A novel approach to preventing adverse events after circumferential endoscopic submucosal dissection of the ileocecal valve.

Endoscopic submucosal dissection (ESD) involving the ileocecal valve (ICV) remains a technically challenging procedure due to the anatomical complexity, limited maneuverability, and the thin submucosal layer in this region.[ 1​ ] In certain cases, particularly those involving large laterally spreading tumors (LSTs), circumferential resection may be required; however, this approach is associated with a significant risk of adverse events.[ 2​ ] [ ​3​ ] A 71-year-old patient was referred for a recurrent 30-mm homogeneous granular LST (Kudo pit pattern IIIL), after three prior incomplete endoscopic resections, involving both lips of the valve circumferentially and extending 1 cm into the terminal ileum ([ Video 1 ]). Video 1 A dual approach to prevent adverse events after circumferential ICV endoscopic submucosal dissection using selective cecal clipping and application of a peptide matrix to the colonic margin to promote controlled mucosal remodeling. Download Video The procedure began with a circumferential incision along the ileal margin, followed by an incision on the colonic side. The lesion was resected using an underwater ESD technique with a multitunneling approach,[ 4​ ] performed with a colonoscope fitted with a conic hood ([ Fig. 1 ]). Fig. 1 Circumferential defect after complete dissection. An integrated needle-tipped IT knife was used with Swift Coag (Effect 4.0) for coagulation and selected phases of dissection, and Endo Cut Q (Effect 3-3) for mucosal incision and dissection. To prevent post-ESD complications, a dual strategy was employed: (1) the ileal margin was everted and fixed to the distal colonic margin using endoscopic clips, achieving partial closure over approximately 180° of the defect ([ Fig. 2 ]); (2) on the contralateral side, where clip placement on the proximal colonic margin was technically challenging, a self-assembling peptide matrix was applied. This approach aimed to avoid a circumferential mucosal defect, thereby promoting asymmetric healing and supporting granulation and re-epithelialization of the unclipped colonic margin. No adverse events occurred. Fig. 2 Use of an endoscopic clip to evert the ileal margin and fix it to the distal colonic margin. Histology confirmed an R0 resection. At 3-month and 1-year follow-ups, the ICV appeared widely patent. This video illustrates a reproducible strategy to prevent stenosis after circumferential ICV ESD. Although this peptide matrix is primarily used for hemostasis, preclinical studies suggest a potential role in reducing fibrosis.[ 5​ ] Endoscopy_UCTN_Code_TTT_1AQ_2AD_3A Publication History Received: 06 February 2026 Accepted after revision: 23 May 2026 Article published online: 17 June 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany