Novel three-traction strings device with endoscopic submucosal dissection for the removal of a large rectal sessile serrated adenoma

A 65-year-old woman presented with a large rectal laterally spreading tumor (4 × 5 cm) (Fig. 1A). Endoscopic submucosal dissection (ESD) was proposed to remove the lesion. Herein we present a novel three-traction strings device aiding in the ESD procedure (Video S1). This traction device included one central rubber ring and three subsidiary rubber rings obtained from a rubber glove, while the three subsidiary rubber rings were attached with the central rubber ring (Video S1 and Fig. 1B). After submucosal injection and a circumferential mucosal incision was completed, the middle subsidiary rubber ring was fixed at the anal side of the lesion, while the remaining two subsidiary rubber rings were fixed at both lateral sides of the lesion using a reopenable clip (Anrei, Zhejiang, China) (Fig. 1C). The central rubber ring extended beyond the oral side of the lesion, and was fixed at the upstream colonic wall (Fig. 1C). The traction device provided adequate visual field during the entire procedure by colonic air insufflation and inhalation-sustaining traction force (Fig. 1D–G). Consequently, the lesion was removed en bloc without complication (Fig. 1H). The operation duration was about 45 min. Histopathologic findings revealed tubule-villous adenoma with high-grade intraepithelial neoplasia (Fig. 1I).

It is challenging in ESD to remove the large colorectal lesion due to not being capable to maintain good visibility.¹ Traction techniques have been reported to assist the ESD procedure.^2-5 Compared with other traction devices, this traction device has some advantages. First, it is easily obtained and manipulated. Second, it is low cost. Third, it maintains a triangular structure during the entire procedure, which is more stable for mechanical principles (Fig. 2). An imperfection is needed to distinguish central rubber ring and subsidiary rubber rings carefully due to their same color. Therefore, we will improve it with different colors between the central rubber ring and subsidiary rubber rings.

Authors declare no conflict of interest for this article.