Ileocecal valve opening with double clip and rubber band for countertraction facilitates R0 en bloc resection of laterally spreading tumors

Laterally spreading tumors (LSTs) of the ileocecal valve with an extension of the adenoma in the ileum remain challenging for the endoscopist despite the development of colonic endoscopic submucosal dissection (ESD). The ileocecal valve is considered to be one of the most difficult locations for ESD because of poor maneuverability of the scope. Surgery remains common [1]. Here we present a new technique developed to better expose the ileocecal valve and facilitate R0 en bloc resection of ileocecal LSTs ([Video 1]). Two cases are presented here.

Video 1 Opening of the ileocecal valve by countertraction using a double clip and rubber band facilitates R0 en bloc resection of laterally spreading tumors.

The first patient was a 75-year-old man referred for endoscopic resection of a 30-mm nongranular LST. Positioning was difficult owing to cecum recurvatum and an omega loop of the sigmoid colon due to obesity. The second was a 68-year-old man with a granular-homogeneous LST. In the latter patient, ileal intubation was easy, but the lesion occupied two-thirds of the circumference of the distal ileum, hampering visualization of the margins of the adenoma.

In order to open and sufficiently widen the ileocecal valve, we set up two systems of countertraction using a double clip and rubber band on the lips of the valve. The resections were performed by ESD with the DualKnife J (Olympus Surgical Technologies America, Southborough, Massachusetts, USA) and submucosal injection with a glycerol solution. Opening up the ileocecal valve allowed us to clearly delimit the lesions and achieve a healthy margin. R0 en bloc resection was done in both cases. Specimen 1 was a low-grade tubular adenoma, 45 mm × 31 mm in size, and the duration of the procedure was 31 min. Specimen 2 was an adenoma with intramucosal adenocarcinoma, 82 mm × 66 mm with an ileal extension of 52 mm; the duration of the procedure was 101 min.

Opening up the ileocecal valve by countertraction using a double clip and rubber band is simple and reproducible. This technique seems useful for facilitating R0 en bloc resection of LSTs with an adenomatous extension in the distal ileum. A multicentric prospective series is ongoing.

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Competing interests

The authors declare that they have no conflict of interest.

• Reference

• 1 Sano Y, Machida H, Fu KI. et al. Endoscopic mucosal resection and submucosal dissection method for large colorectal tumors. Dig Endosc 2004; 16: S93-S96

Publication History

Article published online:
17 April 2020