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Combination of rubber band traction and partial injection for effective under-gel endoscopic mucosal resection of an ileocecal valve lesion

Open AccessPublished:January 05, 2022DOI:https://doi.org/10.1016/j.vgie.2021.11.007

      Video

      (mp4, (130.29 MB)

      A 25-mm protruding polyp was detected on the proximal lip of the ileocecal valve, extending into the terminal ileum. The tumor was treated effectively with under-gel EMR and a combination of the double-clip and rubber band traction method and partial submucosal injection.

      Abbreviations:

      ICV (ileocecal valve), ESD (endoscopic submucosal dissection)
      Neoplasms on the ileocecal valve (ICV) extending into the terminal ileum complicate EMR and endoscopic submucosal dissection (ESD), resulting in lower complete-resection rates; this leads to tumor recurrence.
      • Kishimoto G.
      • Saito Y.
      • Takisawa H.
      • et al.
      Endoscopic submucosal dissection for large laterally spreading tumors involving the ileocecal valve and terminal ileum.
      ,
      • Andrisani G.
      • Fukuchi T.
      • Antonelli G.
      • et al.
      Superficial neoplasia involving the ileocecal valve: Clinical outcomes of endoscopic submucosal dissection.
      ESD for ICV neoplasms, although feasible and effective, is time-consuming and not yet established as a standard procedure.
      • Andrisani G.
      • Fukuchi T.
      • Antonelli G.
      • et al.
      Superficial neoplasia involving the ileocecal valve: Clinical outcomes of endoscopic submucosal dissection.
      Underwater EMR is considered an effective alternative to ESD for colorectal tumors.
      • Binmoeller K.F.
      • Hamerski C.M.
      • Shah J.N.
      • et al.
      Attempted underwater en bloc resection for large (2-4 cm) colorectal laterally spreading tumors (with video).
      However, when the lesion is on the proximal lip of the ICV (toward the appendiceal orifice), EMR becomes more difficult to accomplish because of poor visualization of the proximal and distal (toward the ascending colon) margins. Our hospital reported that under-gel EMR with partial injection is effective for lesions where the proximal margin is difficult to visualize.

      Yamamoto K, Kanomata N, Ikeya T. Utility of under-gel endoscopic mucosal resection with partial submucosal injection for a laterally spreading tumor. Endoscopy. Epub 2021 Mar 15.

      However, visualization of the distal margin extending into the terminal ileum remains difficult. The double-clip and rubber band traction method, which uses a rubber band and 2 clips, has been reported to be effective during ESD for colorectal lesions, including ICV lesions.
      • Jacques J.
      • Charissoux A.
      • Bordillon P.
      • et al.
      High proficiency of colonic endoscopic submucosal dissection in Europe thanks to countertraction strategy using a double clip and rubber band.
      ,
      • Wallenhorst T.
      • Pioche M.
      • Bouguen G.
      • et al.
      Ileocecal valve opening with double clip and rubber band for countertraction facilitates R0 en bloc resection of laterally spreading tumors.
      Herein, we present a case in which a combination of the rubber band traction method and partial injection was useful for visualizing the proximal and distal margins of a lesion on the proximal lip of the ICV (Video 1, available online at www.VideoGIE.org).
      A 42-year-old woman underwent an initial colonoscopy examination. A 25-mm protruding polyp was detected on the proximal lip of the ICV, extending into the terminal ileum (Fig. 1). On colonoscopy with narrow-band imaging, the polyp was suspected to be an adenoma. Using grasping forceps, we tested the traction to determine the direction in which the distal side of the tumor could be visualized easily. Traction on the distal lip toward the distal side facilitated visualization of the distal margin of the tumor (Fig. 2). A repositionable clip (Sure Clip; Micro-Tech Co, Ltd, Nanjing, China) was used to attach the mucosa of the distal lip to a Fox rubber band (3D [0.25 inch]; 3.5 oz; ORMCO, Calif). An endoclip (EZ-clip; Olympus, Tokyo, Japan) was used to hook the rubber band and was clipped to the ascending colon with traction to the distal side (Fig. 3). Consequently, the distal margin of the tumor remained visible throughout the procedure (Fig. 4).
      Figure thumbnail gr1
      Figure 1Colonoscopy reveals a 25-mm protruding polyp on the proximal lip of the ileocecal valve, which extends into the terminal ileum. In these types of lesions, it is difficult to visualize the proximal and distal margins.
      Figure thumbnail gr2
      Figure 2Testing traction with the grasping forceps: Traction on the distal lip toward the distal side makes visualizing the distal margin of the tumor easier.
      Figure thumbnail gr3
      Figure 3Double-clip and rubber band traction.
      Figure thumbnail gr4
      Figure 4A, Illustration depicting the effect of the double-clip and rubber band traction and partial submucosal injection. B, After double-clip and rubber band traction, the distal margin of the tumor is visible during under-gel EMR. C, After partial submucosal injection of saline solution along the proximal side of the tumor, the proximal margin of the tumor is visible.
      Partial submucosal saline solution injection was performed along the proximal side of the tumor to allow visibility of the proximal tumor margin (Fig. 4). The lumen was filled with a gel (VISCOCLEAR; Otsuka Pharmaceuticals Factory, Inc, Tokushima, Japan), and an under-gel EMR was performed with a hexagonal snare (13-mm Captivator, small hex-type; Boston Scientific, Natick, Mass, USA) (Fig. 4). The EMR site could be closed completely (Fig. 5). En bloc resection was achieved without residual resection (Fig. 6). The total procedure time was 12 minutes, and there were no adverse events. The histopathological diagnosis was of an adenoma with negative margins. No recurrence was observed at the 3-month follow-up colonoscopy examination.
      Figure thumbnail gr5
      Figure 5The EMR site has been completely closed with clips.
      The advantages of this method are as follows: (1) The direction of traction can be checked several times with grasping forceps before application of traction; (2) because the traction is applied on the ICV side opposite to the lesion, it does not interfere with the EMR; and (3) this traction can be applied through the device’s channel, and thus the endoscope need not be removed.
      In this case, the tumor on the proximal lip of the ICV was treated effectively with under-gel EMR and a combination of the double-clip and rubber band traction method and partial submucosal injection.

      Disclosure

      All authors disclosed no financial relationships.

      Supplementary data

      References

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