Usefulness of a clutch cutter combined with an S-O clip in improving stability when opening the pocket in the pocket-creation method

The pocket-creation method (PCM) is a useful resection technique that has been developed to overcome difficulties in colorectal endoscopic submucosal dissection (ESD) [1] [2]. However, this technique itself poses certain challenges in resection when opening the pocket, particularly when there are considerable respiratory changes. Here, we report the usefulness of combining a clutch cutter [3] – a scissor-type knife – with an S-O clip [4] for overcoming instability when opening the pocket in the PCM.

A 76-year-old man underwent ESD for a 23-mm type IIa tumor on the cecum. Marked respiratory changes were observed. We first created a pocket using a clutch cutter. Next, adequate dissection directly beneath the lesion was performed under a stable visual field. When opening the pocket, marked respiratory changes were observed again. An S-O clip was attached to the anal side of the lesion, and once traction was obtained ([Fig. 1]), the surrounding normal mucosa and submucosa were cut in a manner similar to cutting paper (paper cutting technique [PCT]), and the tumor was removed ([Fig. 2]). Even with respiratory changes, resection could be safely performed because the lesion was anchored by the S-O clip, as well as by the clutch cutter, and the procedure was completed without any complications ([Video 1]).

Fig. 1 Figure showing a submucosal pocket that was created and the lesion with an S-O clip attached. a We created a submucosal pocket under most of the lesion using a clutch cutter. b An S-O clip was attached to the anal side of the lesion, and traction was obtained.

Fig. 2 The normal mucosa and submucosa surrounding the lesion were cut in a manner similar to cutting paper (paper cutting technique). a Cutting on the left side. b, c Cutting on the right side.

Video 1 Video showing the usefulness of the paper cutting technique for overcoming instability when opening the pocket in the pocket-creation method.

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Previously, a tip-type knife was used for PCM; however, for lesions beyond the sigmoid colon with major respiratory changes, instability when opening the pocket was frequently experienced despite the use of an S-O clip. This problem was subsequently overcome by the combined use of a clutch cutter only when opening the pocket. We present this video report of the PCT as an aid for novice surgeons performing colorectal ESD.

The PCT is useful for overcoming instability when opening the pocket in the PCM.

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• References

• 1 Hayashi Y, Miura Y, Yamamoto H. Pocket-creation method for the safe, reliable, and efficient endoscopic submucosal dissection of colorectal lateral spreading tumors. Dig Endosc 2015; 27: 534-535
• 2 Sakamoto H, Hayashi Y, Miura Y. et al. Pocket-creation method facilitates endoscopic submucosal dissection of colorectal laterally spreading tumors, non-granular type. Endosc Int Open 2017; 5: E123-E129
• 3 Akahoshi K, Minoda Y, Komori K. et al. Endoscopic submucosal dissection using the “Clutch Cutter” for early esophageal squamous cell carcinoma. Endoscopy 2013; 45: 1035-1038
• 4 Sakamoto N, Osada T, Shibuya T. et al. The facilitation of a new traction device (S-O clip) assisting endoscopic submucosal dissection for superficial colorectal neoplasms. Endoscopy 2008; 40: E94-E95