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Endoscopic submucosal dissection (ESD) is a challenging technique that bears a significant risk of perforation. Given that standard endoscopy, unlike laparoscopy, does not permit traction, the difficulty of ESD is augmented. Countertraction techniques have been shown to improve the speed of dissection, the rate of R0 resection, and the safety of the procedure.
The materials needed are readily available and include conventional dental rubber bands (2D [3/16”] 3.5 ounce force) and clips.
If available, a new generation of removable clips (Pulp Medical, Athens, Greece; Hangzhou AGS MedTech Co, Ltd, Hangzhou, Zhejiang, China) can be used to easily detach the band whenever necessary. These clips are reopening; allow 360° bidirectional synchronous rotation control; have a 135° claw angle and opening span of 11 or 16 mm, depending on the model; and are available in working lengths compatible with either a gastroscope or a colonoscope.
The clip can be reopened after deployment by grasping the tip of the clip tightly with a polypectomy snare that has a thin wire (0.36-0.41 mm). Furthermore, a novel endoscopic tool that combines a clip and band in a single device was recently commercialized in the United States.
The purpose of this video (Video 1, available online at www.VideoGIE.org) is to demonstrate various strategies of clip and band countertraction in 4 cases in the stomach and colon.
Standard clip and band countertraction in the stomach
The first step is to make a circumferential incision and create a short flap on one side (Fig. 1). A clip, grasping a rubber band is inserted into the working channel, and the clip is fixed to the mucosal flap. Next, a second clip is introduced, grasps the band, and anchors it to the opposite side of the gastric wall, which allows for strong traction of the lesion. This traction allows for a faster and streamlined dissection. Because of the elastic band’s properties, the traction remains constant despite the progress of the dissection. At the end of the procedure, the specimen is detached from the wall by cutting the rubber with a loop cutter. Alternatively, the clip can be detached by applying gentle traction with a snare or rat-tooth forceps. We present this technique in the case of a prepyloric antral adenoma (Fig. 2).
The clip and band countertraction method allows for the possibility of axis traction modification dynamically during the procedure, according to the dissection strategy. The first attached clip is removed, and the band is then grasped with a new clip and anchored in a new location (Fig. 3). The decision to change the direction of countertraction is made when the initial traction is no longer efficient. We demonstrate this technique for the resection of an obstructive fibroid inflammatory polyp of the antrum (Fig. 4).
For large lesions in difficult locations, multiple bands can be deployed. Clips and bands anchor 2 or more points of the dissection plane, and tension is therefore exerted over a broad zone of the submucosal plane (Fig. 5). Multifocal countertraction is usually applied for lesions larger than 3 cm, in cases of fibrosis, or in challenging anatomic locations. This technique is demonstrated in a gastric ESD for multifocal dysplasia of the gastric incisura, where retroflexion was technically challenging (Fig. 6).
Technique considerations for colonic ESD
Typically, a submucosal lift in the colon may be less lasting than that in the esophagus or stomach. In an effort to mitigate seepage of the submucosal cushion and apply countertraction, the pocket creation method
Application of the clip and band technique is usually combined with the aforementioned methods. In particular, only a partial, and not full circumferential, incision is performed at the oral side and at the anal side of the lesion. Next, the clip/band complex is attached (Fig. 7). However, the strategy of circumferential incision before countertraction may still be preferred by some endoscopists. In this video (Video 1, available online at www.VideoGIE.org), we present the case of a 3-cm serrated adenoma of the cecum resected by clip and band ESD, in combination with the pocket creation method and under the saline solution immersion technique for adjuvant space expansion (Fig. 8).
Attention should be paid to avoid placing the first clip before flap creation; a misplaced clip may interfere with further dissection. In particular, the endoscopist should avoid grasping the muscle layer with the clip because this may lead to deep muscle injury or perforation.
In the event of failure to cut the rubber with the endoloop cutter, the specimen can be retrieved by applying gentle traction to the tip of the clip with a snare or a rat-tooth forceps.
Another challenge that may be encountered in clip and band colonic ESD is traction that is so strong that it pulls the muscularis propria. In this situation, the endoscopist should try to decompress the bowel lumen to decrease the force of tension that is exerted on the flap (Fig. 9). Alternatively, the clip should be repositioned at a shorter distance.
In conclusion, the clip and band technique is an efficient method of countertraction that can be applied even in the cecum. The main advantages of this technique are the ability to change the axis of countertraction during the procedure and the opportunity to apply multifocal traction if needed.
The authors would like to thank the nursing team of the department of Endoscopy (Mediterraneo Hospital) for their invaluable contribution, as well as Mr Aris Kostaras (Pulp Medical) for his help in the creation of the video.