Device-assisted traction methods in colorectal endoscopic submucosal dissection and options for difficult cases

Abstract

Endoscopic submucosal dissection (ESD) procedure has a longer procedure time and higher perforation rate than endoscopic mucosal resection owing to technical complications, including a poor field of vision and inadequate tension for the submucosal dissection plane. Various traction devices were developed to secure the visual field and provide adequate tension for the dissection plane. Two randomized controlled trials demonstrated that traction devices reduce colorectal ESD procedure time compared with conventional ESD (C-ESD), but they had limitations, including a single-center fashion. The CONNECT-C trial was the first multicenter randomized controlled trial comparing the C-ESD and traction device-assisted ESD (T-ESD) for colorectal tumors. In the T-ESD, one of the device-assisted traction methods (S–O clip, clip-with-line, and clip pulley) was chosen according to the operator’s discretion. The median ESD procedure time (primary endpoint) was not significantly different between C-ESD and T-ESD. For lesions ≥ 30 mm in diameter or in cases treated by nonexpert operators, the median ESD procedure time tended to be shorter in T-ESD than in C-ESD. Although T-ESD did not reduce ESD procedure time, the CONNECT-C trial results suggest that T-ESD is effective for larger lesions and nonexpert operators in colorectal ESD. Compared with esophageal and gastric ESD, colorectal ESD has some difficulties, including poor endoscope maneuverability, which may be associated with prolonged ESD procedure time. T-ESD may not effectively improve these issues, but a balloon-assisted endoscope and underwater ESD may be promising options and these methods can be combined with T-ESD.

Effect of Time-Limited Training on Endoscopic Submucosal Dissection in an Ex Vivo Porcine Stomach Model: A Prospective Randomized Controlled Study

“…Therefore, animal model training should be arranged efficiently. Operation time is often used as an indicator to measure operator proficiency in animal model training, 22 23 24 25 26 and limiting the operating time may be beneficial for improving training efficiency. In our study, each trainee had a time limit of 30 minutes based on good criteria in the skill assessment of participants according to the consensus of the National Cancer Centre of Japan and Western supervisory endoscopy experts with experience in ESD.…”

Underwater endoscopic submucosal dissection with dental floss traction for the treatment of early pharyngeal cancer

“…However, the technical complexity of the procedure is compounded by factors such as the narrow pharyngeal cavity, tracheal intubation, and the potential influence of the hyoid bone, further augmenting the challenges associated with pharyngeal endoscopy [3]. The application of dental floss traction during ESD, along with the water immersion technique, which capitalizes on the inherent buoyancy of water, provides enhanced traction and improved visual acuity [4]. This heightened visual en- ▶ Fig.…”