Multitraction with a single rubber band and clips: a simple tip for endoscopic submucosal dissection of a recurrent lesion with previous clip

 

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Endoscopic submucosal dissection (ESD) with double-clip traction (DCT) with a rubber band and two clips allows excellent en bloc and curative resection rates and is probably the cheapest traction system available [1]. Incomplete previous resection or recurrence is associated with a higher piecemeal resection rate [2] and severe fibrosis is an independent predictor of perforation [3]. DCT is also safe and effective in these settings [4]. Multipolar traction has been reported to improve the visualization of the submucosa with four peripheral rubber bands fixed with four clips on the edges and attached to a central band that is fixed on the opposite wall with a fifth clip [5]. This is effective but requires some time to set up the device, which can be difficult to advance up through a thin operative channel.

We report the case of a 63-year-old woman with a partially resected cecal granular laterally spreading tumor (LST) and a clip placement, referred for ESD. Initial evaluation showed a 50 × 40-mm granular LST with a retractive aspect on a fold and persistence of the clip, without signs submucosal invasion ([Fig. 1]). After submucosal injection of glycerol mixed with indigo carmine, circumferential incision, and trimming of the edges, a first clip with a rubber band attached was introduced into the scope and fixed to the medial part of the anal side of the lesion ([Video 1]). Then two other clips were placed on either side of the first one, also gasping the elastic. Finally, the elastic was caught with a fourth clip and fixed on the opposite wall ([Fig. 2]). This simple strategy allowed even better exposure of the submucosa, in particular in the lateral edges of the lesions, and sufficient view under the previous clip ([Fig. 3]), which was the site of intense fibrosis, to achieve en bloc resection of the lesion without any perforation. After resection, the fold was almost erased.

Video 1 Multitraction with a single rubber band and clips: a simple tip for endoscopic submucosal dissection of a recurrent lesion with previous clip.

Multitraction with a single rubber band is a cheap and easy-to-use technique that could help to expose lateral edges of submucosa even better in challenging cases of ESD like recurrent lesions.

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Publication History

Article published online:
15 June 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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