Novel counter traction method using a clip with a looped thread

Video 1  Colorectal ESD using a clip with a looped thread.

The authors have previously reported this traction method 10 . First, a clip with a LT was prepared with a 3–0-nylon suture and a clip (HX-610-135; Olympus, Tokyo, Japan). Two loops were made with a 3–0-nylon suture. The first loop was made by looping and knotting a thread. The major axis of this loop was set between 5 and 10 mm because if it was too large, the counter traction would not be sufficient, and if it was too small, it would be difficult to place the second clip ( Fig. 2a ). Thereafter, the second loop was made by looping and keeping it in the middle of ligature ( Fig. 2b and Fig. 2c ). After making the LT, this second loop was tied to the arm part of the clip that was opened halfway ( Fig. 2d and Fig. 2e ). The key point is to tie the second loop tightly. Then, the unnecessary part of the thread was cut ( Fig. 2f ). The procedure was completed by resetting the clip with a LT ( Fig. 2g ). This 2- to 3-minute process completed the preparation before ESD.

 Clip with a looped thread. a The first loop is made by looping and knotting a 3–0 nylon suture. b The second loop is made by looping and keeping in the middle of ligature. c The unnecessary part of the thread is cut. d A clip is opened halfway. e The second loop of the thread is tied tightly to the arm part of the clip. f The unnecessary part of the thread is cut. g A completed clip with a looped thread.

After preparation of a clip and a thread, ESD was performed ( Video 1 ). First, a mucosal circumferential incision was made ( Fig. 3a and Fig. 3b ). Then, a clip with a LT that was prepared in advance was placed at the proximal end of the lesion ( Fig. 3c ). Finally, a second new clip was placed on the contralateral side of the lesion with the other loop of the thread ( Fig. 3d ). By elevating the mucosa, the dissection of the remaining submucosal layer was performed ( Fig. 3e ). After the completion of ESD, the loop of thread was cut using a loop cutter (FS-5Q-1; Olympus, Tokyo, Japan). The lesion was then recovered along with the first clip and thread 10 . If the loop cutter is not available due to institution reasons, the alternative is to grasp the clip on the normal mucosa side with a polypectomy snare and remove the clip with gentle traction.

 Colorectal ESD using a clip with a looped thread. a Granular laterally spreading tumor (25 mm in size) in the cecum. b Mucosal circumferential incision and submucosal dissection. c A first clip with a looped thread is placed at the proximal end of the lesion. d A second clip is placed on the contralateral side of the lesion. e Completion of the counter traction.

After resection, we evaluated the location of the lesions, findings of the macroscopic examination, histopathological findings, tumor diameter, approximate resected area, procedure time, and dissection speed per minute. Histopathological findings were classified according to the Japanese classification 11 . The shorter and longer axes were measured after ESD. Tumor diameter was defined as the longer axis. Procedure time was defined as the time from the initiation of mucosal incision to the end of dissection. The approximate resected area (mm 2 ) and dissection speed (mm 2 /min) were calculated by using the following formulas:

Approximate resected area (mm 2 ) = Major axis (mm)/2 × Minor axis (mm)/2 × 3.14

Dissection speed (mm 2 /min) = resected area (mm 2 )/procedure time (min)

Procedure success rate and setting time of the counter traction using a clip with a LT were not evaluated because the new clip with the LT can be prepared in a few minutes and used in case of procedure failure.

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