A novel strategy for performing endoscopic submucosal dissection for circumferential superficial esophageal neoplastic lesions with kissing traction

Endoscopic submucosal dissection (ESD) is a widely utilized procedure for early esophageal cancer and precancerous lesions. However, it remains technically challenging and time consuming for circumferential lesions. Numerous studies have utilized various techniques for improving the efficacy of ESD in the treatment of esophageal circumferential lesions [1] [2] [3]. Herein, we propose a novel approach for improving ESD for esophageal peripheral lesions, termed the “kissing traction technique” (KT-ESD).

Over 3 years, six patients (four male, two female; mean age 62.5 years) with circumferential superficial esophageal neoplastic lesions underwent KT-ESD. Informed consent for the procedure was signed by all patients before the procedure intervention.

The steps of KT-ESD were as follows ([Video 1]). 1) Esophageal iodine staining ([Fig. 1] a). 2) Marking the lesion. 3) Marking a circumferential incision on the anal and oral sides of the lesion (0.5 cm away from the lesion). 4) Dissection to reveal the mucosal flap from the oral side of the lesion ([Fig. 1] b). 5) Using two legs of titanium clips to clamp the two kissing mucosal flaps before traction ([Fig. 1] c,d), so that only one traction is needed to pull up the whole lesion. 6) Complete dissection along the submucosa. 7) Injection of triamcinolone acetonide solution on the wound; postoperative oral steroids were administered to prevent stenosis.

A novel strategy for performing endoscopic submucosal dissection for circumferential superficial esophageal neoplastic lesions with kissing traction.Video 1

Fig. 1 The procedural steps of endoscopic submucosal dissection with kissing traction. a Esophageal iodine staining. b The mucosal flap from the oral side of the lesion. c Using two legs of titanium clips to clamp the two kissing mucosal flaps. d Established status of post-kissing traction.

The length of the lesions ranged from 5.0 to 9.5 cm, with operation times ranging from 55 to 92 minutes ([Table 1]). None of the patients experienced intraoperative or postoperative bleeding or perforation. No recurrence was observed in subsequent follow-up. During the 3–30 months of postoperative follow-up, two of the six patients developed esophageal stenosis; however, the stenosis was successfully relieved following two to three balloon dilation procedures.

Table 1 Characteristics of six patients undergoing endoscopic submucosal dissection with kissing traction.

Sex	Age	Location1	Longitudinal diameter, cm	Macroscopic type	Operative time, minutes	Adverse events	Pathological type	Follow up, months
1Superior, middle, and inferior of the esophageal.
M	69	Middle and inferior	6	IIb	65	No	Intramucosal cancer	3
F	56	Middle	5	IIb	55	Stenosis	High grade intraepithelial neoplasia	5
F	64	Middle and inferior	6.5	IIb+IIa	70	No	Intramucosal cancer	15
M	56	Middle and inferior	9.5	IIb+IIa	92	Stenosis	Intramucosal cancer	25
M	60	Middle and inferior	7	IIb	80	No	High grade intraepithelial neoplasia	12
M	70	Middle and inferior	5	IIb	60	No	Intramucosal cancer	30

In conclusion, KT-ESD demonstrated a significant improvement in dissection efficiency for peripheral esophageal lesions, without an increase in complications.

Endoscopy_UCTN_Code_TTT_1AO_2AG_3AZ

Publication History

Article published online:
30 July 2024

• References

• 1 Fraile-López M, Parra-Blanco A. Double-tunnel circumferential endoscopic submucosal dissection with double clip-band-line traction for an esophageal squamous neoplasm. Endoscopy 2020; 52: E303-E305
• 2 Li X, Sun Z, Ye L. et al. Wide-tunnel endoscopic submucosal dissection with clip-and-line traction for large circumferential esophageal neoplasm. Endoscopy 2022; 54: E670-E671
• 3 Lu Q, Du ZQ, Zhou XR. et al. Snare-based circumferential traction technique for endoscopic submucosal dissection of long circumferential early esophageal carcinoma. Endoscopy 2023; 55: E920-E921