Post written by Georgios Mavrogenis, MD, from the Third Space Endoscopy Unit, Department of Gastroenterology, Mediterraneo Hospital, Athens, Greece.

This video demonstrates endoscopic submucosal dissection (ESD) of a 4-cm nongranular adenoma involving the ileocecal valve with extension into the terminal ileum—one of the most technically demanding locations for colorectal ESD. The procedure combined saline-immersion ESD with dynamic clip-and-band countertraction to improve visualization and exposure of the submucosal layer. En bloc resection was achieved without adverse events, and follow-up showed complete healing with no evidence of residual or recurrent adenoma.

Lesions involving the ileocecal valve and terminal ileum remain challenging because of unstable scope positioning, abundant submucosal fat, and limited visualization. This case illustrates how combining saline immersion with internal traction can overcome these obstacles by providing a stable operative field and continuous exposure of the dissection plane. We hope this video encourages endoscopists to consider combining complementary techniques rather than relying on a single technical modification when approaching complex colorectal ESD.

The video highlights several practical technical points: maintaining stable saline immersion, using ENDO CUT current (Erbe VIO 3, Tübingen, Germany) to minimize bubble formation during under-saline dissection, dynamically repositioning clip-and-band traction as the procedure progresses and preserving continuous visualization of the submucosal plane. These strategies can facilitate safe and efficient ESD even in anatomically difficult locations such as the ileocecal valve and terminal ileum.

We hope this video stimulates further evaluation of combined under-saline and traction-assisted techniques for complex colorectal ESD and contributes to expanding indications for minimally invasive endoscopic treatment in difficult anatomic locations. 

Exposed ileocecal valve at the end of the procedure.

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