Fig. 3 .

DCT-ESD strategy. a Complete circumferential incision and deep trimming were performed around the appendiceal area to make a mucosal flap with large free margins . b The first clip (Resolution 360, Boston Scientific, Boston, Massachusetts, United States) grasping a rubber band was inserted through the working channel and was fixed on the edge of the mucosal flap. Immediately after, a second clip was used to grasp the rubber band stretching and fixing it to a fold of the opposite colonic wall. The elasticity of rubber band created more or less traction according to the degree of inflation to adjust the traction force. As a result, the tumor was pulled out gradually from the orifice, which allowed stretching the submucosal layer facilitating deep dissection. c’ If possible, we cut all submucosal space through the base of the orifice. c” If submucosal space could not be seen despite enough injection, and deep progression became impossible, we cut the appendiceal mucosa circumferentially to achieve resection. d Finally, we used 10-mm snare to remove the clip attached to the opposite colonic wall to withdraw the resected lesion.