Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video)

Abstract

Background The lack of countertraction in endoscopic submucosal dissection (ESD) results in increased technical demand and procedure time. Although the suture-pulley method for countertraction has been reported, its effectiveness compared with the traditional ESD technique remains unclear. Objective To objectively analyze efficacy of countertraction using the suture-pulley method for ESD. Design Prospective ex vivo animal study. Setting Animal laboratory. Interventions Twenty simulated gastric lesions were created in porcine stomachs by using a standard circular template 30 mm in diameter. In the control arm (n = 10), ESD was performed by using the standard technique. In the suture-pulley arm (N = 10), a circumferential incision was made, and an endoscopic suturing device was used to place the suture pulley. Main Outcome Measurements The primary outcome of this study was total procedure time. Results The median total procedure time with the suture-pulley method was significantly shorter than the traditional ESD technique (median, 25% to 75%, interquartile range [IQR]: 531 seconds [474.3–549.3 seconds] vs 845 seconds [656.3–1547.5 seconds], P < .001). The median time (IQR) for suture-pulley placement was 160.5 seconds (150.0–168.8 seconds). Although there was a significantly longer procedure time for proximal versus middle/lower stomach lesions with traditional ESD (median, 1601 seconds; IQR, 1547.5–1708.8 seconds vs median, 663 seconds; IQR, 627.5–681.8 seconds; P =.01), there was no significant difference in procedure time for lesions of various locations when using the suture-pulley method. Compared with traditional ESD, the suture-pulley method was less demanding in all categories evaluated by the NASA Task Load Index. Limitations Ex vivo study. Conclusions The suture-pulley method facilitates direct visualization of the submucosal layer during ESD and significantly reduces procedure time and technical difficulty. In addition, the benefit of the suture-pulley method was seen for both simple and more complicated ESDs.

Endoscopic submucosal dissection with an additional working channel (ESD+): a novel technique to improve procedure time and safety of ESD

“…Many approaches have been tested to accelerate and secure endoscopic resections. For the purpose of achieving better intraluminal tissue traction, various endoscopic devices have been designed, including external forceps, magnetic anchors, clips with attached strings, rubber bands, the EndoLifter, and the creation of a pulley system with clips to facilitate endoscopic traction [15,[21][22][23][24][25][26][27]. However, the optimal traction device for endoluminal surgery has not been identified so far.…”

Current state of education and training for endoscopic submucosal dissection: Translating strategy and success to the USA

“…A suture-pulley method to facilitate direct visualization of the submucosal layer during gastric ESD has also been shown to reduce the learning curve for trainees. 56,57 Traditionally, lack of counter-traction during ESD results in increased technical demand and procedure time. Results from this animal model study by Aihara and colleagues demonstrated significantly reduced procedure times (531 s vs 845 s; P < 0.001) with ease in technical difficulty.…”

“…Results from this animal model study by Aihara and colleagues demonstrated significantly reduced procedure times (531 s vs 845 s; P < 0.001) with ease in technical difficulty. 56 Furthermore, among novice endoscopists new to ESD, the suture-pulley counter-traction method significantly decreased procedure time and technical demand. 57 Additional systems designed to provide counter-traction with clip placement attached to rubber bands have also been established to facilitate colorectal ESD.…”

Endoscopic Submucosal Tunnel Dissection for Large Gastric Neoplastic Lesions: A Case-Matched Controlled Study

“…Several traction methods for ESD have been investigated to overcome the problem, such as percutaneous traction [ 5 ], clip with line [ 6 – 8 ], clip-and-snare [ 9 ], external grasping forceps [ 10 ], internal traction [ 11 , 12 ], suture-pulley [ 13 ], magnetic anchor [ 14 ], double-channel endoscope [ 15 ], double-endoscope [ 16 ], and robot-assisted method [ 17 ]. However, those traction methods need extra devices or equipment and may be invasive or difficult to control the pulley strength and direction or inconvenient to be operated.…”