Post written by Darshan Parekh, MBBS, MS, from the Department of Endoscopy, Thane Institute of Gastroenterology, Thane, Maharashtra, India, and Ken Ohata, MD, PhD, from the NTT Medical Center Tokyo, Tokyo, Japan.

A 69-year-old woman underwent endoscopic submucosal dissection (ESD) for a recurrent, circumferential, rectal tumor starting just above the anal verge and extending 5 cm proximally with a previous ESD scar. ESD was planned using multiple tunnel techniques.

However, because the lesion was just above the anal verge and previous ESD and steroid injection resulted in severe submucosal fibrosis, neither the mucosa nor adequate submucosa could not be preserved. This led to the lesion falling proximally into the lumen, impairing submucosal visibility.

Hence, 3 clip-line tractions were placed in a triangular manner over the lesion at the beginning of each tunnel. En bloc resection was achieved. The specimen measured 110 x 75 mm. There were no adverse events during and immediately postprocedure. Pathology reported tubular adenoma with high-grade dysplasia with negative margins. Follow-up endoscopy after 45 days revealed no stricture with complete mucosal healing and no residual lesion.

To our knowledge, this is the first report describing the strategy of using multiple clip-line tractions to draw a circumferential lesion outward in the rectum and create space as required by adjusting the direction of external pull to facilitate visibility and counter severe submucosal fibrosis.

ESD is a dynamic procedure, and there can be various intraprocedural challenges. It is important to have the knowledge and experience to modify and apply different strategies to manage such complex cases.

Past endoscopic submucosal dissection. A, Tumor in retroflexion view with white light. B, Tumor from retroflexion view with narrow-band imaging (NBI). C, Tumor from forward view with white light. D, Tumor from forward view with NBI. E, Ulcer from forward view. F, Ulcer in retroflexion. G, En bloc specimen.

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