Conventional versus traction-assisted endoscopic submucosal dissection for large esophageal cancers: a multicenter, randomized controlled trial (with video)

Yoshida, Masao; Takizawa, Kohei; Nonaka, Satoru; Shichijo, Satoki; Suzuki, Shinichi; Sato, Chiko; Kohno, Hiroyuki; Minagawa, Takeyoshi; Oda, Ichiro; Hirasawa, Kingo; Matsumoto, Kenshi; Sumiyoshi, Tetsuya; Mori, Keita; Gotoda, Takuji; Ono, Hiroyuki; Kusano, Chika; Takeda, Tsutomu; Fujii, Ryoji; Yamasaki, Yasushi; Minashi, Keiko; Nakajima, Takako Eguchi; Kurokawa, Yukinori

doi:10.1016/j.gie.2019.08.014

Cited by 85 publications

(82 citation statements)

References 37 publications

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“…Regarding the submucosal dissection time, no signi cant differences were observed between ESD-S and ESD-N, indicating that differences in the endo-knife type may not affect the outcomes of submucosal dissection. Furthermore, the DFC traction method was applied to all cases in order to simplify the submucosal dissection procedure; this may have reduced the difference in the treatment outcomes between the two groups [25][26][27].…”

Section: Discussionmentioning

confidence: 99%

Ex Vivo Porcine Model Study on the Treatment Outcomes of Scissor-type Knife Versus Needle-type Knife in Endoscopic Submucosal Dissection Performed by Trainees

Ichijima

Esaki

Yamakawa

et al. 2020

Preprint

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BackgroundTrainee endoscopists find endoscopic submucosal dissection (ESD) for gastrointestinal neoplasms difficult to perform independently; furthermore, there is no consensus on which endo-knife type is the most suitable for them. Therefore, we conducted a prospective study comparing the treatment outcomes of scissor-type and needle-type knives in ESD performed by trainees in an ex vivo porcine model.MethodsAround 22 trainees from 13 institutions, divided into two groups according to their endoscopic experience, performed ESD in a porcine model. Each trainee performed two ESDs under expert supervision: one with a scissor-type knife (ESD-S) and the other with a needle-type knife (ESD-N). The efficacy and safety, including the procedure time and rates of self-completion, en bloc resection, and complications, were compared between ESD-S and ESD-N. ResultsEight trainees had an experience of over 1,000 endoscopies (senior trainee: S-Trainee), whereas the remaining had an experience of less than 1,000 endoscopies (junior trainee: J-Trainee). Among the S-Trainees, no significant differences were observed in any treatment outcome between ESD-S and ESD-N. Among the J-Trainees, the total procedure and mucosal incision times were significantly shorter in ESD-S than in ESD-N [total procedure time: 16.5 min (range: 10.0–31.0) vs. 22.3 min (range: 10.0–38.0), P = 0.018; circumferential incision time: 10.0 min (range: 6-16) vs. 17.0 min (range: 5.0–31.5); P = 0.019]. Regarding complications, muscular injury occurred in two patients during ESD-N performed by J-Trainees; however, no muscular injury occurred during ESD-S.ConclusionsS-Trainees could perform ESD safely in an ex vivo porcine model under expert supervision, regardless of the endo-knife type used. However, the scissor-type knife is desirable if J-Trainees were to perform the ESD procedure.

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Section: Discussionmentioning

confidence: 99%

Ex Vivo Porcine Model Study on the Treatment Outcomes of Scissor-type Knife Versus Needle-type Knife in Endoscopic Submucosal Dissection Performed by Trainees

Ichijima

Esaki

Yamakawa

et al. 2020

Preprint

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“…The authors concluded that TA-ESD should be the preferred method for removing esophageal cancers !20 mm because of the significantly shorter procedure times resulting from an expansion of the submucosal cutting area and improved visualization of the submucosal plane and dissection line regardless of the effect of gravity or the volume of submucosal injection. 1 We congratulate Yoshida et al 1 on conducting this rigorous, appropriately powered, and well-designed multicenter randomized controlled trial, which now provides high-level evidence that clip-and-line traction makes ESD swifter, easier, and possibly safer than ESD performed without traction assistance, at least in the esophagus. Patients in this trial underwent ESDs performed by Japanese board-certified endoscopists who had performed !40 gastric ESDs, and this study included several expert and senior endoscopists who have performed more than a thousand ESDs.…”

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confidence: 94%

“…The drawbacks of clipping the edge of an ESD resection specimen are that endoclips can slip off, and also traction-related damage can occur to the specimen, which occurred respectively in 16.4% and 1.7% of patients undergoing TA-ESD in CONNECT-E. 1 However, the rates of horizontal margin involvement were not statistically different when both treatment groups were compared. A benefit of clippingdin addition to enabling external traction with a linedis that the length and mass of the stem of the clip (which elongates the edge of the tissue flap) can augment the traction produced by the lowprofile distal attachment cap fitted on the tip of the endoscope.…”

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confidence: 96%

“…In this issue of Gastrointestinal Endoscopy, Yoshida et al 1 report the results of the CONNECT-E trial. This study is the first multicenter, randomized, superiority trial to assess the technical and safety outcomes of tractionassisted endoscopic submucosal dissection (TA-ESD) compared with conventional ESD without the use of adjunctive traction methods for the endoscopic removal of large esophageal tumors, defined as size !20 mm.…”

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confidence: 99%

“…17 In fact, this approach is endorsed by the CONNECT-E authors, who stated: "Applying a tunneling traction-assisted technique might help improve technical outcomes for lesions that spread the entire circumference of the esophagus." 1 In the field of esophageal ESD in Western nations, dysplastic Barrett's esophagus is the most frequent esophageal pathologic condition encountered for resection, and ESD has an important role in treating this disease. 18 However, because Barrett's is uncommonly found in Asian populations, additional data from Western populations are required to better define how ESD should be optimally used in clinical practice to treat dysplastic Barrett's esophagus and early esophageal adenocarcinomas.…”

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See 2 more Smart Citations

Traction-assisted endoscopic submucosal dissection in the esophagus: Should we all be flossing?

Uppal

Wang

2020

Gastrointestinal Endoscopy

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Endoscopic resection of esophageal squamous cell carcinoma: Current indications and treatment outcomes

et al. 2021

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Endoscopic resection (ER) is an alternate minimally invasive treatment for superficial esophageal squamous cell carcinoma (SESCC). We aimed to review the clinical indications and treatment outcomes of ER for SESCC. Endoscopic mucosal resection is relatively easy and efficient for SESCC ≤ 15 mm. In contrast, endoscopic submucosal dissection (ESD) is recommended to achieve en bloc resection for lesions >15 mm, in view of the accurate pathological evaluation. The Japan Gastroenterological Endoscopy Society guidelines recommend ER for non‐circumferential cT1a‐EP/LPM (epithelium/lamina propria mucosae), cT1a‐MM/T1b‐SM1 (muscularis mucosa/superficial submucosa ≤ 200μm) SESCC, and whole‐circumferential T1a‐EP/LPM SESCC ≤ 50 mm (upon implementing preventive measures for stenosis), considering the risk‐benefit balance of ER. It defines pT1a‐EP/LPM without lymphovascular invasion as a curative endoscopic resection. The guidelines recommend additional esophagectomy or chemoradiotherapy for pT1b SESCC or any SESCC, with lymphovascular invasion. However, there is no recommendation for or against the administration of additional treatments for pT1a‐MM without lymphovascular invasion, owing to limited evidence. Researchers have reported on high en bloc and R0 resection rates of ESD, and a randomized controlled trial demonstrated that clip‐line traction‐assisted ESD could significantly reduce the ESD procedural time. Moreover, steroid treatment has been developed to prevent post‐ESD esophageal strictures. There have been reports on favorable long‐term outcomes of ESD. However, most of them are retrospective studies. Further robust data in prospective trials are warranted to achieve a definitive evidence of ESD, which will be beneficial to patients with SESCC.

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Conventional versus traction-assisted endoscopic submucosal dissection for large esophageal cancers: a multicenter, randomized controlled trial (with video)

Cited by 85 publications

References 37 publications

Ex Vivo Porcine Model Study on the Treatment Outcomes of Scissor-type Knife Versus Needle-type Knife in Endoscopic Submucosal Dissection Performed by Trainees

Ex Vivo Porcine Model Study on the Treatment Outcomes of Scissor-type Knife Versus Needle-type Knife in Endoscopic Submucosal Dissection Performed by Trainees

Traction-assisted endoscopic submucosal dissection in the esophagus: Should we all be flossing?

Endoscopic resection of esophageal squamous cell carcinoma: Current indications and treatment outcomes

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