Water pressure method endoscopic submucosal dissection with clip traction for early gastric cancer with submucosal fibrosis

Endoscopic submucosal dissection (ESD) is widely performed; however, difficult cases remain, and submucosal fibrosis is a risk factor for difficulty.¹ Recently, the effectiveness of the clip traction and water pressure method (WPM) has been reported^{2, 3}; gastric ESD using WPM has also been reported.^{4, 5} We report a case of early gastric cancer with severe fibrosis that was successfully treated with WPM combined with clip traction (Video S1).

An 82-year-old man who had undergone curative resection of early gastric cancer on the anterior wall of the angulus 4 years ago was referred to our hospital with metachronous cancer adjacent to the ESD scar (Fig. 1a). ESD was performed under conscious sedation. A mucosal incision was performed using a dual knife and insulated-tip knife-2 (Olympus Medical Systems, Co., Tokyo, Japan); however, the anal side, which straddled the ESD scar, was poorly injected (Fig. 1b). After the mucosal incision, submucosal dissection was initiated from the anal side. However, severe fibrosis prevented sufficient formation of the mucosal flap, causing difficulty in visualizing the submucosal layer. Therefore, a small-caliber tip transparent hood (DH-28CR; Fujifilm, Tokyo, Japan) was attached and converted to underwater conditions. WPM temporarily visualized the submucosal layer; however, it was difficult to maintain (Fig. 2a,b). Hence, a clip (EZ clip, HX-610-090; Olympus Medical Systems, Co.) with a thread was attached to the mucosal flap adjacent to severe fibrosis because the fibrotic area had not sufficiently formed the mucosal flap for attaching the clip, allowing a clear view of the submucosal layer (Fig. 2c,d). We dissected the fibrotic submucosal layer and performed a curative en bloc resection with a negative margin.

WPM is useful for viewing the fibrotic submucosal layer; however, in this case, the combination of clip traction was more effective in maintaining the resection layer.

Authors declare no conflict of interest for this article.

Approval of the research protocol by an Institutional Reviewer Board: N/A.

Informed Consent: Informed consent was obtained from the patient in this case report.

Registry and the Registration No. of the study/trial: N/A.

Animal Studies: N/A.