Saline-Immersion ESD with Dynamic Traction for Complex Ileocecal Valve Adenomas: GIE | August 2026

Introduction:

Endoscopic submucosal dissection (ESD) of lesions involving the ileocecal valve (ICV) and extending into the terminal ileum is among the most technically challenging colorectal procedures. Difficult scope stability, abundant submucosal fat, and limited visualization increase procedural complexity and the risk of incomplete resection. This "Top Tips" video demonstrates how combining saline-immersion ESD with dynamic clip-and-band traction can facilitate safe en bloc resection in this difficult anatomical location.

Why was this technique needed?

Ileocecal valve lesions are among the most difficult colorectal lesions to treat with ESD.

Conventional ESD often suffers from poor visualization and unstable endoscope positioning.

Submucosal fat obscures the dissection plane, increasing technical difficulty.

Traction alone or saline immersion alone may not provide adequate exposure in complex lesions.

Combining complementary techniques may improve procedural safety and resection success.

Key Technical Points:

A 4-cm nongranular adenoma involving the ileocecal valve with extension into the terminal ileum was successfully removed en bloc using combined saline-immersion ESD and dynamic clip-and-band traction.

Saline immersion created a stable operative field, improved visualization, and enhanced identification of the submucosal dissection plane.

Dynamic clip-and-band traction provided continuous countertraction, maintaining optimal exposure throughout the procedure.

Traction was repositioned during dissection as needed to preserve visualization and facilitate safe progression.

ENDO CUT current was used during underwater dissection to minimize bubble formation and maintain a clear endoscopic field.

The procedure was completed without adverse events, and follow-up demonstrated complete healing with no residual or recurrent adenoma.

Clinical Impact:

This technique demonstrates that combining saline immersion with internal traction can overcome many of the technical limitations encountered during ESD of complex ileocecal valve lesions. Rather than relying on a single procedural modification, integrating complementary strategies provides improved visualization, better tissue exposure, and greater procedural stability. As experience grows, this combined approach may expand the role of minimally invasive endoscopic resection for lesions that might otherwise require surgery.

Bottom Line:

The combination of saline-immersion ESD and dynamic clip-and-band traction enables safe, effective en bloc resection of challenging ileocecal valve adenomas with terminal ileal extension. This complementary technique improves visualization and submucosal exposure, offering a valuable strategy for complex colorectal ESD in expert hands.