A recurrent lesion with severe fibrosis of colorectal endoscopic submucosal dissection using the combination of pocket-creation method and traction device

(English narration)

1. The pocket-creation method (PCM) creates a submucosal pocket below a tumor. PCM has several advantages. First, an endoscope can be stabilized in the pocket. Second, Good traction is achieved by stretching the submucosa. Third, breathing movement and poor manipulation are lessened. Thus, PCM is useful for endoscopic submucosal dissection (ESD) in cases of severe fibrosis, large tumors, and unstable locations. However, it is sometimes difficult to create a submucosal pocket.

2. Marking was performed with forced coagulation. Mucosal incision was performed with Endocut I. For precoagulation, 1 to 2 pedals of forced coagulation were used. Submucosal dissection was performed with 1 to 2 pedals of forced coagulation followed by 1 to 2 pedals of Endocut I. Coagulation for minor to middle diameter vessels was performed with rapid-step pedaling of forced coagulation. Coagulation for thick vessels was performed with soft coagulation followed by rapid-step pedaling of forced coagulation. Hemostasis was performed mainly with soft coagulation.

3. Use of the foot pedal for incision and dissection.

4. Use of the foot pedal for dissection of vessels.

5. S-O clip (Zeon Medical Co, Tokyo, Japan) is a traction device consisting of metallic clip, spring, and loop for ESD. It enables us to pull a lesion upward. Several reports showed reduced ESD procedure time. However, cases with breathing movement and poor manipulation are still difficult.

6. Case A 74-year-old woman underwent colonoscopy after endoscopic mucosal resection. A recurrent lesion 50 mm in size was detected at the ascending colon and was diagnosed as high-grade dysplasia. We herein present a case of colorectal ESD with the combination of PCM and S-O clip to ameliorate each difficulty. The S-O clip allows easy formation of a submucosal pocket. Moreover, the combination of PCM and S-O clip enable adequate traction.

7. A recurrent lesion 50 mm in size was located on the ascending colon.

8. First, we made an injection of 0.2% hyaluronic acid with indigo carmine.

9. We incised the mucosa using a scissors-type knife from the oral side.

10. We then achieved a full circumferential incision.

11. We performed an additional injection at the anal side of the lesion.

12. Next, we deployed the S-O clip at the anal side of the partially resected specimen.

13. The S-O clip and the lesion were pulled up with another regular clip.

14. Sufficient traction with the S-O clip was achieved.

15. We created a pocket for dissecting only the center of the submucosa below the tumor even during breathing movement.

16. In the pocket, the endoscope became stable. We could perform accurate dissection for severe fibrosis with enough traction with the PCM and S-O clip.

17. After dissecting most of the submucosa, we dissected both lateral sides of the pocket.

18. The dissection was easy because sufficient traction was maintained with the S-O clip.

19. En bloc resection was achieved, and the ESD procedure time was 80 minutes.

20. We disconnected the loop of the S-O clip using the clip device.

21. We removed the tumor from the rectum with big forceps using a forefinger compression method, which was our original method.

22. The histopathologic diagnosis was high-grade dysplasia with free margins.

23. In conclusion, we present ESD for a recurrent lesion with severe fibrosis that was resected successfully using the combination of PCM and S-O clip. This technique is novel for overcoming the difficulties in creating a pocket and maintaining sufficient traction.