Counter traction makes endoscopic submucosal dissection easier

Abstract

Poor counter traction and poor field of vision make endoscopic submucosal dissection (ESD) difficult. Good counter traction allows dissections to be performed more quickly and safely. Position change, which utilizes gravity, is the simplest method to create a clear field of vision. It is useful especially for esophageal and colon ESD. The second easiest method is clip with line method. Counter traction made by clip with line accomplishes the creation of a clear field of vision and suitable counter traction thereby making ESD more efficient and safe. The author published this method in 2002. The name ESD was not established in those days; the name cutting endoscopic mucosal resection (EMR) or EMR with hook knife was used. The other traction methods such as external grasping forceps, internal traction, double channel scope, and double scopes method are introduced in this paper. A good strategy for creating counter traction makes ESD easier.

Keywords: Counterattraction; Endoscopic submucosal dissection; Stomach neoplasms; Surgical instruments.

Fig. 1

An illustration showing clip with line method. A clip with line was placed at the edge of the target lesion when the circumferential incision was completed. Good counter traction and a clear field of vision were obtained when the line was pulled very gently (reprinted from Oyama T, et al. Stomach Intest 2002;37:1155-1161, with permission).

Fig. 2

The second clip can change the direction of traction (reprinted from Oyama T, et al. Stomach Intest 2002;37:1155-1161, with permission).

Fig. 3

A long, 3-0, silk line was tied to the arm part of the clip.

Fig. 4

The clip with line is reset in the cassette. Then the clip with line can be set in the applicator like a usual clip.

Fig. 5

Endoscopy showed a well demarcated semicircumferential iodine unstaind lesion in the lower esophagus.

Fig. 6

The circumferential incision was completed. The next step is submucosal dissection. However, the field of vision was not clear enough because the submucosal space is narrow.

Fig. 7

The clip with line was placed at the submucosal side of the targeted specimen.

Fig. 8

A clear field of vision and adequate counter traction were gained when the line was pulled gently.

Fig. 9

Procedure after traction. (A, B) The movement of specimen could be stopped by the traction made by the line. Submucosal dissection was then performed more easily, safely, and quickly.