Post written by Edward John Despott, MD, FRCP, FEBGH, FASGE, FJGES, FESGE, MD (Res), Elisabet Maristany Bosch, MD, and Georgios Kalopitas, MD, PhD, from the Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, London, United Kingdom.

We present a case of endoscopic submucosal dissection (ESD) of an 80-mm sessile lesion of the transverse colon of a 64-year-old woman with difficult access because of an irreducible sigmoid loop. Standard colonoscopy could not achieve stable positioning, so a double-balloon endoscope was used to gain access and achieve optimal stability.

ESD was performed using our saline-immersion/irrigation technique combined with the pocket-creation method, transient clip-band traction, and a novel advanced imaging mode (amber-red color imaging; Fujifilm Healthcare, Tokyo, Japan) to enhance layer and vessel visualization. En bloc R0 resection of a low-grade tubulovillous adenoma was achieved without any intraprocedural adverse events.

This case exemplifies how a tailored combination of techniques and the latest equipment and technology can transform a highly challenging colonic ESD where a traditional approach would struggle. The video provides a real-world demonstration of the integration of multiple modalities to overcome anatomical difficulty, optimize visualization, manage vessels effectively, and maintain patient comfort, maximizing both technical expertise and clinical impact.

Endoscopists can learn how a tailored combination of technology and techniques expands the boundaries of minimally invasive endoscopic resection. Specifically, the combination of saline-immersion/irrigation technique (through improved optical clarity, magnification, and vessel management) and a double-balloon endoscope can offer access and stability in difficult proximal lesions; the pocket-creation method (and adjunctive clip-band traction) aid a more efficient dissection.

Also incorporating the latest imaging technology with amber-red color imaging can help increase visual contrast, aiding both dissection and hemostasis. This case encourages adopting flexible, structured strategies to safely manage complex cases while maintaining procedural efficiency.

Amber light provides enhancement of layer distinction and vessel recognition in third-space endoscopy. Notice color enhancement provided with amber light on (A) when compared with white light (B).

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