Traction method versus conventional endoscopic submucosal dissection for gastric epithelial neoplasms

Abstract

Introduction: Endoscopic submucosal dissection (ESD) is an advanced therapeutic technique for en bloc resection of superficial gastrointestinal neoplasms. Although gastric ESD is minimally invasive and provides favorable outcomes, it is technically difficult and requires a long procedure time for dissection. The traction-assisted approach overcomes some of the difficulties of gastric ESD, but its ability to reduce the procedure time remains unclear. The traction-assisted approach using dental floss and a clip did not reduce procedure time in the total population, but it reduced procedure time for lesions limited to the greater curvature of the upper or middle of the stomach. Although the traction direction of the clip-with-line method may be limited to the oral side via the cardia, EndoTrac ESD may provide flexible traction at any time during the procedure. This prospective randomized control study has been designed to compare the efficacy and safety of EndoTrac and conventional gastric ESD.Methods/design: This multicenter, randomized control trial will enroll 150 patients at 2 hospitals in Japan undergoing EndoTrac or conventional ESD for gastric epithelial neoplasia. Patients with a single gastric epithelial neoplasm who meet the inclusion and exclusion criteria will be randomized to EndoTrac or conventional ESD. Patients will be randomized by a computer-generated random sequence with stratification by operator experience, tumor size, tumor location, and institution. The primary endpoint will be ESD procedure time, defined as the time from the start of the submucosal injection to the completion of resection. Other outcomes will include the rates of adverse events and pathological curability Discussion: The ability of EndoTrac ESD to reduce the long procedure time and/or adverse events observed with conventional ESD can not only reduce physical stress on the patient, but can also reduce length of hospital stay and medical costs. Reduced technical difficulty will contribute to the widespread adoption of this ESD technique worldwide.

The Role of Specialized Instruments for Advanced Endoscopic Resections in Gastrointestinal Disease

“…The increased number of publications on the traction-countertraction issue in flexible endoscopy in recent years could reflect a lack of this function in current available endoscopic instruments [20][21][22][23][24][25][26]. During high-end therapeutic endoscopies such as ESD, traction may be necessary on the gut wall or the specimen, which can be solved using the demonstrated instruments, such as the Endo-dissector and/or the EINTS.…”

“…Endoscopic experts may get by without these options since they can compensate for this lack with their vast experience. For "average" endoscopists, this limitation of optimal instrument function may be critical, and the literature provides some examples of instrument optimization regarding interventional endoscopic procedures [19][20][21][22][23][24][25][26]. Several attempts were reported to create additional assisting instruments using external tools other than the regular endoscope, based on a more surgical paradigm, to facilitate endoscopic procedures [19][20][21][22][23][24][25][26].…”

“…For "average" endoscopists, this limitation of optimal instrument function may be critical, and the literature provides some examples of instrument optimization regarding interventional endoscopic procedures [19][20][21][22][23][24][25][26]. Several attempts were reported to create additional assisting instruments using external tools other than the regular endoscope, based on a more surgical paradigm, to facilitate endoscopic procedures [19][20][21][22][23][24][25][26]. The unmet need for a better traction-countertraction function is resolved in endoscopic practice using various grasping systems, such as the AWC system, EINTS, and SPOT [15][16][17][18][19].…”

A novel method of endoscopic submucosal dissection using a threaded clip for a lesion of the greater curvature of the gastric body

“…Gastric endoscopic submucosal dissection (ESD) for lesions of the greater curvature of the gastric body is challenging owing to difficulty in approaching the lesion, submersion 1 , and vertical confrontation with the lesion. Threaded-clip traction attached to the lesion is widely used in gastric ESD 2 3 .…”

Advancing endoscopic traction techniques in endoscopic submucosal dissection

“…Clip-line assisted ESD has been reported to significantly shorten procedure time without compromising safety while performing resection of gastric lesions ( 27 ). Further prospective, randomized and controlled study of this technique revealed that the procedure time reduction is most pronounced when performing ESD in the greater curvature of the upper or middle stomach with a low risk of perforation ( 28 ).…”