Endoscopic submucosal dissection for a rectal tumor behind a rectal fold with novel two-step utilization of a traction device

Colorectal endoscopic submucosal dissection (ESD) can be challenging depending on the location of the lesion [1] [2]. A tangential endoscopic approach is key to success. Herein, we describe successfully performing ESD for a rectal cancer using a novel means of achieving a tangential endoscopic approach ([Video 1]).

Endoscopic submucosal dissection (ESD) for a rectal tumor behind a rectal fold with novel two-step utilization of a multiloop traction device for lifting the adjacent oral-side mucosa and then for suturing the post-ESD ulcer.Video 1

A 63-year-old man was referred to our hospital for endoscopic treatment of a rectal neoplasm. Colonoscopy revealed a 20-mm laterally spreading tumor behind the upper valve of Houston ([Fig. 1]). The transverse rectal fold in the forward view made it difficult to approach the oral side of the lesion ([Fig. 2] a) and a retroflex maneuver enabled only a perpendicular approach. We therefore used a multiloop traction device (MLTD) (Boston Scientific, Tokyo, Japan) [3], not to apply traction to the lesion, but to lift the rectal wall on the oral side of the lesion ([Fig. 2] b), markedly improving accessibility to that side of the lesion in the forward view. En bloc resection by ESD was then achieved under stable tangential endoscopic view. The MLTD was then used to complete closure of the post-ESD ulcer. The attached oral-side loop of the MLTD ([Fig. 2] b) was removed and traction applied to its middle loop ([Fig. 2] b, [Fig. 3] a), enabling fixation to the anal side of the post-ESD ulcer ([Fig. 3] b). This made the post-ESD ulcer narrower, facilitating smooth closure with endoclips. The patient was discharged 4 days after ESD having had no adverse events. Histopathological examination showed a well-differentiated intramucosal adenocarcinoma with negative resection margins.

Fig. 1 Endoscopic view of a 20-mm laterally spreading tumor located behind the upper valve of Houston.

Fig. 2 The endoscopic approach to the oral side of a lesion located behind a rectal fold. a The lesion was located behind the fold. b The multiloop traction device (MLTD) was used to lift the rectal wall on the oral side of the lesion (yellow arrow), to enable endoscopic submucosal dissection (ESD) of the lesion. For closure of the post-ESD ulcer, the attached oral-side loop (red arrowhead) was removed and traction applied to the middle loop (black arrowhead) (see [Fig. 3] a).

Fig. 3 Clip closure of the post-ESD ulcer using the traction device. a After removal of the oral-side loop, traction toward the anal side was applied to the middle loop. b The middle loop could then be fixed to the anal side of the post-ESD ulcer, which had become narrower.

Location of a tumor behind a fold can pose difficulties during colorectal ESD. Our novel usage of a traction device is an effective means of improving the endoscopic approach and is doubly useful in that it facilitates clip closure after ESD.

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Conflict of Interest

Ryu Ishihara has received honoraria from Olympus, Fujifilm Medical, Daiichi-Sankyo, Miyarisan Pharmaceutical, AI Medical Service, Astra Zeneca, MSD, and Ono Pharmaceutical. No other authors have financial relationships to disclose.

Acknowledgement

We thank Dr. Trish Reynolds, MBBS, FRACP, from Edanz for editing a draft of this manuscript.

• References

• 1 Hori K, Uraoka T, Harada K. et al. Predictive factors for technically difficult endoscopic submucosal dissection in the colorectum. Endoscopy 2014; 46: 862-870
• 2 Imai K, Hotta K, Yamaguchi Y. et al. Preoperative indicators of failure of en bloc resection or perforation in colorectal endoscopic submucosal dissection: implications for lesion stratification by technical difficulties during stepwise training. Gastrointest Endosc 2016; 83: 954-962
• 3 Jinushi R, Tashima T, Terada R. et al. Effectiveness of a multi-loop traction device for colorectal endoscopic submucosal dissection performed by trainees: a pilot study. Sci Rep 2022; 12: 10197

Publication History

Article published online:
25 October 2024