ENDOSCOPIC SUBMUCOSAL DISSECTION WITH TRIANGULATED TRACTION WITH CLIP AND RUBBER BAND: THE “WALLET” STRATEGY

ESD is the reference method to allow curative endoscopic resection of colorectal tumours.

Nevertheless, it is technically challenging and new strategies to facilitate procedure are requested. Counter traction strategies allows enlarging submucosal space like in the clip and rubber band approaches. In the rectum, line traction makes a tangential traction without triangulation and is not really adaptive as the dissection progresses.

We report a case of ESD for a colonic LST of a patient with ulcerative colitis.

For this resection, we used the “improved wallet strategy” (video): first the two edges (oral and anal) of the lesion were incised, then, trimming was performed at both edges in direct and retroflexed approaches to have a deep access to the submucosa and to release both mucosal edges.

After this step, two elastic rubber bands were fixed to both proximal and distal mucosal margins of the lesion by way of catching it with metallic clips. By trapping both rubber bands with the third metallic clip we used a triangulation traction and fixed the clip to the opposite mucosal wall (wallet aspect). The submucosa was strongly stretched perpendicularly to the muscular layer plan facilitating dissection.

This strategy must be compared prospectively to other traction strategies but seems to offer a strong counter traction. Furthermore, this strategy is adaptive since rubber band traction is moving as the dissection progresses changing the axis of the traction strength.