Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey

Figure 24 Endoscopic submucosal dissection of 15-mm IIa+c intramucosal carcinoma of stomach along lesser curve body using multi-loop technique. A: The lesion is marked using spot coagulation; B: Circumferential incision is performed using the i-knife, however the angle of approach on the proximal side is difficult for submucosal entry and dissection; C: Three loops are created using dental floss, captured with a clip passed through the biopsy channel (no need for scope removal or additional equipment); D: The clip is opened (the string can be pre-tied to one leg of the clip) and positioned to grasp the proximal edge of the specimen; E: The 1^st clip is released, anchoring the string to the specimen; F: A 2^nd clip is used to catch the distal loop and anchor to opposite wall of stomach; G: If necessary, a 3^rd clip can be used to grasp the middle loop; H: This can be helpful to further tighten or re-direct the traction angle; I: the submucosal space is much easier to enter with multi-loop traction; J: submucosal dissection in the antegrade approach is greatly facilitated; K: The specimen is resected en bloc; L: Histology confirmed a well differentiated grade 1 adenocarcinoma with invasion to the muscularis mucosa with negative deep and lateral margins, no lymphovascular invasion.