Post written by Tatsuma Nomura, MD, from the Department of Gastroenterology, Mie Prefectural Shima Hospital, Shima, and the Department of Gastroenterology, Ise Red Cross Hospital, Ise, Mie, Japan.

We describe a novel technique for overcoming severe fibrosis encountered during endoscopic submucosal dissection (ESD) using a calibrated, small-caliber tip, transparent hood (CAST hood) with Pocket-creation method (PCM) and/or saline-immersion conditions. 

To date, various methods to manage severely fibrotic lesions encountered during ESD have been described. In this regard, the method of dissecting the submucosa on both sides of the fibrotic area before dissecting the severely fibrotic part has been reported to be beneficial. In particular, the pocket-creation method is considered to be a useful method for adding adequate traction to the fibrotic area by using a small-caliber tip, transparent (ST) hood with a tapered tip and allowing the muscles to be approached in parallel. In recent years, the performance of ESD in saline environments has been reported. A CAST hood has been designed for small intestinal strictures by using a tapered hood that can measure the diameter and perform balloon dilation of the stricture. The CAST hood is a transparent hood with a 4-mm tip diameter that can be used in ESD. We present a technique for overcoming severe fibrosis encountered during ESD using a CAST hood with PCM and/or saline-immersion conditions in the following video cases of stomach, rectum, and duodenum ESD.    

The advantages of ESD using the CAST hood with a 4-mm tip compared to the conventional tapered hood are listed below.

Advantages:

・One can easily dive into the submucosal layer when the submucosal flap is made.

・The small volume inside the CAST hood makes it easy to replace saline in saline-immersion conditions.

・Accurately sized small pockets can be intentionally created in the normal mucosa on both sides of the severely fibrotic area in the submucosal pocket.

・In dissecting with saline-immersion, the visibility of the endoscope is magnified 1.3 times, allowing accurate dissection.

The CAST hood using PCM and/or saline-immersion conditions is suitable for lesions with severe fibrosis encountered during gastrointestinal ESD.

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