Two-step traction-assisted endoscopic submucosal dissection for a gastric neoplasm using a clip with a traction band and thread

The traction technique is a common assistance method for gastric endoscopic submucosal dissection (ESD) [1] [2] [3]. We previously developed intralesional traction-assisted ESD (ILT-ESD) [4] [5]. Although this provides a favorable clear view of the submucosal layer by achieving intralesional elevation using clips with a traction band, there is one problem to be solved. The traction force decreases because of the reduced area of lesion attachment as submucosal dissection progresses. To resolve this problem, we further developed a two-step traction-assisted ESD (TT-ESD), where intralesional traction is performed in the first half and clip-with-thread traction is applied in the latter half of the submucosal dissection ([Video 1]).

Video 1 Two-step traction-assisted endoscopic submucosal dissection is performed for a gastric neoplasm using a clip with a traction band and thread.

A gastric lesion with a 15-mm diameter was located at the greater curvature of the gastric body. TT-ESD was applied to the lesion. A clip with traction band and thread were prepared, with the thread tied to the traction band ([Fig. 1]). After the circumferential mucosal incision around the lesion had been completed, the clip with the traction band and thread was placed at the proximal margin of the mucosal flap ([Fig. 2 a]). Subsequently, the second clip was placed at the distal margin of the lesion by hooking the traction band ([Fig. 2 b, c]). Intralesional traction was achieved by the elastic force of the band between the clips ([Fig. 2 d]). Submucosal dissection was conducted with a clear view of the submucosal layer in the first half of the procedure ([Fig. 2 e]). In the second part of the procedure, when the intralesional traction force decreased, conventional clip-with-thread traction was applied to generate an effective traction force on the lesion ([Fig. 2 f]). Submucosal dissection was therefore completed with a clear view of the submucosal layer throughout the procedure, and en bloc resection was achieved without any complications.

Fig. 1 Photograph of the threaded clip that is created by manually tying floss onto the clip.

Fig. 2 Endoscopic and schematic images of the procedure showing: a the clip, with the traction band and the thread tied to it, is placed at the proximal edge of the lesion; b the opposite ring of the traction band is hooked by the second clip; c the second clip is placed at the distal edge of the lesion; d intralesional traction is achieved; e submucosal dissection is started with a clear view of submucosal layer; f clip-with-thread traction is applied to the lesion once the effects of intralesional traction have decreased.

Intralesional traction assists the first half of the submucosal dissection, while clip-with-thread traction assists the latter stages of the procedure. This combined technique provides a clear view of the submucosal layer throughout the dissection procedure.

Endoscopy_UCTN_Code_TTT_1AQ_2AD

Competing interests

H. Ogino and E. Ihara are involved in the endowed course supported by Miyarisan Pharmaceutical Co. Ltd., Fujifilm Medical Co., Ltd., Terumo Corporation, Fancl Corporation, and Muta Hospital. E. Ihara has also received a lecture fee from Takeda Pharmaceutical Co. K. Nishioka, M. Esaki, T. Iwasa, Y, Minoda, and N. Shiga declare that they have no conflict of interest.

• References

• 1 Esaki M, Ihara E, Gotoda T. Endoscopic instruments and techniques in endoscopic submucosal dissection for early gastric cancer. Expert Rev Gastroenterol Hepatol 2021; 15: 1009-1020
• 2 Yoshida M, Takizawa K, Suzuki S. et al. Conventional versus traction-assisted endoscopic submucosal dissection for gastric neoplasms: a multicenter, randomized controlled trial (with video). Gastrointest Endosc 2018; 87: 1231-1240
• 3 Suzuki S, Gotoda T, Kobayashi Y. et al. Usefulness of a traction method using dental floss and a hemoclip for gastric endoscopic submucosal dissection: a propensity score matching analysis (with videos). Gastrointest Endosc 2016; 83: 337-346
• 4 Shoguchi Y, Esaki M, Minoda Y. et al. Innovative endoscopic submucosal dissection for early gastric neoplasm using intralesional traction and snaring techniques. Endoscopy 2022; 54 (Suppl. 02) E865-E866
• 5 Shoguchi Y, Esaki M, Minoda Y. Intralesional traction-assisted endoscopic submucosal dissection for early gastric neoplasm using the ProdiGI traction wire. Dig Endosc 2022; 34: e56-e57

Publication History

Article published online:
15 September 2023