Impact of Traction Direction in Traction-Assisted Gastric Endoscopic Submucosal Dissection (with Videos)

Nagata, Mitsuru; Namiki, Masayuki; Fujikawa, Tomoaki; Munakata, Hiromi

doi:10.1007/s10620-023-07870-z

Dig Dis Sci

2023

DOI: 10.1007/s10620-023-07870-z

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Impact of Traction Direction in Traction-Assisted Gastric Endoscopic Submucosal Dissection (with Videos)

Mitsuru Nagata¹,

Masayuki Namiki

Tomoaki Fujikawa

et al.

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Cited by 2 publications

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Two traction methods that can facilitate esophageal endoscopic submucosal dissection

Nagata¹

2023

World J Gastrointest Endosc

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Different traction devices that can provide a visual field and attain appropriate tension at the dissection plane during endoscopic submucosal dissection (ESD) have been developed. Clip-with-line (CWL) is a classic traction device that can offer per-oral traction toward the direction where the line is drawn. A multicenter randomized controlled trial (CONNECT-E trial) comparing the conventional ESD and CWL-assisted ESD (CWL-ESD) for large esophageal tumors was conducted in Japan. This study showed that CWL-ESD was associated with a shorter procedure time (defined as the time from initiating submucosal injection to completing tumor removal) without increasing the risk of adverse events. Multivariate analysis revealed that whole-circumferential lesion and abdominal esophageal lesion were independent risk factors for technical difficulties, which were defined as a procedure time of > 120 min, perforation, piecemeal resection, inadvertent incision (any accidental incision caused by the electrosurgical knife within the marked area), or handover to another operator. Therefore, techniques other than CWL should be considered for these lesions. Several studies have shown the usefulness of endoscopic submucosal tunnel dissection (ESTD) for such lesions. A randomized controlled trial conducted at five Chinese institutions showed that compared with the conventional ESD, ESTD had a significantly reduced median procedure time for lesions covering ≥ 1/2 of the esophageal circumference. In addition, a propensity score matching analysis conducted at a single Chinese institution showed that compared with the conventional ESD, ESTD had a shorter mean resection time for lesions at the esophagogastric junction. With the appropriate use of CWL-ESD and ESTD, esophageal ESD can be performed more efficiently and safely. Moreover, the combination of these two methods may be effective.

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Two traction methods that can facilitate esophageal endoscopic submucosal dissection

Nagata¹

2023

World J Gastrointest Endosc

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

Nagata¹

2023

World J Gastrointest Endosc

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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.

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Impact of Traction Direction in Traction-Assisted Gastric Endoscopic Submucosal Dissection (with Videos)

Cited by 2 publications

References 40 publications

Two traction methods that can facilitate esophageal endoscopic submucosal dissection

Two traction methods that can facilitate esophageal endoscopic submucosal dissection

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

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