Traction-assisted endoscopic submucosal dissection of colonic lateral spreading polyps, a case presentation and educational overview. In this video, in collaboration with my co-authors, we will review traction-assisted ESDs do's and don'ts. Colonic ESD could be challenging due to limited submucosal space within the colonic wall. Traction-assisted ESD improves visualization and facilitates dissection in the colon. Using figure-of-eight rubber band clip traction in traction-assisted ESD is economic yet effective method to apply traction. The aim of this review is to establish an educational material on do's and don'ts of colonic traction-assisted ESD. Traction-assisted ESD starts with circumferential marking and incision around the lesion to create mucosal flap. The first clip attached to the figure-of-eight rubber band then is to be applied at the center of the lesion within the anal side. Then the rubber band is grabbed with the second clip and dragged to the oral side of the lesion parallel to the lesion axis or towards the opposite wall. It is important to deflate the colon before this step to achieve maximum traction as with colonic insufflation, rubber band clip traction can have dynamic traction ability. After placing the traction the maximum point of tension which is usually within the center of the lesion and beneath the clip should be released first. Systematic dissection from one margin to the other would maintain the force of traction effectively throughout the dissection. After complete removal of the lesion the clip attached to the colonic wall not the lesion can be removed using a snare or a raptor grasper. Our case is a 55 year old male with a 45 millimeter sessile granular lateral spreading polyp in the ascending colon. This polyp was removed with traction assisted ESD. Final pathology was remarkable for tubular adenoma and this polyp was removed R0. In the next video we will demonstrate a step-by-step placement of figure-eight rubber band clip traction resulting in safe and expedited dissection. In this case we started with circumferential incision and creating a mucosal flap around the lesion. Then we grabbed the mucosa in the anal side with the rubber band clip within the center of the lesion, however before clip deployment the lesion was moved to various direction to ensure correct placement. Then using the second clip the rubber band was dragged to the opposite wall towards the oral side, again emphasizing on colonic deflation during this step to achieve maximum traction. Upon colonic insufflation the lesion is being pulled away so it's important to release the maximum point of tension within the center of the lesion underneath the clip. Then we proceeded with systematic dissection from one margin to the other this will allow maintaining the force of traction. During traction assisted ESD it is important to dissect parallel to the muscle layer within the lower third of submucosal space and always aim for dissection away from the muscle layer. Traction assisted ESD particularly would be useful for dissecting the corners or part of the specimen behind colonic folds. With correct utilization of rubber band clip traction this large lesion expanding over a colonic fold and occupying over 50% of the colonic lumen was dissected in less than 20 minutes. No muscle injury was noted in the resection bed. Now we would like to discuss few common mistakes when applying traction assisted ESD. In the next video we will show the importance of compliance with these three steps. The first one is to avoid tissue tenting which is favoring dissection of one lateral margin over the other one. Also avoid missing the axis and direction of the lesion. Gravity enhanced traction assisted ESD is important. Under traction would result in a need for multi-traction. In this case as you can see not enough colonic deflation is applied and the lesion is being pulled away only towards the same axis of the lesion few centimeters behind the oral side of the lesion favoring one side and not centered. This wrong placement of traction resulted in poor visualization of the other margin. When this happens although harder but dissection should be focused on the least accessible corner favoring the easy side and ignoring the hard corner would result in tissue tending. Also as you can see considering the clip was placed close to the oral side under traction is encounter and there is a need for additional traction to complete dissection safely. The second traction should be applied as close as possible to the original one to maintain the axis of traction and avoid creating any tissue groove as you can see in this video. A very most important don't in traction assisted ESD is over traction. Avoid over traction as the excess force can tear up the specimen. Avoid pulling the lesion forcefully in the same axis of the lesion as raising the muscle layer would result in confusion and perhaps unnecessary intramuscular dissection. Lack of systematic dissection in the setting of over traction may lead to incomplete resection. You can see the rubber band is being pulled away forcefully in the same axis of the lesion. This resulted in elevation of the muscle layer. It is important to inject the submucosa carefully and avoid intramuscular dissection. Due to the extremely high tension from the traction the specimen was torn as you can see. Without careful dissection and releasing the tension appropriately incomplete resection may occur as you can see in this case. Few more important don'ts are forceful placement or intramuscular placement of traction with favoring one side. As you can see forcefully pulling away the rubber band without deflation of the colon resulted in dislodgement of the rubber band from the clip. The traction is also being placed in one margin and not centered which will be problematic soon. In the second attempt as you can see with deflation of the colon we were able to place the traction correctly beyond the oral side of the lesion. Misplacement of the traction clip could be problematic and may increase the need for additional traction as you can see in this case. Also always remember any additional force while grabbing the mucosa may result in grabbing the muscle layer which would be associated with unnecessary intramuscular dissection. Traction-assisted ESD has certain principles and learning curve. If the principles of traction-assisted ESD are not followed the procedure could be more cumbersome resulting in less success rate and increasing frustration with the technique. Traction-assisted ESD could be beneficial in expediting the procedure particularly in lesion where traditional pocket technique is not feasible. In conclusion there is a learning curve associated with traction-assisted ESD. Figure of eight rubber band clip traction is an effective method particularly when gravity is not favorable.

traction-assisted ESD

colonic polyps

rubber band clip

endoscopic dissection

surgical technique