Two traction methods that can facilitate esophageal endoscopic submucosal dissection

Abstract

Different traction devices that can provide a visual field and attain appropriate tension at the dissection plane during endoscopic submucosal dissection (ESD) have been developed. Clip-with-line (CWL) is a classic traction device that can offer per-oral traction toward the direction where the line is drawn. A multicenter randomized controlled trial (CONNECT-E trial) comparing the conventional ESD and CWL-assisted ESD (CWL-ESD) for large esophageal tumors was conducted in Japan. This study showed that CWL-ESD was associated with a shorter procedure time (defined as the time from initiating submucosal injection to completing tumor removal) without increasing the risk of adverse events. Multivariate analysis revealed that whole-circumferential lesion and abdominal esophageal lesion were independent risk factors for technical difficulties, which were defined as a procedure time of > 120 min, perforation, piecemeal resection, inadvertent incision (any accidental incision caused by the electrosurgical knife within the marked area), or handover to another operator. Therefore, techniques other than CWL should be considered for these lesions. Several studies have shown the usefulness of endoscopic submucosal tunnel dissection (ESTD) for such lesions. A randomized controlled trial conducted at five Chinese institutions showed that compared with the conventional ESD, ESTD had a significantly reduced median procedure time for lesions covering ≥ 1/2 of the esophageal circumference. In addition, a propensity score matching analysis conducted at a single Chinese institution showed that compared with the conventional ESD, ESTD had a shorter mean resection time for lesions at the esophagogastric junction. With the appropriate use of CWL-ESD and ESTD, esophageal ESD can be performed more efficiently and safely. Moreover, the combination of these two methods may be effective.

Keywords: Clip-with-line; Endoscopic submucosal dissection; Endoscopic submucosal tunnel dissection; Traction.

Figure 1

A clip-with-line was made by tying a commercially available dental floss to the arm section of the hemoclip. Reprinted from Mitsuru Nagata. Optimal traction direction in traction-assisted gastric endoscopic submucosal dissection. World J Gastrointest Endosc 2022; 14: 667-671. Copyright © Mitsuru Nagata 2022. Published by Baishideng Publishing Group Inc[10].

Figure 2

Classification of the traction direction. A: Vertical traction; B: Proximal traction; C: Proximal traction combined with hood traction; D: Diagonally proximal traction; E: Diagonally distal traction; F: Distal traction. Citation: Reprinted from Mitsuru Nagata. Advances in traction methods for endoscopic submucosal dissection: What is the best traction method and traction direction? World Journal of Gastroenterology 2022; 28: 1–22. Copyright © Mitsuru Nagata 2022. Published by Baishideng Publishing Group Inc[9].

Figure 3

Difference in traction direction depending on the lesion location in the clip-with-line method. A: Distal traction; B: Proximal traction; C: Vertical traction. Citation: Reprinted from Mitsuru Nagata. Advances in traction methods for endoscopic submucosal dissection: What is the best traction method and traction direction? World Journal of Gastroenterology 2022; 28: 1–22. Copyright © Mitsuru Nagata 2022. Published by Baishideng Publishing Group Inc[9].