A modified method of endoclip-and-snare to assist in endoscopic submucosal dissection with mucosal traction in the upper GI tract Qiang Zhang, MD, Xiang.

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A modified method of endoclip-and-snare to assist in endoscopic submucosal dissection with mucosal traction in the upper GI tract Qiang Zhang, MD, Xiang Yao, MD, Zhen Wang, BN VideoGIE Volume 3, Issue 4, Pages 137-141 (April 2018) DOI: 10.1016/j.vgie.2018.01.002 Copyright © 2018 American Society for Gastrointestinal Endoscopy Terms and Conditions

Figure 1 The key procedures. A, B, C, The traction method of pulling or pushing the snare. A, After a snare is fixed to 1 side of the incised mucosa with endoclips, the incised mucosa is pulled through the snare to expose the submucosa for dissection. B, C, The snare is fixed with endoclips to the target mucosa intended for further dissection. D, E, F, The method of internal traction. D, The mucosa is circumferentially incised. E, A snare is fixed to the target mucosa with endoclips and also to the gastric wall on the opposite side with endoclips. F, The snare is tightened up to pull the target mucosa. VideoGIE 2018 3, 137-141DOI: (10.1016/j.vgie.2018.01.002) Copyright © 2018 American Society for Gastrointestinal Endoscopy Terms and Conditions

Figure 2 Resection of a mucosal lesion with endoscopic snare and endoclips. A, The lesion is circumferentially incised. B, The snare is fixed to 2 sides of the incised mucosa with 2 endoclips to assist in dissecting the submucosa there. C, During dissection, the snare is fixed to the third side of target mucosa with another endoclip to assist in dissecting the submucosa there. D, E, The mucosae fixed on the snare are pulled by pulling the snare to dissect the submucosa with a clear field of vision. F, The wound. VideoGIE 2018 3, 137-141DOI: (10.1016/j.vgie.2018.01.002) Copyright © 2018 American Society for Gastrointestinal Endoscopy Terms and Conditions

Supplementary Figure 1 Efficient delivery of the snare to the target mucosa. The snare is strained to hitch one of the arms of the endoclip, and then delivered to the target mucosa. VideoGIE 2018 3, 137-141DOI: (10.1016/j.vgie.2018.01.002) Copyright © 2018 American Society for Gastrointestinal Endoscopy Terms and Conditions

Supplementary Figure 2 Resection of a submucosal tumor at the gastric antrum with internal traction during endoscopic snare and endoclips. A, The snare is fixed to the target mucosa and also to the gastric wall on the opposite side. B, C, The snare is tightened up to pull the target mucosa and enable good visualization of the operation. VideoGIE 2018 3, 137-141DOI: (10.1016/j.vgie.2018.01.002) Copyright © 2018 American Society for Gastrointestinal Endoscopy Terms and Conditions

Supplementary Figure 3 Resection of a laterally spreading tumor (LST) at the duodenal bulb. A, LST at duodenal bulb. B, Circumferential resection of the lesion. C, D, The incised mucosa is pulled to effectively expose the submucosa by pulling the snare, then the submucosa is dissected. E, After the snare is tightened up with appropriate force, the snare is held up by the endoscope’s front end with a transparent cap to expose the submucosa. F, The wound. LST, laterally spreading tumor. VideoGIE 2018 3, 137-141DOI: (10.1016/j.vgie.2018.01.002) Copyright © 2018 American Society for Gastrointestinal Endoscopy Terms and Conditions