Post written by Hisatomo Ikehara, MD, PhD, from the Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan.

The patient in this video case underwent endoscopic submucosal dissection (ESD) for a recurrent tumor in the cecum 11 months after initial piecemeal endoscopic mucosal resection (p-EMR). The recurrent tumor showed remarkable converging folds suggesting severe submucosal fibrosis. Therefore, ESD was planned for this lesion as salvage treatment. After circumferential mucosal incision, original dental floss clip (DFC) method was tried to unfold the mucosal flap. However, adequate traction could not be obtained. To control the direction of traction, additional clipping was performed at the opposite colon wall. As a result, a pulley-like effect unfolded the mucosal flap. Submucosal dissection was then successfully achieved without any complications.

Colonic ESD is technically difficult for many endoscopists. The DFC method is a newly developed traction method. Previous reports have demonstrated the effectiveness of the DFC method for gastric lesions. However, the original DFC method was not effective in this case. This modified DFC technique makes it possible to control the direction of traction and make submucosal dissection easier. This knowledge is useful for many endoscopists.

This video shows the detailed process of setting up the DFC and how to set the additional modified clipping. Readers can easily understand this modification. The final pathological assessment of ESD specimen shows deep submucosal invasion. In this case, initial treatment was p-EMR. Thereafter, a small remnant area was treated by argon plasma coagulation and pathological assessment could not be obtained in this area. Tiny submucosal invasion might exist in this area and cause tumor recurrence with deep submucosal invasion. En-bloc resection for laterally spreading tumors is essential to reduce the risk of recurrence.

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