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The colon is considered to be one of the most technically challenging locations for endoscopic submucosal dissection (ESD) when superficial neoplastic lesions are being treated [1]. The difficulties include: the colonic loops, intestinal motility, the folded anatomy, problems caused by inconstant gravity, and constant modification of the operative fieldof-view attributable to insufflation. Good exposure of the submucosal layer is key for safe and efficient ESD; this can be particularly challenging in the colon where it is difficult to maintain a tangential position close to the muscle layer. Many tips and tricks have been reported to facilitate colonic ESD, including: ▪ the use of gravity; ▪ creation of a pocket [2]; ▪ tunnel dissection; ▪ clip [3] or double-clip countertraction (ring-thread countertraction [4]); ▪ the use of a waterjet injection knife [5]. Although individual physicians will prefer certain tips or tricks with which they are familiar, little information is available on combinations of these technical approaches. As case numbers are increasing worldwide, and as colorectal cancer screening programs are becoming more common and effective, further technical improvements are imperative. Here, we report on our treatment strategy for colonic ESD and seek to facilitate the resection of large superficial colonic lesions.

endoscopy

A combination of pocket, double-clip countertraction, and isolated HybridKnife as a quick and safe strategy for colonic endoscopic submucosal dissection