A novel approach to endoscopic submucosal dissection of a large enteral lesion. We don't have any disclosures. Endoscopic submucosal dissection is a minimally invasive technique that enables unblocked resection of larger and more invasive GI lesions, surpassing the limitations of endoscopic mucosal dissection typically suited for smaller and more superficial lesions. Despite its advantages, conventional ESD often struggles to achieve adequate lesion exposure for precise dissection and robust defect closure, particularly in large and deeply embedded lesions. We present a novel approach to endoscopic submucosal dissection for managing a challenging enteral submucosal lesion, combining enhanced traction-assisted resection with complete defect closure using purse-string suture. Markings were made around the lesion using a pro-knife to outline its boundaries. Then a submucosal injection was performed to lift the lesion, followed by circumferential incision. Submucosal dissection was performed to free up pockets surrounding the lesion. Utilizing a double-channel scope equipped with an overstitched device, a single suture with two bites was placed to apply traction on the lesion. The suture was left loose inside the GI tract. Subsequently, a purse-string suture was partially constructed using seven bites around the margins of the anticipated defect, intending to achieve full thickness closure after lesion resection. This suture was not tightened at this stage, preserving the option to close the defect completely post-resection. Using a clutch-cutter knife, and traction-assisted resection to enhance visualization and facilitate dissection, the lesion was successfully excised en bloc. Full thickness closure of the defect was then completed using the pre-placed purse-string suture, achieving complete defect closure. A 40-year-old patient with a history of microcytic anemia previously underwent an EGD and colonoscopy, during which a subepithelial lesion in the gastric antrum was identified on EGD. Biopsies were obtained at that time. However, the pathology results were inconclusive for the presence of a gastrointestinal stromal tumor. The patient returned for this visit to undergo an EGD with endoscopic submucosal dissection for resection of the gastric lesion. Markings were placed around the lesion using an injectable needle-type electrosurgical knife. A submucosal injection was administered to lift the lesion and a circumferential incision was made. Submucosal dissection was performed to create separation around the lesion. Submucosal dissection was performed to create separation around the lesion. The underlying lesion appeared to be arising from the muscle and had a thick stalk. We decided to perform traction-assisted resection. At this time, we switched to the double-channel therapeutic scope with overstitch device. Using the suturing device, a purse-string suture with 7 bites was placed around the margins of the defect. Multiple bites were carefully taken around the entire parameter of the anticipated defect. The suture threads were left unsecured at this stage until the lesion resection was completed. Then, using another suture, two bites were placed to provide traction. The first bite was taken from the lesion and the second bite was placed more distally in the stomach. This two-byte suture, when traction is applied, lifts the lesion, exposing the stalk and creating space for submucosal resection. The lesion was meticulously dissected and completely removed en bloc using a clutch cutter knife. Traction assistance was applied to lift and stabilize the lesion, providing better visualization of the dissection plane. This approach ensured precise cutting along the submucosal layer, resulting in a clean and intact removal of the lesion in one go. Following resection, the defect was closed completely by pulling by the end of the sutures, achieving full thickness closure with adequate approximation. The suture was cinched and the defect was closed completely. No bleeding or complications were noted. This novel approach enhances the precision of resecting large and deep lesions, while ensuring a secure and effective closure. Traction provides better visualization and stability during dissection, allowing for cleaner on-block lesion removal. The per-string suture then ensures complete full-thickness closure, reducing the risk of complications and facilitating optimal healing. We present a novel approach to endoscopic submucosal dissection for managing a challenging enteral submucosal lesion. This technique combines enhanced traction-assisted resection with advanced closure strategies, addressing the complexities of large and deeply embedded lesions, while optimizing safety and outcomes.

endoscopic submucosal dissection

enhanced traction-assisted resection

purse-string suture

gastric lesion

double-channel scope