Endoscopic intermuscular dissection of an undetermined submucosal lesion with adaptive traction to obtain a free vertical margin

Endoscopic submucosal dissection (ESD) is a well-established technique for resecting superficial gastrointestinal neoplasms [1]. However, achieving clear vertical margins for submucosal lesions, such as neuroendocrine tumors, can be intricate [2]. The endoscopic intermuscular dissection (EID) method, which involves dissection between the two muscular layers of the rectum, was first developed to treat superficial tumors with vertical extension (T1) [3]. We think this technique could be useful to obtain free vertical margins for submucosal tumors.

We detail the case of a 46-year-old woman who was referred to our center for a 1.5-cm submucosal lesion in the rectum, extending to the anal margin, suggestive of a neuroendocrine tumor ([Fig. 1]). EID was chosen as the preferred approach given the tumor’s location and potential depth ([Video 1]).

Fig. 1 Rectal lesion suspected of being a neuroendocrine tumor.

Intermuscular dissection of an undetermined submucosal lesion with the adaptive traction strategy.Video 1

For effective visualization during EID, the A-TRACT-2+2 adaptive traction device was utilized [4] [5] ([Fig. 2]). The lesion was marked, followed by a circumferential incision. The A-TRACT-2+2 was then positioned ([Fig. 3]) to provide consistent exposure of the intermuscular space. Its ability to adjust traction ([Fig. 4]) was beneficial in maintaining a clear view of the dissection plane, reducing the risk of unintended deeper tissue injury.

Fig. 2 The ATRACT 2+2 adaptive traction device.

Fig. 3 Placement of the ATRACT2+2 device.

Fig. 4 Activation of the device to increase traction and improve intermuscular exposure.

The lesion was resected en bloc. To our surprise, histopathology revealed the specimen was a suppurative granuloma, resected with clear resection margins ([Fig. 5]).

Fig. 5 Anatomopathological analysis revealing a suppurated granuloma.

In summary, EID offers a new approach for resecting submucosal lesions suspected of neoplasia. The technique aims to ensure clear resection margins while minimizing potential complications. Proper training and familiarization with the technique and device are essential for optimal outcomes.

Endoscopy_UCTN_Code_TTT_1AQ_2AD

 

MissingLinkText

Conflict of Interest

Louis-Jean Masgnaux, Jean Grimaldi, Timothée Wallenhorst, Jérôme Rivory, Jérémie Jacques and Mathieu Pioche are shareholders of the company ATRACT device & Co. Valerie Hervieu does not have any conflict of interest to declare.

• 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 Wallenhorst T, Masgnaux LJ, Grimaldi J. et al. Obtaining a free vertical margin is challenging in endoscopic submucosal dissection of a rectal neuroendocrine tumor: use of adaptive traction to improve exposure in a child. Endoscopy 2023; 55: 763-764
• 3 Moons LMG, Bastiaansen BAJ, Richir MC. et al. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach. Endoscopy 2022; 54: 993-998
• 4 Masgnaux LJ, Grimaldi J, Legros R. et al. Endoscopic submucosal dissection in the colon using a novel adjustable traction device: A-TRACT-2. Endoscopy 2022; 54: E988-E989
• 5 Masgnaux LJ, Yzet C, Rivory J. et al. Endoscopic intermuscular dissection of rectal T1 cancer with adaptive traction: use of additional loops to improve traction directly on the circular muscular layer. Endoscopy 2023; 55: 410-411

Publication History

Article published online:
01 March 2024