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Abstract

We are very grateful for the thoughtful and supportive letter from Dr Kotzev1Kotzev A.I. A promising countertraction method for faster adoption of endoscopic submucosal dissection in a Western setting.Gastrointest Endosc. 2019; 89: 444-445Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar regarding our article2Ge PS, Thompson CC, Jirapinyo P, et al. The suture pulley countertraction method reduces procedure time and technical demand of ESD among novice endoscopists learning ESD: a prospective randomized ex vivo study. Gastrointest Endosc. Epub 2018 Aug 24.Google Scholar and for the opportunity to further a dialogue on facilitating training for endoscopic submucosal dissection (ESD) in the United States. The lack of reliable countertraction contributes to the technical difficulty and long procedure time in ESD. As a result, despite recently published reviews in support of ESD,3Draganov PV, Wang AY, Othman MO, et al. Clinical practice of endoscopic submucosal dissection in the United States. Clin Gastroenterol Hepatol. Epub 2018 Aug 2.Google Scholar widespread adoption continues to be limited by multiple factors, including the potential for serious adverse events, long procedure length, limited training opportunities, lack of appropriate cases, and lack of adequate reimbursement structure.4Rex D.K. Hassan C.C. Dewitt J.M. Colorectal endoscopic submucosal dissection in the United States: Why do we hear so much about it and do so little of it?.Gastrointest Endosc. 2017; 85: 554-558Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 5Schlachterman A. Yang D. Goddard A. et al.Perspectives on endoscopic submucosal dissection training in the United States: a survey analysis.Endosc Int Open. 2018; 6: E399-E409Crossref PubMed Google Scholar Owing to these challenges, the major aim of our research has been focused toward eliminating these barriers by evaluating ways to make ESD safer, faster, and easier to learn. We hope that increasing clinical experience and technological innovation in the United States will lead to the eventual establishment of a reimbursement structure. With those goals in mind, the major strengths of our study were threefold. First, the study was performed in a randomized prospective nature, albeit in an ex vivo setting. Second, although verbal guidance was provided during each procedure, each endoscopist was required to complete ESD using both the traditional technique and the suture pulley countertraction–assisted technique. Finally, and perhaps most importantly, the study was performed with endoscopists at all stages of training (both attendings and fellows), all of whom were inexperienced in both ESD and endoscopic suturing. This last strength is unique among existing studies of surgical and endoscopic innovation, which overwhelmingly tend to be performed by experts and pioneers in their respective fields and therefore may be less generalizable to those who are learning.6Aihara H. Kumar N. Ryou M. et al.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).Gastrointest Endosc. 2014; 80: 495-502Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar The results unequivocally demonstrated that the suture pulley method significantly reduced procedure time among all participants, including both fellows and attendings. By helping to expose the dissection plane, the time investment required to set up the suture pulley pays off by facilitating submucosal dissection, which was evident in the significantly improved National Aeronautics and Space Administration (NASA) Task Load Index scores. Additionally, the suture pulley method may increase the safety profile of ESD among novices, as evidenced by the lower perforation rate among suture pulley ESD, which trended toward statistical significance. This fulfilled all of our previously stated aims of making the procedure safer, faster, and easier to learn. There remain many unanswered questions and challenges in ESD in the United States, in terms of both training and adoption. From the perspective of this limited ex vivo study, it remains to be seen whether our results are reproducible in the clinical setting. A future United States–based prospective clinical study is warranted and will, we hope, answer this question. All authors disclosed no financial relationships relevant to this publication. A promising countertraction method for faster adoption of endoscopic submucosal dissection in a Western settingGastrointestinal EndoscopyVol. 89Issue 2PreviewThe prospective randomized study from Ge et al1 provoked my strong interest. They examined the efficacy of the suture pulley countertraction method for endoscopic submucosal dissection (ESD) as used by novices for both suturing and ESD. Using an ex vivo porcine stomach model, the participants carried out each technique under the control of an ESD expert. The spectacular results showed that the mean total procedure time was significantly shorter for all participants when suture pulley ESD was performed in comparison with traditional ESD. Full-Text PDF