Optimal traction direction in traction-assisted gastric endoscopic submucosal dissection

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.

Effectiveness of a novel traction device in endoscopic submucosal dissection for colorectal lesions

BACKGROUND

Among all types of superficial gastrointestinal (GI) neoplasms, colorectal lesions are recognized as one of the most difficult locations to operate, due to the limited operation space, physiological bends, poor visualization of the submucosal dissection plane sheltered by colorectal crinkle wall, and the thin intestinal mucosa layer which is easy to perforation. The purpose of this prospective study is to evaluate the feasibility, efficacy, and safety of a novel endoscopic traction technique in assisting the endoscopic submucosal dissection (ESD) procedure in colorectal lesions.

METHOD

A total of 117 patients with colonic lesions who underwent endoscopic treatment were enrolled between August 2020 and January 2021 at the endoscopic center of Beijing Chao-yang Hospital of Capital Medical University. Based on whether traction device was used during the operation, 60 and 57 patients were assigned to the conventional ESD group and clips and rubber band triangle traction-assisted ESD group (CRT-ESD, in which three clips and a rubber band were used to form an elastic triangular traction device), respectively. The total procedure time (TPT), submucosal dissection time (SDT), submucosal dissection speed (SDS), and rate of adverse events of the two groups were analyzed.

RESULTS

After excluding patients who did not undergo treatment (conventional ESD, 1; CRT-ESD, 4), 112 patients were included in the study (conventional ESD, 59; CRT-ESD, 53). The baseline characteristics of the patients were well balanced between the two groups. The TPT (58.71 ± 26.22 min vs 33.58 ± 9.88 min, p < 0.001) and SDT (49.24 ± 23.75 min vs 26.34 ± 8.75 min, p < 0.001) were significantly different between the conventional ESD group and CRT-ESD group. The CRT-ESD group had significantly higher SDS than that of the traditional ESD group (0.54 ± 0.42 cm2/min vs 0.89 ± 0.40 cm2/min, p < 0.001). There were 4 (6.8%) cases of perforation in the traditional ESD group, and no perforation occurred in traction-assisted ESD.

CONCLUSIONS

Compared with traditional ESD, CRT-ESD with clip and rubber band is both safer and more effective in the treatment of colorectal lesions.

Training program using a traction device improves trainees' learning curve of colorectal endoscopic submucosal dissection

BACKGROUND

Colorectal endoscopic submucosal dissection (ESD) requires advanced endoscopic skill. For safer and more reliable ESD implementation, various traction devices have been developed in recent years. The purpose of this research was to evaluate whether an ESD training program using a traction device (TD) would contribute to the improvement of trainees' skill acquisition.

METHODS

The differences in treatment outcomes and learning curves by the training program were compared before and after the introduction of TD (control group: January 2014 to March 2016; TD group: April 2016 to June 2018).

RESULTS

A total of 316 patients were included in the analysis (TD group: 202 cases; control group: 114 cases). The number of cases required to achieve proficiency in ESD techniques was 10 in the TD group and 21 in the control group. Compared to the control group, the TD group had a significant advantage in ESD self-completion rate (73.8% vs. 58.8%), dissection speed (19.5 mm²/min vs. 15.9 mm²/min), en bloc resection rate (100% vs. 90%), and R0 resection rate (96% vs. 83%).

CONCLUSIONS

The rate of colorectal ESD self-completion by trainees improved immediately after the start of the training program using a traction device compared to the conventional method, and the dissection speed tended to increase linearly with ESD experience. We believe that ESD training using a traction device will help ESD techniques to be performed safely and reliably among trainees.

Efficacy of the pocket-creation method with a traction device in endoscopic submucosal dissection for residual or recurrent colorectal lesions

Background/Aims

Endoscopic submucosal dissection (ESD) for residual or recurrent colorectal lesions after incomplete resection is challenging because of severe fibrosis. This study aimed to compare the efficacy of the pocket-creation method (PCM) with a traction device (TD) with that of conventional ESD for residual or recurrent colorectal lesions.

Methods

We retrospectively studied 72 patients with residual or recurrent colorectal lesions resected using ESD. Overall, 31 and 41 lesions were resected using PCM with TD and conventional ESD methods, respectively. We compared patient background and treatment outcomes between the PCM with TD and conventional ESD groups, respectively. The primary endpoints were en bloc resection and R0 resection rates. The secondary endpoints were the dissection speed and incidence of adverse events.

Results

En bloc resection was feasible in all cases with PCM with TD, but failed in 22% of cases of conventional ESD. The R0 resection rates for PCM with TD and conventional ESD were 97% and 66%, respectively. Dissection was significantly faster in the PCM with TD group (13.0 vs. 7.9 mm²/min). Perforation and postoperative bleeding were observed in one patient in each group.

Conclusions

PCM with TD is an effective method for treating residual or recurrent colorectal lesions after incomplete resection.

The usefulness of combining the pocket-creation method with a traction device using a scissor-type knife for colorectal endoscopic submucosal dissection

INTRODUCTION

Technical issues and long procedure time still remain a concern in colorectal endoscopic submucosal dissection (ESD). We examined the usefulness of combining the pocket-creation method (PCM) with a traction device (S-O clip; SO) using a scissor-type knife (Clutch Cutter 3.5 mm; CC) for decreasing ESD procedure time.

METHODS

We retrospectively analyzed 95 ESD cases of PCM + SO + CC managed from August 2017 to April 2020 and 103 cases of PCM + CC treated from July 2016 to July 2017. We compared these two groups through propensity score matching. The main outcome was the analysis of the ESD procedure times under various conditions in each group.

RESULTS

After matching, 52 cases in the PCM + SO + CC and PCM + CC groups were analyzed. The PCM + SO + CC group showed a significantly shorter ESD procedure time than the PCM + CC group (57.8 ± 31.4 vs. 81.7 ± 33.5 min, p < 0.01). Additionally, the ESD procedure time was significantly shorter in the PCM + SO + CC group than in the PCM + CC group: tumor size (tumor size < 40 mm: 45.6 ± 15.8 vs. 72.7 ± 22.9 min, p < 0.01; tumor size ≥ 40 mm: 83.1 ± 40.1 vs. 111.8 ± 45.3 min, p = 0.04), tumor location (right side: 64.7 ± 33.3 vs. 81.0 ± 29.7 min, p = 0.03; left side: 50.5 ± 28.0 vs. 82.3 ± 36.9 min, p < 0.01), tumor morphology (polypoid: 39.2 ± 18.6 vs. 74.7 ± 28.6 min, p < 0.01; nonpolypoid: 62.3 ± 32.3 vs. 84.5 ± 35.2 min, p < 0.01), endoscopist (expert: 67.3 ± 41.2 vs. 91.9 ± 40.2 min, p = 0.02; nonexpert: 50.4 ± 18.3 vs. 73.6 ± 24.9 min, p < 0.01), and fibrosis (severe fibrosis: 82.0 ± 20.5 vs. 99.8 ± 40.4 min, p = 0.169; non-severe fibrosis: 52.1 ± 23.8 vs. 75.6 ± 29.0 min, p < 0.01).

CONCLUSIONS

The combination of the PCM and SO using CC achieved a reduction in the colorectal ESD procedure time.

Multiplanar fracture reducer versus manual traction in the treatment of tibial shaft fractures with intramedullary nails

OBJECT

The purpose of this study was to propose a new traction device, a multiplanar fracture reducer (MFR), for the treatment of tibial shaft fractures with intramedullary nails (IMN). The efficiencies of the multiplanar fracture reducer and manual traction (MT) in the treatment of tibial shaft fractures with IMN were compared.

METHODS

From January 2019 to January 2020, a total of 79 patients were enrolled in this study, among whom 38 were treated with MFR while 41 were treated with MT. Their demographics and fracture characteristics, surgical data, and prognostic data between the two groups were compared.

RESULTS

The mean number of intra-operative fluoroscopies in the MFR group was less than that in the MT group (19.4 vs 21.2, p < 0.001); surgical procedures involving open reduction were more in the MT group than in MFR group (0 vs 5, p = 0.026); there were less assistants in the MFR group than in the MT group (1 vs 1.9, p < 0.001), while the average Lysholm Knee Function Score and knee flexion were 92.7 ± 2.0 and 128.8 ± 1.4 in the MFR group, and 91.9 ± 2.1 and 127.5 ± 1.8 in the MT group, respectively. Both LKFS and knee flexion in the MFR group were significantly better than those in the MT group (p = 0.032 and p < 0.001). The remaining data between the two groups were comparable.

CONCLUSION

MFR is a safe and effective device for the minimal invasive treatment of tibial shaft fractures fixed with IMN.

Clinical utility of the pocket-creation method with a traction device for colorectal endoscopic submucosal dissection

BACKGROUND

Colorectal endoscopic submucosal dissection (ESD) is technically demanding while ensuring safety, especially in cases with fibrosis and/or poor maneuverability. To overcome such difficulties, we developed a novel method called the pocket-creation method with a traction device (PCM with TD). We then evaluated the effectiveness and safety of PCM with TD in colorectal ESD compared to other conventional methods.

METHODS

In total, 324 colorectal lesions treated with ESD from July 2018 to June 2019 were included. The following three treatment strategies were used: conventional ESD (CE), CE with TD, and PCM with TD. Patient backgrounds and treatment outcomes were retrospectively compared and analyzed.

RESULTS

As ESD methods, CE, CE with TD, and PCM with TD account for 58% (187/324), 24% (78/324), and 18% (59/324), respectively. No significant difference was observed among the three groups in en bloc and R0 resection rates or adverse events. The rate of lesions with fibrosis and poor maneuverability was significantly higher in the PCM with TD group (CE group vs CE with TD group vs PCM with TD group: fibrosis, 24% vs 47% vs 64%, p < 0.001; poor maneuverability, 5.3% vs 13% vs 20%, p = 0.002). Dissection speed was significantly higher in the PCM with TD than in the CE with TD group (p = 0.003).

CONCLUSIONS

PCM with TD can achieve a stable en bloc resection rate and R0 dissection rate without adverse events even in the hands of trainees, irrespective of the size and location of the lesion, presence of fibrosis, and under poor maneuverability conditions.