Endoscopic submucosal dissection of colonic residual laterally spreading tumor with adaptive traction: use of the additional loops to improve traction focally in difficult area

Multipolar traction is a recent advance in colorectal endoscopic submucosal dissection (ESD) to expose the submucosal field [ 1 ] particularly for challenging lesions like residual lesions [ 2 ]. Nevertheless, two limitations exist with four-point traction. First, traction tends to reduce as ESD progresses, although new devices that can be stretched during the procedure to increase traction seem promising [ 3 ] [ 4 ]. Second, systematically placing four traction points is expensive (four clips), time-consuming, and not needed for lesions < 4 cm. For small lesions, two-point adaptive traction seems sufficient, but additional focal traction on the difficult area could help the physician. We developed a traction device (A-TRACT 2 + 2, Hospices Civils de Lyon) ([ Fig. 1 ]) with two adjustable loops with a tightening link and two additional large loops that can be used to stretch any part of the lesion when the procedure is in progress. Fig. 1 A-TRACT device with the different components. 1 Fixed point attached to the oral side. 2 Second blue loop linked to the tightenable part. 3 Lateral free loops to obtain four-cardinal-point traction. 4 Rubber band attached to the opposite wall. 5 Closure loop with notched wire. We report here the case of a 66-year-old patient with a 4-cm residual non-granular laterally spreading tumor in the transverse colon previously resected partially by endoscopic mucosal resection (EMR). After complete circumferential incision and trimming, we fixed the device by catching the two adjustable loops ([ Video 1 ]); the rubber band was then attached to the opposite wall. Afterward, ESD began but one clip was snatched out when the system was tightened, with the remaining traction on a single point. ESD became difficult because of a severe fibrosis, and additional traction was needed. Therefore, we caught the two additional loops to fix the device to the two edges when exposure became difficult. The loop fixed on the right edge where fibrosis was severe was the most help. We achieved an R0 resection without an adverse event. Video 1 Endoscopic submucosal dissection strategy for a residual non-granular laterally spreading tumor using A-TRACT 2 + 2. Quality: mobile 360 480 720 Download In conclusion, this device allows adjustable traction with the capability to add traction at the difficult area using the additional loops on the device. Endoscopy_UCTN_Code_TTT_1AQ_2AD Endoscopy E-Videos https://eref.thieme.de/e-videos Endoscopy E-Videos is an open 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. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available. This section has its own submission website at https://mc.manuscriptcentral.com/e-videos Publication History Article published online: 25 November 2022 © 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany