Efficacy of Current Traction Techniques for Endoscopic Submucosal Dissection

Abstract

This systematic review aimed to assess the efficacy of the current approach to tissue traction during the endoscopic submucosal dissection (ESD) of superficial esophageal cancer, early gastric cancer, and colorectal neoplasms. We performed a systematic electronic literature search of articles published in PubMed and selected comparative studies to investigate the treatment outcomes of tractionassisted versus conventional ESD. Using the keywords, we retrieved 381 articles, including five eligible articles on the esophagus, 13 on the stomach, and 12 on the colorectum. A total of seven randomized controlled trials and 23 retrospective studies were identified. Clip line traction and submucosal tunneling were effective in reducing the procedural time during esophageal ESD. The efficacy of traction methods in gastric ESD varied in terms of the devices and strategies used depending on the lesion location and degree of submucosal fibrosis. Several prospective and retrospective studies utilized traction devices without the need to reinsert the colonoscope. When pocket creation is included, the traction devices and methods effectively shorten the procedural time during colorectal ESD. Although the efficacy is dependent on the organ and tumor locations, several traction techniques have been demonstrated to be efficacious in facilitating ESD by maintaining satisfactory traction during dissection.

Keywords: Colorectal neoplasms; Early gastric cancer; Endoscopic submucosal dissection; Esophageal neoplasms; Traction.

Fig. 1

Endoscopic submucosal tunneling technique of an extensive esophageal squamous cell carcinoma. (A) Markings were performed for a widespread superficial esophageal cancer involving complete luminal circumference in the middle thoracic esophagus. (B) Semicircumferential mucosal incision on the proximal side was performed using a dual knife. (C) Complete circumferential mucosal incision of the distal side to make an endpoint for submucosal dissection. (D) A submucosal tunnel was created with the use of the backside electrode of an insulated tipped nano device. This technique allowed satisfactory tissue traction to be maintained inside the tunnel. (E) After completing submucosal tunneling, submucosal dissection was continued, expanding the tunnel to the lateral side. (F) En bloc resection was achieved. (G) An illustration of endoscopic submucosal tunneling dissection.

Fig. 2

Clip line traction of gastric endoscopic submucosal dissection. (A) Circumferential mucosal incision was performed for an early gastric cancer measuring 50 mm in size located in the lesser curvature of the upper gastric body. (B) A line was tied to an endoclip outside the patient. (C) The endoclip with the line was applied to the distal side of the specimen in retroflexion. (D) After pulling the line back proximally, the submucosal plane was well visualized and lifted with sufficient tissue retraction. (E) An illustration of the clip and line traction.

Fig. 3

S-O clip traction of colorectal endoscopic submucosal dissection. (A) A pale, laterally spreading nodular elevated lesion was observed in the cecum close to the appendix orifice. (B) An S-O clip was applied to the distal side of the specimen after partial mucosal incision. (C) The ring loaded onto the clip was picked up by another endoclip, and the clip was anchored to the opposite side of the lumen. This procedure allowed sufficient tissue traction, and the submucosal space was well exposed. (D) This traction technique facilitated entering the submucosal space. (E) An illustration of S-O clip-assisted endoscopic submucosal tunneling dissection.

Fig. 4

Pocket creation method in colorectal endoscopic submucosal dissection. (A) A laterally spreading reddish elevation was observed in the transverse colon. (B) Mucosal entry was created by dissecting the submucosa and opening the submucosal space. (C) A submucosal pocket was created by dissecting the submucosa both laterally and proximally. This procedure allowed stable scope position and sufficient tissue traction inside the pocket. (D) Circumferential mucosal incision was performed along the edge of the pocket. (E) En bloc resection was achieved. (F) An illustration of the pocket creation method.