Switching from the pocket-creation method to double clip and rubber-band traction in colonic endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) has become the standard treatment for large superficial colorectal neoplasms. The pocket-creation method developed in Japan is safe and has a high en bloc resection rate . However, the method cannot be completed if the fibrosis is severe or the approach to the lesion is unstable . These technical difficulties necessitate a switch in strategy. We demonstrate the effective treatment of colonic neoplasms by switching the ESD strategy from the pocket-creation method to the double clip and rubber-band traction method ([Fig. 1 a – d]), now rapidly accepted in the Western countries   ([Video 1]).
Video 1 The two colonic neoplasms were effectively treated by switching from the pocket-creation method to the double clip and rubber-band traction method in endoscopic submucosal dissection.
The first case was the recurrence of a sigmoid adenocarcinoma following a previous endoscopic mucosal resection. The elevated lesion (10 × 15 mm) was located within the scar ([Fig. 2 a – b]). Although we initially attempted creating a pocket using a small-caliber-tip transparent hood, the submucosal space was narrowed by severe fibrosis ([Fig. 2 c]). In light of the potential technical difficulty, the ESD strategy was changed to the double clip and rubber-band traction method. After complete mucosal incision, we caught the edge of the lesion with the first recapture clip, which was grasping a rubber band. The second clip catching the rubber band was then placed on the opposite wall. This traction method is flexible because the rubber band can be stretched or loosened according to the endoscopic air supply. This method allowed us to clearly expose the submucosal layer ([Fig. 2 d]) and perform en bloc resection.
The second case was a cecal cancer. The elevated lesion (22 × 24 mm) was located under the ileocecal valve ([Fig. 3 a – b]). Here, an unstable approach to the lesion (respiratory fluctuation and intestinal peristalsis) prompted us to change the ESD strategy ([Fig. 3 c – d]).
ESD with the double clip and rubber-band traction method is usually planned but without the use of a small-caliber transparent hood ([Fig. 4]). We illustrate the feasibility and effectiveness of switching the ESD strategy from the pocket-creation to the double clip and rubber-band traction method.
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20 August 2020 (online)
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