Colorectal endoscopic submucosal dissection (ESD) is considered one of the most challenging
procedures owing to the difficulty in maintaining good visualization of the submucosal
layer. To improve the visibility of the submucosal layer, various traction methods
have been invented [1−4]. We have developed a new and efficient traction method called
the “dental-floss with rubber-band method” (DRM).
First, we connect rubber bands to the dental floss at intervals of about 3 cm ([Fig. 1 a]). The dental floss with the rubber bands attached is then fixed in position with
tape so that the rubber bands are visible from the transparent hood when the endoscope
is pulled out ([Fig. 1 b] and [Fig. 2 a]). The endoscope is inserted as usual, and circumferential dissection of the mucosa
around the lesion is performed. The endoscope is pulled out a little or retroflexion
is performed to bring a rubber band into the view of the endoscope. The rubber band
is applied to the edge of the dissected mucosa and affixed with a clip to the contralateral
colonic mucosa ([Fig. 2 b, c]). Traction is added through the dental floss and the rubber band, so improving visibility
of the submucosa. The direction of traction may be changed by gently pulling the dental
floss, and sustained and efficient traction can be obtained ([Fig. 2 d]).
Fig. 1 Photographs showing: a the rubber bands fixed at intervals of about 3 cm along the dental floss; b the dental floss with rubber bands attached fixed with tape in a position where the
rubber bands are visible from the transparent hood.
Fig. 2 Schematic showing: a the dental floss with attached rubber bands affixed to the endoscope and transparent
hood with tape; b a rubber band being applied to the edge of the dissected mucosa after the mucosa
around the lesion has been circumferentially dissected; c the rubber band being affixed with a clip to the contralateral colonic mucosa; d the good view of the submucosa that can be obtained by gently pulling the dental
floss.
[Video 1] shows how to prepare the dental floss and rubber bands and an example of colonic
ESD using the DRM. The patient had a large elevated lesion 65 mm in size in the cecum
([Fig. 3 a]), and ESD was performed. After the circumferential incision, it was difficult to
see the submucosal layer ([Fig. 3 b]). Continuous traction was applied several times using the DRM and good visualization
of the submucosa was obtained ([Fig. 3 c]). The lesion was completely removed with free margins.
Video 1 The procedure for attaching the rubber bands to the dental floss and fixing the dental
floss with the rubber bands attached to the colonoscope. Colonic endoscopic submucosal
dissection is then performed using the “dental-floss with rubber-band method.”
Fig. 3 Colonoscopic views showing: a a large elevated lesion (65 mm) in the cecum; b the lesion after circumferential incision; c the improved visibility of the submucosa when traction is applied by the dental floss
and rubber bands.
Effective traction in colorectal ESD requires the following:
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it should be inexpensive
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it should not require reinsertion
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the direction of traction should be changeable, and
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it should afford continuous traction.
The DRM is a new and efficient method that satisfies all of the above.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
