Case 1

1. First case: A 60-year-old man. A mucosal lesion was at gastric angle and anterior wall of the antrum-to-body junction, of which the size was 11cm×7cm.

2. Description of key technology for the case 1

A. Fix a snare to one site of incised mucosa with endoclips, then pull the mucosa by pulling the snare to expose the submucosa for dissection;

B and C. When the mucosae at the other sites were further dissected, adjust the sites of mucosal traction by fixing the snare to corresponding mucosae and then pull the mucosae there to expose the submucosa for dissection.

  1. The snare was fixed to the incised mucosa at the anterior wall of the antrum-to-body junction with two endoclips.
  2. The target mucosa was pulled to expose the submucosa by pulling the snare, then the submucosa was dissected under a good visualization.
  3. For further dissection, the snare was fixed to the target mucosa at the posterior part of the gastric angle with another endoclip to expose the submucosa there by pulling the snare.
  4. The lesion was dissected by SC-ESD.

Case 2

  1. Second case: A 50-year-old man. A submucosal tumor was at gastric antrum, involving the anterior wall and intra-orifice of pylorus, of which the size was 4cm×3cm.
  2. Description of key technology for the case 2

A. Circumferentially incise gastric mucosa;

B. Fix the snare to the target mucosa intended for dissection with endoclips, and to the gastric wall on the opposite side as well. The two fixed positions were at certain intervals;

C. tighten up the snare to draw the endoclips closer, which would make the target mucosa pulled to expose the submucosa for dissection.

  1. A snare was fixed with endoclips to the oral side mucosa of the tumor, and to the gastric wall on the opposite side as well.
  2. The mucosa was pulled to effectively expose the submucosa by tightening up the snare, then the submucosa was dissected.
  3. The mucosa was pulled to effectively expose the submucosa by tightening up the snare, then the submucosa was dissected.

Case 3

  1. Third case: A 65-year-old man. A laterally spreading tumor (LST) was at duodenal bulb, of which the size was 4.5cm×3.5cm.
  2. Description of key technology for the case 3

Fix a snare to one site of incised mucosa with endoclips, then pull the mucosa by pulling the snare to expose the submucosa for dissection. In additon, the snare could be held up by endoscopic front end with a transparent cap to expose the submucosa in the duodenal bulb.

  1. Clamp the metal loop of snare with an endoclip, strain the snare to hitch one of the two arms of endoclip, and then deliver and fix the snare to the incised mucosa.
  2. The mucosa was pulled to effectively expose the submucosa by pulling the snare, then the submucosa was dissected.
  3. In addition, after the snare was tightened up with appropriate force, the snare could be held up by endoscopic front end with a transparent cap to expose the submucosa.
  4. The lesion was removed successfully by SC-ESD under a good visualization of operation.

Technique Highlights

This method had its own unique characteristics:

1. The site of mucosal traction could be quickly and effectively adjusted during the operation by fixing the snare to the target mucosa intended for traction with the endoclips.

2. A wide-range of submucosa could be exposed in one time by fixing the snare to multiple sites of target mucosa.

3. A method of internal traction could be achieved.

Conclusions

In the study, the lesions were completely resected safely and efficiently without any immediate or delayed complications, and there were not any tissue trauma or specimen fragmentation during the closing, pulling and pushing of snare. Thus, the modified method of endoclip-and-snare to assist in ESD in the upper gastrointestinal tract is technically feasible and safe.

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