Application of traction-method to hybrid endoscopic submucosal dissection for gastrointestinal tumors

Hybrid endoscopic submucosal dissection (ESD) is a simplified endoscopic treatment for conventional ESD that consists of snaring of submucosal layer after completion of circumferential mucosal incision and subsequent partial submucosal dissection [1] Previous studies have revealed that hybrid ESD reduces the en bloc resection rate although it significantly shortens the treatment procedure time [2] [3]. To improve the en bloc resection rate, we proposed a traction-assisted hybrid ESD using the clip-with-thread technique and a multi-functional snare, SOUTEN (Kaneka Medix, Tokyo, Japan), in the porcine stomach model [4].

A 20-mm mock lesion was prepared at the greater curvature of the gastric body. Hyaluronic acid was injected into the submucosal layer around the lesion using an injection needle. Then, circumferential mucosal incision and partial submucosal dissection were performed using the distal tip of the SOUTEN. Subsequently, a clip with thread was placed on the proximal mucosal flap of the lesion ([Fig. 1 a]). The thread was passed through a ring of the snare being inserted through a biopsy channel ([Fig. 1 b]). After insertion of the endoscope, the loosened thread was straightened ([Fig. 1 c, d]). The distal tip of the snare was placed at the distal edge of the lesion. With the snare open, the clip-with-thread was pulled until the lesion was lifted high enough to conduct snaring under direct vision of the submucosal layer ([Video 1]). En bloc resection of the lesion was achieved by snaring without any fault.

Fig. 1 The schemas showing the step-by-step procedure for traction-assisted hybrid endoscopic submucosal dissection. a A clip-with-thread was placed near the proximal part of the lesion. b A thread was passed through a ring of the snare being inserted through a biopsy channel. c A standard single-channel endoscope was inserted into the stomach. d The loosened thread was straightened.

Video 1 Traction-assisted hybrid endoscopic submucosal dissection.

Traction-assisted hybrid ESD can be performed using a standard single-channel endoscope to achieve en bloc resection of gastrointestinal tract tumors. The application of the traction method could expand the indication for hybrid ESD of larger lesions.

Endoscopy_UCTN_Code_TTT_1AO_2AC

Publication History

Article published online:
20 April 2021

• References

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