Use of a novel articulation arm device for endoscopic submucosal dissection of a rectal laterally spreading tumor

Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic resection method that allows for larger lesions to be removed en bloc. ESD has become more popular in the Western world over the past decade as a surgical sparing procedure. It can be performed for superficial lesions in the esophagus, stomach, duodenum, and large intestine. However, ESD can be technically challenging for larger lesions in difficult locations. Unlike surgery that applies direct traction, endoscopy does not have hands-on traction.

The main benefits of traction include decreased procedure time and lower adverse event risk because of better visualization of the subepithelial planes. In an effort to counteract the lack of traction with endoscopy, novel traction devices were developed. Some traction methods that are widely available to use include clip and line, where an endoclip is attached to a thin thread (eg, dental floss), and the elastic band method using an endoclip and a small rubber band. The main benefit of using one of these methods is obtaining traction with low expense, yet a major downside is difficulty adjusting, if needed. To further build on this, a new traction wire device made with nitinol was developed (ProdiGi Traction Wire; Medtronic, Minneapolis, Minn, USA), which added the benefit of easier adjustment and better traction compared to a thread.

While these traction models have their benefits, the time it takes and extent to make an adjustment may still be limiting for ESD. A novel device has recently been developed that is a single operator 360° articulating arm (TRACMOTION; Fujifilm Healthcare Americas Corporation, Lexington, Mass, USA), which provides traction as well as mobility (Fig. 1). We present a case of a successful ESD involving a large rectal laterally spreading tumor (LST) using the articulating arm device (Video 1, available online at www.giejournal.org).

A 58-year-old man with no significant medical history underwent a colonoscopy and was found to have a 10-cm rectal LST with pathology revealing a tubulovillous adenoma. He was subsequently referred for ESD removal. For the procedure, a double-channel therapeutic gastroscope (GIF-2TH180; Olympus, Hamburg, Germany), electrocautery knife (DualKnife J; Olympus), and the articulating arm device (TRACMOTION) were used. Upon careful inspection with high-definition white-light and narrow-band imaging, the lesion was determined to be Paris classification 0-IIc with granular and nodular pit patterns arising 10 cm away from the dentate line and comprising 60% of the area of the rectum (Figs. 2 and 3).

Markings using the electrocautery knife were made around the lesion using soft coagulation (Fig. 4). The distal portion of the lesion was then injected with a submucosal lifting agent, and the initial incision was made. Dissection continued around to the proximal borders of the lesion with ongoing submucosal injection until a flap was created (Fig. 5). Because of the large, bulky nature of the lesion against gravity, we opted to use the articulating arm device. The device was put through the 3.7-mm working channel of the therapeutic gastroscope, and it grabbed the flap to better expose the submucosal plan for continued dissection (Fig. 6). The remainder of the LST was completely dissected en bloc using this method. The resection bed was evaluated for any blood vessels and full-thickness defects with soft coagulation and/or endoclips placed in any area of concern. The lesion was retrieved, pinned to a board, and sent to pathology, which confirmed tubulovillous adenoma with clean margins (Fig. 7). The patient did not receive antibiotics and was admitted to the hospital after the procedure for close monitoring. He did very well, with no adverse events post-ESD including pain, leakage, or bleeding and was discharged the following day. A repeat flexible sigmoidoscopy 2 weeks later revealed 3 hemostatic clips in place, which were subsequently removed, and no adenomatous tissue was visualized, which was confirmed with biopsies of the site revealing normal rectal mucosa.

This device has several features that set it apart from other traction devices. It has 360° jaw movement that can grasp and re-grasp tissue easily. It can perform movement within the channel, independent of the endoscope movement, and no locking mechanisms are needed. As a result, this is a single-operator device. The mobility of the articulating arm is useful in adding efficiency and decreasing procedure time for large lesions in difficult locations. Being able to move a lesion continuously during dissection allows for improved visualization of the subepithelial planes. In turn, blood vessels and small full-thickness defects are better recognized and treated, preventing development of adverse events later on.

In summary, we present a novel articulating arm device and demonstrate its ease of use while performing ESD on a large rectal LST. This now introduces continuous mobility with traction during complex dissections, which has been lacking to date. Future studies will need to compare this device to other traction devices with regard to efficiency and adverse events.