Endoscopic submucosal dissection remains challenging, even with traction [1] to assist the procedure [2]. To overcome the decline in traction force as the dissection proceeds, an adaptive
traction device, capable of being tightened to increase traction during the procedure,
has shown interesting results [3]. Pulley methods have been described for early-stage gastric cancer [4]. However, since this first evaluation, no further study has been made in rectal
and colonic locations.
We report the case of an endoscopic resection in a 73-year-old woman with a giant,
rectal, granular mixed-type, laterally spreading tumor. We faced two difficulties.
First, keeping good submucosal exposure without moving the patient, who was obese.
Second, maintaining effective traction throughout the resection of this long lesion,
which measured 10 cm from the oral to anal end. We decided to combine underwater dissection
and multipolar traction with the pulley method.
As shown in [Video 1], after complete circumferential incision and trimming, we fixed a clip with a line
attached and a rubber band to the anal side of the lesion ([Fig. 1]). The rubber band was then fixed at both lateral sides of the lesion to obtain a
multipolar traction effect. A line loop was passed over the original line, grasped
with a clip, and fixed in the upstream colonic wall, beyond the oral edge of the lesion
to maintain good traction during the entire procedure. Finally, we attached a surgical
forceps to the line externally in order to apply constant weight. Dissection was performed
with underwater saline immersion to counter unfavorable gravity effects. Pathology
analysis revealed complete R0 resection of a 95 × 85 mm adenoma with intramucosal
adenocarcinoma.
Multipolar traction pulley method combined with underwater endoscopic submucosal dissection
for a large, rectal, laterally spreading tumor.Video 1
Fig. 1 Schematic representation of submucosal dissection of a rectal laterally spreading
tumor using multipolar traction with the pulley method. a Line-attached clip fixation at the anal side, with a free rubber band. b Multipolar traction effect: fixation of the rubber band at both lateral sides. c Pulley traction effect: fixation of a loop in the upstream colonic wall. d Submucosal dissection.
The multipolar traction pulley method combined with underwater resection could provide
an additional traction tool to facilitate the endoscopic submucosal dissection procedure.
Further studies are needed.
Endoscopy_UCTN_Code_TTT_1AQ_2AC
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
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