Endoscopic submucosal dissection of a large sessile serrated lesion recurrence using an adaptive traction device

Large serrated sessile lesions (SSLs) of the colon are challenging to resect completely because it is difficult to determine the margins. Therefore, recurrences are frequent and challenging to treat. For small recurrences (< 10 mm), there are a few possible resection strategies, such as underwater endoscopic mucosal resection (UEMR), endoscopic full-thickness resection (EFTR), and hot avulsion. There remains an ongoing debate as to the best way to remove larger recurrences when, because of the lesion size, EFTR risks incomplete removal (> 20 mm) or is impossible (> 30 mm) [1]. Hot avulsion usually requires several sessions to completely eradicate the recurrence. As a result, the only method for a complete single-session resection is dissection, but ESD in such lesions is challenging because of fibrosis and location (mostly in the right colon). Therefore, methods are needed to improve exposure and make dissection possible.

We present a case of ESD for a 4-cm SSL recurrence at the site of a previous piecemeal EMR performed 7 months previously in the right colon. The margins of the lesion were delineated using i-SCAN digital contrast (Pentax, Tokyo, Japan) on a therapeutic colonoscope (E34i10). An adaptive traction device (A-TRACT 2 + 2; Hospices Civils de Lyon) was used to improve the exposure of the area [2] [3] [4], according to the current setup strategy [5]. After a circumferential incision with large margins (to fix the clips onto normal tissue) had been made, the first two loops were placed at the oral and anal edges of the target area ([Video 1]), then the two additional loops were placed on the two side edges and the rubber band was fixed to the opposite wall to get 90° traction. We began the dissection process and, when exposure tended to be poor, we tightened the device to increase traction and improve exposure and visualization ([Fig. 1]).

Video 1 Endoscopic resection of a large sessile serrated lesion recurrence after piecemeal endoscopic mucosal resection using the adaptive traction device (A-TRACT 2 + 2).

Fig. 1 Illustration showing the adaptive traction system (A-TRACT 2 + 2) fixed on a lesion: a before tightening; b after tightening, which increases the traction during dissection.

Thanks to adaptive traction, ESD is feasible for large recurrences or difficult residual lesions, offering a chance of successful endoscopic treatment in a single session.

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Competing interests

L.-J. Masgnaux, Mathieu Pioche and Jérôme Rivory are cofounders of the start up A-tract.

• References

• 1 Faller J, Jacques J, Oung B. et al. Endoscopic submucosal dissection with double clip and rubber band traction for residual or locally recurrent colonic lesions after previous endoscopic mucosal resection. Endoscopy 2020; 52: 383-388
• 2 Grimaldi J, Masgnaux L-J, Rivory J. et al. Multipolar traction with adjustable force increases procedure speed during endoscopic submucosal dissection: the A-TRACT-4 traction device. Endoscopy 2022; 54 (Suppl. 02) E1013-E1014
• 3 Masgnaux L-J, Grimaldi J, Legros R. et al. Endoscopic submucosal dissection in the colon using a novel adjustable traction device: A-TRACT-2. Endoscopy 2022; 54 (Suppl. 02) E1013-E1014
• 4 Yzet C, Masgnaux L-J, Rivory J. et al. Endoscopic submucosal dissection of colonic residual laterally spreading tumor with adaptive traction: use of the additional loops to improve traction focally in difficult area. Endoscopy 2023; 55 (Suppl. 01) E260-E261
• 5 Pioche M, Masgnaux L-J, Rivory J. et al. Endoscopic submucosal dissection in the colon with adaptive traction device: resection strategy and device setup. Endoscopy 2023; 55 (Suppl. 01) E171-E172

Publication History

Article published online:
10 May 2023