Transnasal endoscope-assisted endoscopic submucosal dissection for gastric adenoma and early gastric cancer in the pyloric area: a case series

Abstract

Endoscopic submucosal dissection (ESD) is an important therapeutic option for gastric adenoma and early gastric cancer (EGC). However, ESD is technically difficult when lesions are located in the pyloric area. Our aim was to introduce the transnasal endoscope-assisted ESD method, which provides for excellent cutting-line visualization through control of submucosal traction. A total of eight patients with gastric adenoma or EGC located in the pyloric area were consecutively enrolled. A primary operating endoscope was used to perform marking, incision, submucosal dissection, and hemostasis, while a thinner, transnasal endoscope operated by a second endoscopist was used to retract connective submucosal tissue to provide cutting-line visualization using V-shaped grasping forceps. En bloc resection was achieved in all eight cases, as was complete resection. The median longest lesion diameter was 19 mm (range: 12-25 mm), and the median procedure time was 37.5 minutes (range: 29-59 minutes). There were no incidents of significant bleeding or perforation. Transnasal endoscope-assisted ESD was useful for treating gastric neoplasms in the pyloric area. The procedure was relatively easy and safe, provided excellent visualization through tissue retraction, and allowed for complete en bloc resection.

Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video)

“…However, the operative field yielded by this transparent hood is still limited by its diameter and length and theoretically requires substantial experience. The efficacy of novel devices that provide endoscopists with countertraction and direct visualization of the dissection line have been investigated, including the sinker device 10 ; external grasping forceps 11–13 ; thin endoscope 14,15 ; and internal traction using nylon suture, 16 a spring, 17 and a rubber band 18,19 ; percutaneous traction 20 ; and peroral traction 21 with a pulley method. 2,22 In addition, injectable reverse-phase polymer has been suggested to assist in ESD by providing mechanical force in transitioning from a liquid to a more solid substance.…”

“…First, compared with the internal traction methods (the sinker device, 10 internal traction using nylon suture, 16 a spring, 17 and a rubber band, 18,19 the assistant can maintain and precisely adjust the tension force in accordance with ESD progression simply by pulling the suture tail. Second, compared with the external traction methods using assistive endoscopic devices (external grasping forceps 11–13 and an additional thin endoscope 14,15 ), the working space of therapeutic endoscope is not restricted by the traction device.…”

Counter Traction Makes Endoscopic Submucosal Dissection Easier

“…Some methods using a second endoscopy have been reported 14-17. The direction of traction could be controlled easily with the double scope method.…”

Clinical outcomes of endoscopic resection for gastric neoplasms in the pylorus

“…Transnasal endoscope-associated traction was performed with a transnasal endoscope operated by a second endoscopist to retract submucosal tissue to visualize the cutting line using grasping forceps, while the primary endoscopist performed the main procedure ( Fig. 1) [16]. Double-channel endoscope-assisted traction was performed with a grasping forceps inserted into one channel of a double-channel endoscope to make counter traction during resection [17].…”