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Pocket‐creation method with pulley clip elastic line traction for large rectal tumors

ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) of early rectal tumors is an established technique while ESD of rectal tumors >5 cm is considered difficult. The pocket-creation method (PCM) allows tumor dissection just above the muscularis, but multiple submucosal pockets are required for large tumors because a single large submucosal pocket does not stabilize endoscopic maneuvering or provide effective traction. Multiple pockets are complicated since a small area of submucosa must remain. Most conventional traction devices cannot control traction direction in the capacious rectum. Therefore, we evolved the PCM into the PCM with pulley clip elastic line traction (PCM-PET) method, especially for large early tumors in the capacious rectum. .In the PCM-PET, a submucosal pocket is created at the lesion (Fig. 1a–f) as in the PCM. Water immersion facilitates stretching the submucosa with buoyancy and minimizes electric sparks damaging surrounding tissue. The submucosa is dissected even in the presence of severe submucosal fibrosis and/or a slightly invasive submucosal cancer. A circumferential mucosal incision is made around the lesion after creating the submucosal pocket. A clip (HX-610-090S/