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Nagata M, Namiki M, Fujikawa T, Munakata H. Impact of Traction Direction in Traction-Assisted Gastric Endoscopic Submucosal Dissection (with Videos). Dig Dis Sci 2023; 68:2531-2544. [DOI: https:/doi.org/10.1007/s10620-023-07870-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/03/2023] [Indexed: 05/21/2023]
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Impact of Traction Direction in Traction-Assisted Gastric Endoscopic Submucosal Dissection (with Videos). Dig Dis Sci 2023; 68:2531-2544. [PMID: 36853551 PMCID: PMC9971682 DOI: 10.1007/s10620-023-07870-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/03/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND The impact of traction direction in traction-assisted gastric endoscopic submucosal dissection (ESD) has not been adequately investigated. A clip with line (CWL) is a classical single-directional traction device. In contrast, a spring and loop with clip (SLC; S-O clip) is a newly developed multidirectional traction device. AIMS To investigate the impact of traction direction in gastric ESD by comparing the procedure-related outcomes of CWL-assisted ESD (CWL-ESD) and SLC-assisted ESD (SLC-ESD). METHODS We retrospectively examined 140 patients with superficial gastric neoplasms who underwent SLC-ESD or CWL-ESD by a single ESD expert during November 2017-September 2020. The traction direction was classified based on the endoscopic finding in the following five categories: proximal, diagonally proximal, vertical, diagonally distal, and distal. In SLC-ESD, we set vertical traction, using the multidirectional traction function. Propensity score matching was conducted to compensate for the differences in lesion size, injection function of electrosurgical knife, ulcerative lesion, lesion location, and lesion position. The primary outcome was gastric ESD procedure time. RESULTS Propensity score matching created 42 pairs. The median gastric ESD procedure time in the SLC-ESD group was significantly shorter than that in the CWL-ESD group (28.3 min vs. 51.0 min, P = 0.022). All traction direction in the SLC-ESD group was vertical, while only 16.7% in the CWL-ESD group. En bloc resection was attained without perforation in all the patients in both groups. CONCLUSION Our findings suggest that SLC can provide vertical traction, which reduces the gastric ESD procedure time. Multidirectional traction devices can provide vertical traction in most cases of gastric ESD, unlike single-directional traction devices. Vertical traction may reduce the gastric ESD procedure time.
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Nagata M. Optimal traction direction in traction-assisted gastric endoscopic submucosal dissection. World J Gastrointest Endosc 2022; 14:667-671. [PMID: 36438880 PMCID: PMC9693688 DOI: 10.4253/wjge.v14.i11.667] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/02/2022] [Accepted: 10/14/2022] [Indexed: 11/14/2022] Open
Abstract
Various traction devices have been developed to secure a visual field and sufficient tension at the dissection plane during endoscopic submucosal dissection (ESD). However, few large-scale studies have investigated the effectiveness of traction devices in gastric ESD. Clip-with-line (CWL) is one such traction device that is widely used in cases of gastric ESD. The CONNECT-G trial was the first multicenter randomized controlled trial to compare conventional ESD with CWL-assisted ESD (CWL-ESD) for superficial gastric neoplasms. Overall, no significant intergroup difference was observed in terms of the gastric ESD procedure time. However, subgroup analysis according to lesion location revealed a significant reduction in the procedure time of gastric ESD for the lesion located at the greater curvature of the middle and upper third of the stomach in the CWL-ESD group. In this subgroup analysis, lesion location was categorized as follows: anterior wall, posterior wall, lesser curvature, and greater curvature of the upper, middle, and lower thirds of the stomach. However, the gastric ESD procedure time showed no significant difference, except for lesions located at the greater curvature of the upper and middle thirds of the stomach. The traction direction of CWL in the stomach was limited to the cardia and changed depending on the lesion location. Therefore, outcomes of the CONNECT-G trail suggest that the effectiveness of CWL was influenced by lesion location, i.e., traction direction. Further studies are warranted to investigate the optimal traction direction in gastric ESD.
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Affiliation(s)
- Mitsuru Nagata
- Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Fujisawa 251-0041, Kanagawa, Japan
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Abstract
Endoscopic submucosal dissection (ESD) has been developed as a treatment for superficial gastrointestinal neoplasms, which can achieve en bloc resection regardless of the lesion size. However, ESD is technically difficult because endoscopists cannot bring their hand into the gastrointestinal tract, unlike surgeons in regular surgery. It is difficult to obtain sufficient tension in the dissection plane and a good field of vision. Therefore, ESD is associated with a long procedure time and a high risk of adverse events in comparison with endoscopic mucosal resection. Traction methods have been developed to provide sufficient tension for the dissection plane and a good field of vision during the ESD procedure. However, traction direction is limited in most traction methods, resulting in insufficient effect in some cases. Although traction direction is considered important, there have been few investigations of its effect. In the first half of this review, important traction methods are discussed, including traction direction. In second half, appropriate traction methods for each organ are considered. Other important considerations for traction method, such as ability to adjust traction strength, interference between traction device and endoscope, and the need for specialized devices are also discussed.
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Affiliation(s)
- Mitsuru Nagata
- Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Kanagawa 251-0041, Japan.
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Nagata M. Advances in traction methods for endoscopic submucosal dissection: What is the best traction method and traction direction? World J Gastroenterol 2022; 28:1-22. [PMID: 35125817 PMCID: PMC8793018 DOI: 10.3748/wjg.v28.i1.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/13/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) has been developed as a treatment for superficial gastrointestinal neoplasms, which can achieve en bloc resection regardless of the lesion size. However, ESD is technically difficult because endoscopists cannot bring their hand into the gastrointestinal tract, unlike surgeons in regular surgery. It is difficult to obtain sufficient tension in the dissection plane and a good field of vision. Therefore, ESD is associated with a long procedure time and a high risk of adverse events in comparison with endoscopic mucosal resection. Traction methods have been developed to provide sufficient tension for the dissection plane and a good field of vision during the ESD procedure. However, traction direction is limited in most traction methods, resulting in insufficient effect in some cases. Although traction direction is considered important, there have been few investigations of its effect. In the first half of this review, important traction methods are discussed, including traction direction. In second half, appropriate traction methods for each organ are considered. Other important considerations for traction method, such as ability to adjust traction strength, interference between traction device and endoscope, and the need for specialized devices are also discussed.
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Affiliation(s)
- Mitsuru Nagata
- Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Kanagawa 251-0041, Japan
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Esaki M, Ihara E, Gotoda T. Endoscopic instruments and techniques in endoscopic submucosal dissection for early gastric cancer. Expert Rev Gastroenterol Hepatol 2021; 15:1009-1020. [PMID: 33909540 DOI: 10.1080/17474124.2021.1924056] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Endoscopic submucosal dissection (ESD) is a less invasive local treatment for early gastric cancer (EGC).Areas covered: Japanese guidelines have recently expanded the endoscopic treatment indications for EGC. ESD is sometimes performed for lesions with a relative indication that has not previously been considered for ESD. ESD procedures are technically difficult, especially for larger and more invasive lesions. Complete resection and accurate histological assessment of EGC lesions are essential to evaluate endoscopic curability. Various endoscopic instruments, including three types of endoscopic knives and specific hemostatic forceps, have been developed, and endoscopic techniques, including the traction method, have been modified to simplify the procedure.Expert opinion: An insulated-tip knife with large tissue contact allows us to perform faster incisions, while a needle-type knife with minimal tissue contact allows us to perform precise incisions. Furthermore, a scissor-type knife with grasping tissues allows us to perform more secure incision. The traction method enables the operator to proceed with submucosal dissection procedures. In cases with small lesions, snaring can be used, as well as knife dissection. Understanding the features of each endoscopic instrument and technique is essential because appropriate selection and usage contribute to successful and safe ESD procedures.
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Affiliation(s)
- Mitsuru Esaki
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Nagata M, Fujikawa T, Munakata H. Comparing a conventional and a spring-and-loop with clip traction method of endoscopic submucosal dissection for superficial gastric neoplasms: a randomized controlled trial (with videos). Gastrointest Endosc 2021; 93:1097-1109. [PMID: 33058886 DOI: 10.1016/j.gie.2020.09.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Several traction methods have sought to overcome the technical difficulties of endoscopic submucosal dissection (ESD). However, traction direction has remained limited in most of these methods, with lack of clarity about the optimal method and traction direction for gastric ESD. A spring-and-loop with clip (SLC) has been developed as a multidirectional traction device. Here, we investigated whether SLC traction-assisted ESD (SLC-ESD) improved procedure-related outcomes compared with conventional ESD (C-ESD) among patients with superficial gastric neoplasms. METHODS This single-center randomized controlled trial included patients with superficial gastric neoplasms undergoing SLC-ESD or C-ESD between October 2018 and December 2019. Using the multidirectional traction function, we set traction vertical to the gastric wall for SLC-ESD. The primary outcome was the median procedure time for gastric ESD. RESULTS The SLC-ESD and C-ESD groups comprised 40 patients each, and all the enrolled patients underwent the assigned treatment. The median ESD procedure time was significantly shorter in the SLC-ESD group (29.1 minutes) than in the C-ESD group (52.6 minutes; P = .005). SLC had a mean attachment time of 1.82 minutes. En bloc resection was achieved without perforation in all the patients in both groups. CONCLUSIONS Our findings suggest that SLC-ESD reduces gastric ESD procedure time without increasing the risk of perforation and that the vertical direction to the gastric wall is the appropriate traction direction for gastric ESD. (Clinical trial registration number: UMIN 000034533.).
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Affiliation(s)
- Mitsuru Nagata
- Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Fujisawa-shi, Kanagawa, Japan
| | - Tomoaki Fujikawa
- Center for Digestive and Hepato-Biliary-Pancreatic disease, Shonan Fujisawa Tokushukai Hospital, Fujisawa-shi, Kanagawa, Japan
| | - Hiromi Munakata
- Center for Digestive and Hepato-Biliary-Pancreatic disease, Shonan Fujisawa Tokushukai Hospital, Fujisawa-shi, Kanagawa, Japan
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Ueyama H, Murakami T, Matsumoto K, Sakamoto N, Osada T, Yao T, Nagahara A. Modified attachment method using S-O clip and multibending scope for gastric ESD at the greater curvature of the fundus. Endosc Int Open 2021; 9:E195-E196. [PMID: 33532558 PMCID: PMC7834921 DOI: 10.1055/a-1315-0293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Hiroya Ueyama
- Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Takashi Murakami
- Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Kenshi Matsumoto
- Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Naoto Sakamoto
- Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Taro Osada
- Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Takashi Yao
- Department of Human Pathology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University, School of Medicine, Tokyo, Japan
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Tamari H, Oka S, Ninomiya Y, Tanaka S, Chayama K. Use of a new traction device to expose the base of a pedunculated appendiceal polyp. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2021; 6:38-40. [PMID: 33490755 PMCID: PMC7804993 DOI: 10.1016/j.vgie.2020.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Affiliation(s)
- Hirosato Tamari
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuki Ninomiya
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
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Nagata M. Internal traction method using a spring-and-loop with clip (S-O clip) allows countertraction in gastric endoscopic submucosal dissection. Surg Endosc 2020; 34:3722-3733. [PMID: 32350668 PMCID: PMC7326859 DOI: 10.1007/s00464-020-07590-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Insufficient countertraction and poor field of vision make endoscopic submucosal dissection (ESD) difficult. Internal traction method using a spring-and-loop with clip (SLC) allows sufficient traction in any direction and good field of vision. However, the attachment procedure is difficult and interference with the endoscope can occur in the retroflexed endoscopic position. We have developed a new use of SLC that simplifies the attachment procedure, eliminating interference with the endoscope. The aim of this study was to investigate the efficacy of SLC for gastric ESD. METHODS We retrospectively recruited 140 patients with gastric neoplasms who underwent ESD between November 2015 and October 2018 at our department. Among them, 51 patients treated using SLC-assisted ESD (SLC-ESD) and 89 patients treated using conventional ESD (C-ESD) were compared. Propensity score matching was performed to compensate for the differences in age, sex, lesion location, lesion position, specimen size, and ulcer findings. The primary outcome was ESD procedure time. RESULTS Propensity score matching generated 51 matched pairs. The procedure time in the SLC-ESD group was significantly shorter than that in the C-ESD group (median [interquartile], 40.0 [27.0-81.5] minutes versus 69.0 [46.5-113.5] minutes, P = 0.008). The mean SLC attachment time was 2.08 min. There were no significant differences in complete en bloc resection rate between SLC-ESD and C-ESD groups (100% versus 96.1%, P = 0.495). There were not perforation cases in either group. CONCLUSIONS SLC may offer an efficient method for gastric ESD, with a short attachment procedure time.
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Affiliation(s)
- Mitsuru Nagata
- Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, 1-5-1, Tsujidoukandai, Fujisawa-shi, Kanagawa, Japan.
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Mavrogenis G, Bazerbachi F, Tsevgas I, Zachariadis D. Dynamic and multifocal clip and band countertraction for endoscopic submucosal dissection. VideoGIE 2020; 5:451-454. [PMID: 33102994 PMCID: PMC7569738 DOI: 10.1016/j.vgie.2020.04.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
| | - Fateh Bazerbachi
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ioannis Tsevgas
- Department of Gastroenterology, Mediterraneo Hospital, Athens, Greece
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Okamoto Y, Oka S, Tanaka S, Inagaki K, Tanaka H, Matsumoto K, Boda K, Yamashita K, Sumimoto K, Ninomiya Y, Chayama K. Clinical usefulness of the S-O clip during colorectal endoscopic submucosal dissection in difficult-to-access submucosal layer. Endosc Int Open 2020; 8:E437-E444. [PMID: 32140559 PMCID: PMC7055622 DOI: 10.1055/a-1093-0681] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/11/2018] [Indexed: 02/08/2023] Open
Abstract
Background and study aims In colorectal endoscopic submucosal dissection (ESD), the S-O clip improves the accessibility to the submucosal layer of the colon. However, its safety and usefulness in difficult colorectal ESDs are unclear. Thus, in this study, we aimed to assess the effectiveness of the S-O clip in colorectal ESD in the difficult-to-access submucosal layer. Patients and methods From January 2016 to December 2016, 189 consecutive cases of colorectal ESD were performed at Hiroshima University Hospital before the S-O clip was introduced. Between January 2017 and June 2018, among 271 consecutive colorectal ESD cases, 41 cases were performed colorectal ESD using the S-O clip. We compared outcomes between the two groups (41 cases with S-O clip [use group] and 189 cases without S-O clip [non-use group]) using propensity score matching. Results Prior to propensity score matching, 41 cases with the S-O clip (use group) and 189 cases without the S-O clip (non-use group) were extracted. The degree of submucosal fibrosis was more severe and the procedure time was longer in the use group than in the non-use group. In the use and non-use groups, en bloc resection (100 % vs. 94.7 %) and complete en bloc resection (100 % vs. 92.6 %) rates were satisfactory. After propensity score matching, 33 cases in each group were extracted. As a result, complete en bloc resection rate was significantly higher in the use group than in the non-use group (100 % vs. 84.9 %). Conclusion The S-O clip is effective and can be used safely in colorectal ESD in the difficult-to-access submucosal layer.
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Affiliation(s)
- Yuki Okamoto
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan.
| | - Katsuaki Inagaki
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Kenta Matsumoto
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuki Boda
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Kyoku Sumimoto
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan.
| | - Yuki Ninomiya
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan.
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
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