Multitraction with a single rubber band and clips: a simple tip for endoscopic submucosal dissection of a recurrent lesion with previous clip

Endoscopic submucosal dissection (ESD) with double-clip traction (DCT) with a rubber band and two clips allows excellent en bloc and curative resection rates and is probably the cheapest traction system available [1]. Incomplete previous resection or recurrence is associated with a higher piecemeal resection rate [2] and severe fibrosis is an independent predictor of perforation [3]. DCT is also safe and effective in these settings [4]. Multipolar traction has been reported to improve the visualization of the submucosa with four peripheral rubber bands fixed with four clips on the edges and attached to a central band that is fixed on the opposite wall with a fifth clip [5]. This is effective but requires some time to set up the device, which can be difficult to advance up through a thin operative channel.

We report the case of a 63-year-old woman with a partially resected cecal granular laterally spreading tumor (LST) and a clip placement, referred for ESD. Initial evaluation showed a 50 × 40-mm granular LST with a retractive aspect on a fold and persistence of the clip, without signs submucosal invasion ([Fig. 1]). After submucosal injection of glycerol mixed with indigo carmine, circumferential incision, and trimming of the edges, a first clip with a rubber band attached was introduced into the scope and fixed to the medial part of the anal side of the lesion ([Video 1]). Then two other clips were placed on either side of the first one, also gasping the elastic. Finally, the elastic was caught with a fourth clip and fixed on the opposite wall ([Fig. 2]). This simple strategy allowed even better exposure of the submucosa, in particular in the lateral edges of the lesions, and sufficient view under the previous clip ([Fig. 3]), which was the site of intense fibrosis, to achieve en bloc resection of the lesion without any perforation. After resection, the fold was almost erased.

Fig. 1 Granular laterally spreading tumor with previously placed clip.

Video 1 Multitraction with a single rubber band and clips: a simple tip for endoscopic submucosal dissection of a recurrent lesion with previous clip.

Fig. 2 Placement of multitraction with a single rubber band.

Fig. 3 View under the previously placed clip.

Multitraction with a single rubber band is a cheap and easy-to-use technique that could help to expose lateral edges of submucosa even better in challenging cases of ESD like recurrent lesions.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Bordillon P, Pioche M, Wallenhorst T. et al. Double-clip traction for colonic endoscopic submucosal dissection: a multicenter study of 599 consecutive cases (with video). Gastrointest Endosc 2021; 94: 333-343
• 2 Hori K, Uraoka T, Harada K. et al. Predictive factors for technically difficult endoscopic submucosal dissection in the colorectum. Endoscopy 2014; 46: 862-870
• 3 Hayashi N, Tanaka S, Nishiyama S. et al. Predictors of incomplete resection and perforation associated with endoscopic submucosal dissection for colorectal tumors. Gastrointestinal Endoscopy 2014; 79: 427-435
• 4 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
• 5 Oung B, Albouys J, Geyl S. et al. “Spider traction” endoscopic submucosal dissection for colonic lesion. Endoscopy 2022; 54: E560-E561

Publication History

Article published online:
15 June 2023