Post written by Sukit Pattarajierapan, MD, from the Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

We present 2 cases of a lateral spreading tumor with the pseudo-depressed nongranular type (LST-NG-PD) with submucosal fibrosis at the ascending colon. The tumors were challenging to resect by endoscopic submucosal dissection (ESD) with high risk of perforation. We used the combination of near-focus mode and a self-made rubber band traction clip to improve visualization of the submucosal plane.

Finally, we successfully removed the lesions without an adverse event. The pathologic examination showed intramucosal adenocarcinoma with clear resection margins for the first case and tubular adenoma with high-grade dysplasia with clear resection margins for the second case.

Visualization of the dissection plane is crucial for successful ESD of fibrotic colorectal polyps such as LST-NG-PD. The near-focus mode of a dual-focus colonoscope enhances visualization of the submucosal plane because the typical dissection range is <10 mm, and this range is compatible with the depth of field of the near-focus mode of a dual-focus colonoscope, which is 4 to 9 mm for a 290 series colonoscope (CF-HQ290I; Olympus, Tokyo, Japan).

In addition, we used a self-made rubber band traction clip to increase visualization of the dissection plane. Combining these 2 methods helped us successfully remove the lesions.

The technique with near-focus mode during ESD can be used with many types of caps, such as the transparent cap (Olympus) and the ST Hood (Fujifilm, Tokyo, Japan). However, the limitation of using a dual-focus colonoscope during ESD is endoscope maneuverability. A dual-focus colonoscope has 180^o up-angulation range, which is less than a therapeutic pediatric colonoscope with 210^o up-angulation range.

In conclusion, the combination of near-focus mode and traction device could be helpful during ESD of colon polyps with submucosal fibrosis because they enhance visualization of the dissection plane.

The typical dissection range of endoscopic submucosal dissection is <10 mm. This range is compatible with depth of field of the near-focus mode of a dual-focus colonoscope, which is 4 to 9 mm for a 290 series colonoscope.

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