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Gastrointestinal: Countertraction using clip‐attached rubber band facilitating endoscopic submucosal dissection of gastric lesser curvature lesion

A 70-year-old woman presented with a 3-month history of epigastric pain and nausea with worsening of symptoms in the last month. Gastrointestinal endoscopy revealed a lesion at the lesser curvature of the lower end of the gastric body. Histopathological analysis of the biopsy revealed intraepithelial high-grade dysplasia. Following lesion margin demarcation (Fig. 1a), a circumferential mucosal incision was made (Fig. 1b). An attempt to perform an endoscopic submucosal dissection (ESD) failed due to poor exposure of the submucosal layer and difficulty maintaining a tangential position close to the muscle layer. The lesion was then retracted with clip-attached rubber band (CRB) countertraction. A rubber band was fixed on the anal side of the lesion by the first clip (Fig. 1c) and attached to the gastric wall opposite the oral side of the lesion by another clip (Fig. 1d). This CRB countertraction allows continuous tension on the submucosal fibers (Fig. 1d), which promotes rapid and safe completion of the ESD procedure (Fig. 1e; Video S1). The gastric specimen was resected en bloc in less than half an hour (Fig. 1f). ESD as a first-line treatment for early gastric cancer still faces many challenges especially when lesions are located in difficult position such as the gastric angle and lesser curvature. To overcome these challenges, dental floss clip traction, snare endoclip traction, and ring-shaped thread countertraction have been performed, although with not so much success. Here, we report that the use of CRB countertraction for lesions in difficult locations allows for a convenient and safe gastric ESD. In this study, the use of only one CRB set was enough to achieve sufficient exposure of the whole surgical field. This strategy is more adaptive for gastric ESD because the strength of CRB traction can be easily changed in a large cavity.