Post written by Satoki Shichijo, MD, from the Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan.
We performed endoscopic submucosal dissection (ESD) for a laterally spreading tumor involving a diverticulum in the posterior wall of ascending colon. We performed traction-assisted colonic ESD using a clip-and-line, which usually makes ESD safe and efficient by affording good visibility of the submucosal layer even without reinsertion of the colonoscope. However, in this case, it was impossible to create a flap just by “conventional” traction-assisted colonic ESD because of interference from the anal fold (traction direction was to anal side only). Another clip was added to create a “pulley,” which enabled good visibility of the submucosal layer. By changing the traction direction, we easily performed submucosal dissection, which resulted in en-bloc resection in 29 minutes. The entire mucosal defect, including a small muscle defect, was completely closed with clips. After the line was cut with scissors forceps, the lesion was retrieved through the anus.
The “pulley” method is feasible and effective for upper gastrointestinal endoscopic procedures as well colonoscopies. The “Pulley” method can be applied to other traction methods, such as S-O clip, loops-attached rubber band, and ring-thread counter traction. Furthermore, colonic polyps involving a diverticulum can be removed endoscopically.
“Pulley” traction-assisted ESD worked well in this difficult case. By showing the video, readers can understand the method and its efficacy for good visibility of the submucosal layer.
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