Post written by Naohisa Yoshida, MD, PhD, from the Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.

Colorectal endoscopic submucosal dissection (ESD) is spreading in the world, but there are still several problems such as poor manipulation, breathing movement, severe fibrosis, and long procedure time. Pocket-creation method (PCM) is a method that makes a submucosal pocket below a tumor, so that the endoscope becomes stable in the pocket. This method is useful for a lesion with severe fibrosis or poor manipulation. However, making a pocket is sometimes challenging, especially for non-experts. On the other hand, S-O clip (Zeon Medical Co., Tokyo, Japan) is a traction device, and it allows us to pull a lesion upward and makes ESD procedure time shorter. However, cases with breathing movement and poor manipulation are still difficult when we use S-O clip. We herein presented a case of colorectal ESD using the combination of PCM and S-O clip for improving each difficulty. Sufficient traction with S-O clip allows an easy formation of a submucosal pocket, and PCM enables us to achieve stable endoscopic view even in cases with S-O clip.

PCM and S-O clip are useful and spreading; however, each method has difficulties. Regularly, these 2 methods are each used independently. However, we developed a combination of PCM and S-O clip. First, circumferential mucosal incision is performed followed by deploying S-O clip. Then, only the center of submucosa is dissected to make a pocket, and a stable view can be achieved. It allows us to resolve each difficulty and make ESD fast and standardized. Additionally, Clutchcutter (Fujifilm, Tokyo, Japan), which is a scissor-type knife, makes ESD safer and easier compared to needle-type knives.

Using this combination method with Clutchcutter, endoscopists can perform stable and safe colorectal ESD even if they don’t have enough experience with gastric ESD. So far, S-O clip had not been released in Western countries. There are several other traction devices like S-O clip; we suggest this combination method can be performed with these other devices.

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