Hepatic flexure breakdown strategy with adaptive traction for endoscopic submucosal dissection

Adaptive traction-assisted endoscopic submucosal dissection (ESD) has been shown to be effective in the treatment of difficult colonic lesions [1] [2] [3] [4]. The hepatic flexure is one of the most challenging sites for colonic ESD, associated with longer resection times and more technical failures [5].

We report here the case of a 68-year-old patient referred for ESD resection of a nongranular LST located on the mesenteric side of the hepatic flexure ([Video 1]). The resection of this lesion was complicated by the access to the oral part of the lesion, which was very difficult due to the poor maneuverability of the endoscope ([Fig. 1]). After making a circumferential incision, we positioned the adaptive multitraction device (ATRACT, Lyon, France) at the four cardinal points of the lesion ([Fig. 2]). We then chose to attach the rubber band to the opposite colonic wall, not over the center of the lesion as it is usually done, but in the transverse colon downstream of the lesion. This allowed the hepatic flexure to be aligned with the transverse colon so that ESD was performed in a straight colon rather than an angled colon ([Fig. 3]). The resection was R0 and without complications. The total procedure time was 40 minutes. The lesion was a high-grade dysplastic adenoma.

Hepatic flexure breakdown strategy for ESD.Video 1

Fig. 1 The lesion was located on the mesenteric side of the hepatic flexure with very difficult access to its cecal part due to poor maneuverability of the endoscope in the hepatic flexure.

Fig. 2 Adaptive multitraction device (ATRACT).

Fig. 3 The rubber band of the ATRACT traction device was placed in the transverse colon downstream of the lesion, to align the hepatic flexure with the transverse colon to facilitate ESD.

This case illustrates the great interest of traction in difficult colonic lesions, not only to open the submucosal plane but also to modify the conformation of the colon when this makes resection more difficult. The development of computational modeling tools could help define optimal traction strategies for these difficult and unique lesions, whose resection strategy is still determined empirically today.

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Publication History

Article published online:
18 June 2025

• References

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