Endoscopic submucosal dissection (ESD) is the standard treatment for early gastric neoplasms (EGNs), and traction methods have been developed to make ESD safe and simple [1]
[2]
[3]. Applying appropriate traction provides better visibility of the submucosal layer and enables effective dissection [4]
[5]. We developed a novel three-point traction (TPT) method using a combination of clip-with-thread and clip-with-silicon band for gastric ESD. Here, we present a successful case of TPT-ESD for a large EGN ([Fig. 1], [Video 1]).
Fig. 1 Clip with traction band and pre-tied thread.
Three-point traction method for endoscopic submucosal dissection using clip-with-thread and clip-with-silicon bands for large early gastric neoplasms.Video 1
A 70-year-old woman underwent ESD for a 50-mm EGN on the greater curvature of the antrum.
Marking dots and circumferential mucosal incisions were made around the lesions using an
electrosurgical knife. Subsequently, TPT was performed on the lesions. A clip-with-thread was
placed at the 6 o’clock position of the mucosal flap of the lesion ([Fig. 2]
a). Next, a clip-with-silicon band was placed at the 5 o’clock
position of the mucosal flap. The third clip was placed in the 7 o’clock position of the mucosal
flap while hooking the band, allowing the thread to run underneath the silicon band ([Fig. 2]
b, [Fig. 2]
c). TPT force was achieved by pulling the thread using three
clips ([Fig. 2]
d), which provided a wide and clear view of the submucosal
layer, enabling stable submucosal dissection. En bloc resection was achieved without
complication.
Fig. 2 Each step of the three-point traction method for ESD using a combination of clip-with-thread and clip-with-silicon-band. a A clip-with-thread placed in the 6 o’clock position of the mucosal flap of the lesion. b A clip-with-silicon band placed in the 5 o’clock position of the mucosal flap. c The third clip placed in the 5 o’clock position of the mucosal flap while hooking the silicon band, allowing the thread to run underneath the silicon band (Fig. 2b and Fig. 2c). d The TPT force was achieved by pulling the thread using three clips.
Compared with the conventional one-point-traction using a clip-with-thread, the TPT method provides a wide and clear view of the submucosal layer, elevating a larger area of the lesion and preventing the lesion from twisting during the latter part of dissection. The silicon band traction force generated by two clips in the 5 and 7 o’clock positions of the mucosal flap can bring the submucosal layer toward center, generating a synergistic effect with the TPT force. TPT- ESD can be a treatment option for EGN, particularly large lesions.
