Combination of underwater and traction-assisted endoscopic submucosal dissection: the perfect wedding for a challenging case

Abstract

Figures

Endoscopy picture of a 7 cm granular homogeneous lateral spreading tumor (LST) involving the cecum and extending deeply into the appendix.

Picture of the endoscopic submucosal dissection (ESD) specimen of 7 cm LST.

Picture of the endoscopically resected appendicular specimen.

Full text

Various modifications have been introduced to enhance the effectiveness of endoscopic submucosal dissection (ESD), including tunneling, the pocket-creation method, traction-assisted techniques, hybrid ESD (combined with EMR), and, more recently, underwater ESD 1 2 . In this report, we present a case utilizing a combined approach of traction and underwater-assisted ESD.

A 72-year-old female presented with a 7 cm granular homogeneous lateral spreading tumor (LST) involving the cecum and extending deeply into the appendix in a patient without prior history of appendectomy ( Fig. 1 ). ESD was chosen due to both the size of the lesion and its extension into the appendix.

Endoscopy picture of a 7 cm granular homogeneous lateral spreading tumor (LST) involving the cecum and extending deeply into the appendix.

The procedure was initiated with underwater ESD under propofol deep sedation, achieving complete circumferential dissection around the appendix. After completion of the dissection except for the appendiceal portion, a traction device was placed in a reverse position on the appendix remnant within the lumen. This maneuver allowed the appendix to be pulled fully into the cecal lumen, as demonstrated in the procedural video, and facilitated en bloc resection ( Video 1 ). The 7 cm lesion was successfully resected within 90 minutes without perforation ( Fig. 2 and Fig. 3 ). Closure was performed selectively at the appendiceal scar site using a combination of Mantis clips and through-the-scope clips (TTC) to reduce the risk of delayed complications ( Fig. 3 ). Pathology revealed a tubulovillous adenoma with focal high-grade dysplasia and clear resection margins.

Combination of underwater and traction-assisted ESD for resection of a large cecal LST extending into the appendiceal lumen.Video 1

Picture of the endoscopic submucosal dissection (ESD) specimen of 7 cm LST.

Picture of the endoscopically resected appendicular specimen.

This case highlights the value of combining underwater ESD and traction-assisted ESD as complementary strategies in technically challenging situations. Both techniques are increasingly recognized by endoscopists as practical tools that can be tailored together, with distinct advantages and limitations, to optimize outcomes in difficult resections 3 4 .

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