Endoscopic submucosal dissection of a quasi-circumferential lesion of the ileo-cecal valve by using a novel adjustable traction device

The technique of submucosal dissection has been expanding rapidly for several years thanks to numerous technical advances. One of these major advances is the improvement of traction strategies, and in particular the appearance of the multi-traction technique. However, several locations remain challenging because of their anatomical particularities, especially lesions of the ileo-cecal valve, which have been the subject of the development of different strategies in recent years [1] [2].

We have developed an intensity-modulated multitraction device [3] [4] [5], the A-TRACT 2 + 2 ([Fig. 1]), which seems very promising for ileo-cecal valve lesions because it allows good exposure of the ileal part of the lesion.

Fig. 1 The A-TRACT 2 + 2 device.

We report here the case of a 79-year-old patient referred for resection by submucosal dissection of a quasi-circumferential lesion of the ileo-cecal valve, measuring 6.5 × 4.5 cm ([Video 1]). After making the circumferential incision, we placed the two adjustable loops of the device on the cecal side of the lesion, allowing the start of the dissection on this side ([Fig. 2]). In a second step, we placed the two free loops on the ileal side of the lesion and fixed the elastic band on the cecal wall opposite the lesion, allowing good traction force to continue the dissection on the ileal side.

Video 1 Endoscopic submucosal dissection of a quasi-circumferential lesion of the ileo-cecal valve by using a novel adjustable traction device.

Fig. 2 Schematic representation of the lesion and the valve seen from the front after placement of the four loops on the edges of the lesion. The two adaptable loops are attached to the cecal part and the two free loops are attached to the ileal part.

Finally, after 2/3 of the dissection, the traction force having clearly decreased due to the flexibility of the valve tissues, we re-tensioned the device to obtain excellent exposure and allow completion of the dissection ([Fig. 3]).

Fig. 3 Schematic representation of the lesion and the valve seen from the front after tightening the device, allowing excellent exposure of the sub-mucosae.

To limit the risk of stenosis as much as possible, a strip of healthy ileal mucosa was preserved during the procedure. In addition, we placed the scar closure clips to keep the valve open and obtain a directed wound healing to limit the risk of stenosis.

This technique allowed an R0 resection of the lesion. There were no complications during the procedure.

Endoscopy_UCTN_Code_TTT_1AQ_2AD

Publication History

Article published online:
30 March 2023

• References

• 1 Wallenhorst T, Pioche M, Bouguen G. et al. Ileocecal valve opening with double clip and rubber band for countertraction facilitates R0 en bloc resection of laterally spreading tumors. Endoscopy 2020; 52: E390-E391
• 2 Grimaldi J, Lambin T, Rivory J. et al. Endoscopic submucosal dissection of an ileocecal valve laterally spreading tumor using an adaptable magnetic traction system. Endoscopy 2022; 54: E1064-E1065
• 3 Masgnaux L-J, Grimaldi J, Legros R. et al. Endoscopic submucosal dissection in the colon using a novel adjustable traction device: A-TRACT-2. Endoscopy 2022; 54: E988-E989
• 4 Yzet C, Masgnaux L-J, Rivory J. et al. Endoscopic submucosal dissection of colonic residual laterally spreading tumor with adaptive traction: use of the additional loops to improve traction focally in difficult area. Endoscopy 2023; 55: E260-E261
• 5 Pioche M, Masgnaux L-J, Rivory J. et al. Endoscopic submucosal dissection in the colon with adaptive traction device: resection strategy and device setup. Endoscopy 2023; 55: E171-E172