A combination of the clip-with-line method and the tunnel technique during esophageal endoscopic submucosal dissection: a technical solution?

Abstract

A 76-year-old woman was referred to our endoscopy unit for endoscopic submucosal dissection (ESD) of a 3-cm-diameter nodule exhibiting high grade dysplasia and complicating a large Barrett's esophagus. A classic tunnel was created beneath the lesion ([Fig. 1]) with a HybridKnife Type T (ERBE Electromedizin, Tübingen, Germany). After incision of the mucosa on both sides of the tumor, the scope was withdrawn. A Resolution Clip (Boston Scientific, Natick, Massachusetts, USA) was inserted into the operative channel of the endoscope and attached to a 250-cm line made of nonabsorbable suture wire (Peters Surgical, Paris, France) bent in a U-shape. The scope was reinserted with the line in parallel, and the clip with the attached line was placed at the proximal side of the tunnel ([Fig. 2] and [Fig. 3]). Constant countertraction, applied by grasping the external part of the linewith a plastic 11 g Kocher forceps (Nessicare dressing kit, LCH Medical Products, Paris, France), facilitated excellent exposure of the remaining submucosal layers ([Fig. 4] and [Fig. 5]) on both sides, greatly aiding dissection after tunneling ([Fig. 6], [Video 1]).