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Traction‐assisted colorectal endoscopic submucosal dissection using the Mucosectom2 device

We developed the Mucosectom2, a special instrument for submucosal dissection (HOYA Pentax, Tokyo, Japan) (Fig. 1A), and reported its effectiveness. TheMucosectom2 has two benefits compared to other knives. First, it protects the muscle layer from thermal injury because the tip is covered with an insulated shaft. Second, it cuts fine vessels without causing bleeding because the contact area of its blade and vessel is larger than that of other knives. Thus, basically, the Mucosectom2 is safe and allows the submucosal layer to be dissected even if it cannot be visualized clearly. Nonetheless, in fact, we have encountered intraoperative bleeding and difficult situations in some colorectal endoscopic submucosal dissection (C-ESD) cases. We judge that the safety of C-ESD with the Mucosectom2 can be further improved if a good traction method is applied. Traction-assisted C-ESD with clip-and-thread (TAC-ESD) (Fig. 1B) has been developed by us to maintain good visualization of the submucosa, but the technique has been described with a tip-type knife. Theoretically, TAC-ESD using theMucosectom2 seems to be the best combination.We therefore applied this technique as a trial after informed consent. A clip-and-thread is prepared before insertion of the colonoscope, and submucosal injection and mucosal incision are carried out as usual. The clip-and-thread is then applied to the anal side of the specimen. Good visibility of the submucosal layer can be obtained by pulling the thread gently. Submucosal dissection can then be easily carried out using the Mucosectom2 (swift coagulation mode, effect2 40 W, VIO300D; ERBE, T€ubingen, Germany). The clip-and-thread creates sufficient tension in the dissection area, and the Mucosectom2 slides over it, protecting the muscle layer so that efficient dissection can be achieved. Furthermore, the risk of intraoperative bleeding is considered to be extremely low, as there is good visibility of the incised vessels (Fig. 2A–E; Video S1).