Adjustable countertraction during endoscopic submucosal dissection of a large, fundus-body, laterally spreading tumor

A large tumor of the gastric fundus body, partially involving the gastroesophageal junction (Fig. 1), was diagnosed in a 77-year-old woman, and a total gastrectomy was recommended. She refused the surgical procedure. Thus, an endoscopic submucosal dissection with the patient under general anesthesia was performed (Video 1, available online at www.giejournal.org). To reduce the procedure duration and to improve the technical feasibility, we successfully used an adjustable countertraction technique by placing several standard clips on the resection margins of the lesion and applying traction by using 2 transnasal mucosectomy snares and a nasal overtube. An estimated 20% reduction of procedural time was obtained. Several countertraction systems are reported in the medical literature: our novel method allowed us to easily change the traction point by using coagulation forceps without withdrawing the endoscope. This advantage was especially relevant during the retroflexed dissection of the oral side of the lesion. An intraprocedural perforation was recognized and treated with standard clips without any further management. The patient was discharged 5 days after endoscopy. The tumor was successfully resected en bloc, and histologic examination confirmed a focal, well-differentiated, tubular adenocarcinoma with no submucosal or lymphovascular invasion. During the 3-month follow-up endoscopy, the remaining clips were removed and the absence of recurrence was confirmed.