The suture pulley countertraction method for challenging rectal endoscopic submucosal dissection

摘要

Use of the suture pulley countertraction method for endoscopic submucosal dissection (ESD) of a challenging fibrotic rectal lesion. Histopathologic view of a well-differentiated neuroendocrine tumor with positive lateral and deep margins, in a patient who underwent piecemeal removal of a 10-mm polyp(hematoxylin and eosin stain, 8× magnification). Endoscopic appearance of a densely fibrotic scar with central tattoo. During ESD, dense submucosal fibrosis and large deposits of tattoo ink were noted, fully obscuring the submucosal dissection plane. The suture pulley method was used, with the fulcrum placed at the opposite wall and the anchor placed near the mucosal edge. Using the suture pulley method, we visualized the dissection plane despite extensive tattoo ink and submucosal fibrosis. Endoscopic appearance of resection defect. Specimen after en bloc resection. Histolopathologic view showing benign mucosa with fibrosis and deposits of tattoo ink, with no evidence of residual neuroendocrine tumor (hematoxylin and eosin stain, 4× magnification).