“Pulley type” countertraction for colonic endoscopic submucosal dissection of laterally spreading tumors involving a diverticulum

Colonic endoscopic submucosal dissection (ESD) for tumors involving a diverticulum has a high risk of causing perforation, owing to the lack of a proper muscle layer in the diverticulum [1] [2]. In addition, it is often difficult for endoscopists to obtain a clear field of view in the diverticulum [3].

The advantage of “pulley type” countertraction is that continuous traction can be performed regardless of gravity. In addition, countertraction can be performed with a simple tool made with dental floss and ordinary clips.

The patient was an 80-year-old man. Colonoscopy revealed a 20-mm granular laterally spreading tumor (LST) involving a diverticulum in the ascending colon ([Video 1]). We first made a circumferential mucosal incision using a dual knife (Olympus, Tokyo, Japan) after injecting a glycerol mixture. Next, we resected the lesion from the anal side to the diverticulum as far as possible, and placed dental floss and a clip on the anal side of the lesion. Then, we placed a second clip on the contralateral side of the lesion to enable the dental floss to work as a pulley ([Fig. 1]). This countertraction method created a clear field of view while pulling the lesion into the diverticulum, and enabled ESD to be performed safely and easily ([Fig. 2]). We were able to make an incision with a clear field of view, while avoiding the perforator branch that causes bleeding of the diverticulum ([Fig. 3]), and en bloc resection was completed without any complications ([Fig. 4]). Finally, the diverticulum was closed using the clips. Pathological analysis indicated a high-grade tubular adenoma with free margins. Colonoscopy 3 months after ESD demonstrated that the diverticulum had disappeared and had formed a scar ([Fig. 5]).

Video 1 “Pulley type” countertraction using dental floss and clips for colonic endoscopic submucosal dissection of a laterally spreading tumor involving a diverticulum. Text 1. LST involving a diverticulum. Text 2. Circumferential mucosal incision. Text 3. “Pulley type” countertraction.

Fig. 1 Setting up the dental floss and clips to work as a pulley.

Fig. 2 The countertraction method created a clear field of view while pulling the lesion.

Fig. 3 A clear field of view was achieved, and an incision was made while avoiding the perforator branch that causes bleeding of the diverticulum (black arrowhead).

Fig. 4 En bloc resection was completed without any complications.

Fig. 5 Colonoscopy 3 months after ESD demonstrated that the diverticulum had disappeared and had formed a scar (black arrowhead) .

Our case demonstrates that “pulley type” countertraction using dental floss and clips is a useful and safe method for ESD of LST involving a diverticulum.

Publication History

Article published online:
31 August 2020

• References

• 1 Kim ES, Cho KB, Park KS. et al. Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors. Endoscopy 2011; 43: 573-578
• 2 Sakamoto T, Abe S, Nakajima T. et al. Complete removal of a colonic neoplasm extending into a diverticulum with hybrid endoscopic submucosal dissection–mucosal resection and endoscopic band ligation. Endoscopy 2015; 47: E295-E296
• 3 Iwatsubo T, Uedo N, Yamasaki Y. et al. Traction-assisted colorectal endoscopic submucosal dissection by use of clip and line for a neoplasm involving colonic diverticulum. VideoGIE 2017; 2: 337