in size across a colonic fold in the splenic flexure ([Fig. 1]). Magnified chromoendoscopy revealed a noninvasive pit pattern (type VI mild in Kudo’s classification). The patient opted for endoscopic submucosal dissection (ESD) ([Video 1]).

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Fig. 1 An elevated lesion with central shallow depression in the splenic flexure of the transverse colon.

Video 1 Colorectal endoscopic submucosal dissection was performed for an elevated lesion with central shallow depression across a colonic fold. The traction direction was adjusted from distally to proximally during the procedure using the S-O clip.


Quality:

Mucosal incision was followed by submucosal dissection of the distal side using a DualKnife J (KD-655Q; Olympus Medical, Tokyo, Japan) and insulated-tip knife nano (KD-612U; Olympus Medical). Submucosal dissection was meticulously performed because of poor submucosal lifting despite the use of sodium hyaluronate ([Fig. 2]).

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Fig. 2 Submucosal lifting of the center of the lesion was poor owing to submucosal fibrosis.

To secure the submucosal space, an endoclip with a ring-loaded spring (S-O clip, TC1H05; Zeon Medical, Tokyo, Japan) was applied to the distal edge of the specimen and anchored to the opposite bowel wall with another endoclip. This resulted in sufficient tissue traction at the distal edge, and the submucosal space was well exposed, allowing efficient and safe submucosal dissection ([Fig. 3 a]). The submucosal space became poorly visualized again with insufficient traction when the lesion retracted proximally, obscured by a colonic fold. We removed the second endoclip by pulling the endoclip cover up using a clip device, and anchored the ring to the opposite wall proximally ([Fig. 3 b]), leaving the lesion well stretched with better exposure of the submucosal layer on the proximal side, enabling successful en bloc resection ([Fig. 4]). The resected specimen showed well-differentiated tubular adenocarcinoma histologically, with invasion limited to the superficial submucosa (50 μm from muscularis mucosa), measuring 15 × 14 mm in size, with free margin, and without lymphovascular invasion.

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Fig. 3 Use of the S-O clip for traction. a The S-O clip was applied to the distal edge of the specimen and anchored to the other side of the lumen with another endoclip (arrow). b When visualization deteriorated due to reduced traction as the procedure progressed, the second endoclip was removed and the S-O clip was re-anchored to the opposite bowel wall proximally (arrow).
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Fig. 4 En bloc resection was achieved without complications. The resected specimen showed Type 0-IIa + IIc (laterally spreading tumor, nongranular type), well-differentiated tubular adenocarcinoma histologically, with the depth of invasion limited to the superficial submucosa (50 μm from muscularis mucosa), measuring 15 × 14 mm in size, with free margin, and without lymphovascular invasion.

The S-O clip is a useful traction device in colorectal ESD [1] [2]. In this case, the clips were advantageous as the traction direction could be adjusted from distally to proximally, even during ESD, by removing and re-anchoring the loaded ring.

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Publication History

Publication Date:
20 August 2020 (online)

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