Two-point fixed pulley-traction method in endoscopic submucosal dissection for early gastric neoplasm

Endoscopic submucosal dissection (ESD) is a technically challenging procedure with substantial risk of intraoperative complications. Traction assistance is a promising strategy for simplifying ESD. Although multiple traction methods have been proposed [1] [2] [3] [4] [5], there is room for further optimization. We designed a novel traction method termed the two-point fixed pulley-traction method (TPPT), which is detailed below and illustrated in [Video 1].

Video 1 Two-point fixed pulley-traction method in endoscopic submucosal dissection for early gastric neoplasm.

We implemented TPPT during ESD in an 80-year-old man with an early gastric neoplasm. The lesion measured 10 mm and was located on the lesser curvature of the gastric body. A viscous solution was injected into the submucosal layer and a circumferential mucosal incision was made around the lesion ([Fig. 1 a]). TPPT was implemented as follows. First, a clip hooking a small base ring of silicon bands was placed on the mucosal flap at one side of the lesion ([Fig. 1 b]). A thread had been pre-tied to the central ring of the silicon bands ([Fig. 2]). Second, another clip, hooking the distal ring, was placed on the opposite side of the mucosal flap ([Fig. 1 c]). Finally, a third clip hooking the thread was placed on the greater curvature, opposite the lesser curvature bearing the lesion. TPPT was finalized by pulling the thread ([Fig. 1 d]). TPPT applied a stable vertical traction force to the target lesion, enhancing the visibility of the submucosal layer until the completion of submucosal dissection. Consequently, en bloc resection was performed efficiently without complications.

Fig. 1 Steps of the two-point fixed pulley-traction method. a A circumferential mucosal incision was made around the lesion. b First clip hooking the base: a small ring of silicon bands, with a thread pre-tied to the central ring, was placed on one side of the mucosal flap. c A second clip hooking the distal ring was placed on the other side of the mucosal flap. d The third clip hooked the thread and was placed on the greater curvature of the stomach, opposite the lesser curvature bearing the lesion.

Fig. 2 Clip with traction band and pre-tied thread.

TPPT is a traction method that combines a two-point traction strategy with a pulley system. The entire mucosal flap could be elevated by applying traction at two points. Additionally, a vertical traction force was obtained via the pulley system, offering optimal traction. Therefore, TPPT could potentially serve as a useful tool for assisting ESD procedures for early gastric neoplasms.

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Competing interests

H. Ogino is involved in the endowed course supported by Miyarisan Pharmaceutical Co. Ltd., Fujifilm Medical Co., Ltd., Terumo Corporation, Fancl Corporation, and Muta Hospital. E. Ihara participated in the funded research of Takeda Pharmaceutical. E. Ihara has received a lecture fee from Takeda Pharmaceutical. Yoshihiro Ogawa is conducting a joint study with Fancl Corporation and Fujifilm Medical Co., Ltd. The other authors declare that they have no conflict of interest.

• References

• 1 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
• 2 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
• 3 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
• 4 Nasu T, Esaki M, Shoguchi Y. et al. Application of intralesional traction assistance with traction wire to endoscopic submucosal dissection for colorectal neoplasms. Endoscopy 2022; 54: E784-E785
• 5 Iwao A, Ichijima R, Ikehara H. Usefulness of the “elastic traction device” in gastric endoscopic submucosal dissection. Dig Endosc 2022; 34: e139-e140

Publikationsverlauf

Artikel online veröffentlicht:
27. September 2023