Countertraction Method Research Articles

Inner countertraction facilitating endoscopic submucosal dissection of a difficult early gastric cancer independent of transparent cap.

Endoscopic submucosal dissection (ESD) has been applied widely for treatment of early gastric cancer (EGC) [1]. However, for difficult locations, the submucosal vision is often unclear, resulting in prolonged operation time as well as increased risk of bleeding and perforation. Inner countertraction allows for safe and speedy dissection in the colon [2] but not in the stomach. Here, we developed a preliminary inner countertraction method to facilitate ESD of EGC in difficult locations ([Video 1]).

Countertraction method for reduction of irreducible subcoracoid dislocation of the shoulder joint with Hill-Sacks lesion

To investigate clinical outcomes of countertraction method in treating irreducible subcoracoid dislocation of shoulder joint combined with Hill-Sacks injury. A total of 56 patients with irreducible subcoracoid dislocation of the shoulder joint combined with Hill-Sacks injury admitted from December 2013 to June 2020 were retrospectively analyzed. Under the anesthesia of shoulder joint cavity injection, the reduction was performed by using anti-traction method (experimental group) and traditional Hippocrates method (control group), 28 cases in each group. There were 11 males and 17 females in experimental group, with an average age of (61.95±19.32) years old, 9 cases on the left side, and 19 cases on the right side. Twelve males and 16 females in control group, with an average age of (63.13±12.75) years old, 11 cases on the left side, 17 cases on the right side. The curative effects between two groups were evaluated before and after operation, including the success rate of reduction, the duration of reduction, the distance from successful reduction to injury, complications and functional rehabilitation(Constant score of shoulder joint). The success rates of reduction in experimental group and control group were 92.86%(26/28) and 67.86% (19/28), respectively, and the difference was statistically significant (P<0.05). The duration of simple reduction was (4.25±2.13) min and ( 6.31±1.69) min, the difference was statistically significant (P<0.05);the time from successful reduction to injury was (9.16±0.94) h and (8.94±1.31) h, respectively, with no significant difference(P>0.05). There were no complications such as vascular nerve injury and fracture in experimental group, 2 cases of axillary nerve injury and 1 case of humeral head fracture in control group. Constant scores of shoulder joint between experimental group and control group were (92.34±5.62) points and (90.91±4.73) points, respectively, with no significant difference (P>0.05). For patients with irreducible subcoracoid dislocation of the shoulder joint with Hill-Sacks injury, the countertraction method under anesthesia of the shoulder joint cavity achieved a higher success rate and few complications.

INTRA-ARTICULAR LIGNOCAINE AS ANALGESIA DURING MANUAL REDUCTION OF ACUTE ANTERIOR SHOULDER DISLOCATION: AN OBSERVATIONAL STUDY.

Background:Acute anterior shoulder dislocation needs prompt reduction to provide pain relief. The ideal reduction method should be simple, fast, effective and non- traumatic, with minimal pain, and should not cause further injury to the affected shoulder. Intra-articular lignocaine has been advocated as a means of providing analgesia and subsequent relaxation to the patient.Aim: To assess the efciency of intraarticular lignocaine for reduction of anterior shoulder dislocations. Patients s &amp; Methods: Thirty cases of acute anterior shoulder dislocation were reduced using intraarticular local lignocaine injection as a method of analgesia by Rockwood's traction and counter traction method. Ten to Fifteen ml of 1% lignocaine was injected into the glenohumeral joint through a 20 gauge, 35-mm needle. Approximately ten to fteen minutes were allowed for the local anaesthetic to take effect before any manipulation of the shoulder was attempted. Results: The mean age was 37.2years±18.23 SD with majority of patients in age group of 20 to 40 years. 80% of patients were females. Among thirty patients studied 28 (93.3 %) had primary dislocation and in 18 patients (60 %) dominant shoulder was dislocated. Majority of the dislocations were reduced within 6 hours of injury. Pain assessed through application of a Visual Analog Scale during the maneuver revealed scores ranging from two to eight with mean score of 4.39 ± 1.46 SD (p value 0.049). Conclusion: We conclude method is not only safe and effective but also reduces hospital stay and has negligible adverse effects making it a popular choice for most orthopedists.

Simplified robot-assisted endoscopic submucosal dissection for esophageal and gastric lesions: a randomized controlled porcine study (with videos)

Effective countertraction is a main challenging issue in endoscopic submucosal dissection (ESD). Several countertraction methods have been developed to address this issue. The aim of this study was to compare the efficacy of ESD using a novel simplified robot, the flexible auxiliary single-arm transluminal endoscopic robot (FASTER), with a traditional technique. This was a prospective, randomized animal study. Forty-eight ESDs in 6 pigs were carried out at 8 different locations (gastric antrum, gastric body, lower esophagus, and middle esophagus) by the conventional method (n= 24) and by the FASTER-assisted method (n= 24). The primary outcomes were total procedure time, dissection time, and rate of direct-vision dissection. Secondary endpoints were completeness of en-bloc resection and adverse event rate. The total procedure time was significantly shorter in FASTER-assisted ESD than in conventional ESD (18.8 vs 32.8 minutes; P< .001). In contrast to the median direct-vision dissection rate of 73% with conventional ESD, the FASTER-assisted group had a significantly higher rate of 96% (P< .001). The number of sites of muscular damage was significantly lower using the FASTER-assisted method than the conventional method (6 vs 21, respectively; P= .018). This improvement was more apparent in esophageal lesions compared with gastric lesions. This study demonstrated that using a simplified robot during ESD is technically feasible and enables the endoscopist to dynamically use countertraction. This device could significantly reduce procedure time compared with conventional ESD techniques.

Underwater endoscopic submucosal dissection for a duodenal neuroendocrine tumor using pocket creation and ring-shaped thread countertraction methods.

Underwater endoscopic submucosal dissection for a duodenal neuroendocrine tumor using pocket creation and ring-shaped thread countertraction methods.

The suture pulley countertraction method for challenging rectal endoscopic submucosal dissection

The suture pulley countertraction method for challenging rectal endoscopic submucosal dissection

Evaluation of a robotic arm-assisted endoscope to facilitate endoscopic submucosal dissection (with video)

Endoscopic submucosal dissection (ESD) is considered technically difficult and challenging using a conventional flexible endoscope, mainly due to the lack of proper countertraction to expose the submucosal dissection plane. This study aimed to evaluate the feasibility of a traction method using a dexterous robotic arm in exvivo gastric ESD. ESD was performed in a total of 45 procedures using a portable endoscopic tool handler (PETH) (n= 30) and using the conventional method (n= 15) at various locations in the stomach. For each procedure, the performance data were recorded, including the total procedure time (minutes), incision time (minutes), dissection speed (mm2/minute), and blind dissection rate (%), to enable a comparison of the 2 ESD methods. The total procedure time was significantly shorter with PETH-ESD than in conventional ESD (23 vs 36 minutes, P= .011). This result is mainly attributed to the dissection speed, which was significantly faster, by more than 2.5 times, using the PETH (122.3 ± 76.5 vs 47.5 ± 26.9mm2/minute, P< .001). The blind dissection rate was greatly decreased in PETH-ESD (0 vs 20%, P< .001). There was no significant difference in the incision time (6.1 ± 5.0 vs 5.5 ± 2.9 min, P= .612). The countertraction method using the PETH significantly improved the dissection speed and reduced blind dissection by enhancing direct visualization of the submucosal plane. With the advantages of multidirectional traction, fine tension control, and regrasping, this new device is expected to improve the performance of ESD and further facilitate advanced endoscopic procedures.

Suture pulley countertraction method reduces procedure time and technical demand of endoscopic submucosal dissection among novice endoscopists learning endoscopic submucosal dissection: a prospective randomized ex vivo study

The lack of reliable countertraction in endoscopic submucosal dissection (ESD) contributes to its technical demand and increased procedure time. We aimed to prospectively evaluate the efficacy of the suture pulley countertraction method in endoscopists new to both suturing and ESD. Two 30-mm circular lesions were created in an exvivo porcine stomach model. Endoscopists considered novices for both endoscopic suturing and ESD were randomized to either traditional or suture pulley ESD first and performed ESD using each technique. Procedure time was recorded including time of circumferential incision, suture pulley placement, and submucosal dissection. After completion of each ESD, participants graded the difficulty of the procedure using the National Aeronautical and Space Administration (NASA) Task Load Index. Thirteen participants (8 fellows, 5 attendings) completed the study using both methods. Mean total procedure time was shorter using suture pulley ESD compared with traditional ESD (26.7 ± 7.3 vs 59.4 ± 20.4 minutes, P< .001). The suture pulley required a mean 6.2 ± 2.1 minutes to place. Submucosal dissection time was shorter using suture pulley ESD compared with traditional ESD (8.4 ± 2.9 vs 47.2 ± 16.3 minutes, P< .001). All 7 individual indices and total score on the NASA Task Load Index were significantly improved using the suture pulley ESD method (P< .001). The suture pulley countertraction method significantly decreases procedure time and technical demand of ESD among endoscopists at all skill levels who are new to ESD. The results of this study have potential implications for ESD training in the United States.

Sa1998 - The Suture Pulley Countertraction Method Reduces Procedure Time and Technical Demand of Esd Among Novice Endoscopists Learning Esd: A Prospective Randomized Ex Vivo Study

Sa1998 - The Suture Pulley Countertraction Method Reduces Procedure Time and Technical Demand of Esd Among Novice Endoscopists Learning Esd: A Prospective Randomized Ex Vivo Study

Electromagnetic assisted endoscopic submucosal dissection is more efficient than water-jet assisted and conventional ESD in experimental model.

Background and study aims The adequate visualization of the dissection line, inside the submucosal layer, supposes the main challenging issue in ESD. For this reason, several counter traction methods have been developed focused on overcoming this handicap. One of which, Magnetic anchor guided – ESD (MG-ESD) is an attractive alternative. However, the usefulness of this approach has been scarcely assessed and compared with other ESD strategies. Therefore, the aim of this study is to compare three different ESD alternatives in experimental faction. Methods This was a prospective non-randomized study, in which three different ESD techniques were performed in an ex-vivo gastric porcine model by an endoscopist slight expertise in ESD: conventional ESD, waterjet assisted ESD and MG-ESD. MG-ESD was performed using two different magnets: inner Neodymiun ringed shape magnet attached to the simulated lesions by an endoclip and external electromagnet connected to a Single Output Adjustable 24V/0.3A Power Supply Unit. Results Forty-six ESD procedures were performed: 24 conventional ESD, 12 waterjet-assisted ESD and 10 MG-ESD. Average size of the simulated lesions was 33.86 mm. No differences in terms of safety and efficacy were registered between the three approaches. Nevertheless, MG-ESD proved to be faster and more efficient than conventional ESD and water-jet assisted ESD (min per cm 2 10.85 vs. 7.43 vs. 3,41; P = 0.001). Conclusions MG-ESD could be a feasible alternative to conventional ESD even at the beginning of the learning curve. Therefore, researches focused on developing appropriate ESD magnetic devices and further comparative studies must be promoted, in order to assess the reliable usefulness of the magnet-assistance in ESD.

ESD困難症例におけるカウンタートラクションの工夫

Endoscopic submucosal dissection (ESD) is a useful procedure for digestive tract cancer, and becoming common procedure. As the adaptation spreads, we experience many difficult cases of large lesions, ulcerative scars, and difficult to control bleeding. For performing ESD smoothly, it is most important to keep clear view. Good counter-traction makes ESD easier. Thread-traction-method was reported in esophageal ESD. For example, thread-traction-method is very usefulness, but it has problems in durability and complication. So, we reported an adjustable counter-traction method using suction tube, snare and clips for gastric ESD. After we insert a suction tube intranasally and attached clips to edge of lesion, we insert snare through the tube and catch the clip using snare. This method has strong durability. It is easy to repeatedly use, and makes it possible to push and pull. This point is useful for gastric ESD. Adjustable counter-traction is one useful method to make ESD easier.

Facilitating retroflexed endoscopic full-thickness resection through loop-mediated or rope-mediated countertraction (with videos)

Endoscopic full-thickness resection (EFTR) is difficult to perform in a retroflexed fashion in the gastric fundus and lesser curvature. Here we describe two simple methods to provide countertraction and thereby facilitate dissection. In this retrospective cohort study, 62 patients diagnosed as having gastric submucosal tumors in the fundus or in the lesser curvature received EFTR with or without countertraction methods. For the clip-with-thread method, a clip tied with surgical suture was anchored on the distal edge of the tumor to provide countertraction; for the loop-assisted method, a snare placed on the transparent cap beforehand was adopted to grasp the tumor to provide countertraction. Mean operative time was significantly reduced in the thread-with-clip group and loop-assisted group (45 minutes, 40 minutes, respectively) compared with the time needed in the traditional EFTR group (85 minutes). Intraoperative pneumoperitoneum occurred regularly among the 3 groups because of iatrogenic perforation, but fewer patients in the thread-with-clip group and loop-assisted group (23%, 18%, respectively) needed abdominal puncture to relieve free air and stabilize life signs compared with patients in the traditional EFTR group (63%). A reduced occurrence of high fever after surgery may contribute as another advantage from accelerated dissection. Both techniques did not jeopardize oncologic safety during short-term follow-up. Both the thread-with-clip method and loop-assisted method provide effective countertraction and offer faster and safer gastric EFTR in difficult anatomic locations.

A forearm skin tear during reduction of anterior shoulder dislocaiton in an elderly patient

Anterior shoulder dislocation is the most common type of joint dislocation. Lots of complications like fracture of greater tubercle and glenoid anterior rim or neurovascular injuries may occur at the time of dislocation or reduction of dislocated joint. We aimed to present a case; 76 year old female with anterior dislocation and fracture ; while we were trying close reduction by traction counter-traction method , we experienced a complication which was a non-circulated degloving like skin tear at dorsal middle part of forearm which was not presented in literature before. Since the thin skin has less collagen and elastin in elderly patients, skin tears with traction might occur easily. The fragility of the skin in the elderly patients has to be taken into consideration with other complications presented in the literature. Keywords: Elderly patient, shoulder dislocation, skin tear DOI: 10.12973/ejms.2014.129p

A New Reduction Technique for Completely Displaced Forearm and Wrist Fractures in Children

Most pediatric distal radius fractures are treated with closed methods, however, in recent years an increasing number of fractures are treated with operative management. Multiple reduction techniques are described in the orthopaedic literature but no recent advances have been made in the closed management of these injuries. We describe the efficacy of new, single-provider manual reduction technique that improves reduction efficacy and we separately show its biomechanical superiority to other common techniques. Review the results of a new reduction technique, known as the Lower Extremity-aided Fracture Reduction (LEAFR) maneuver, used on a specific cohort of consecutively treated patients at a single institution over a 4-year period with bayoneted distal radius fractures. Intention-to-treat methodology and descriptive statistics are utilized to analyze accuracy of reduction, need for operative intervention, residual deformity, and complications. In addition, perform a biomechanical comparison between the LEAFR maneuver, the 2 person traction counter-traction method and finger traps. The technique allowed 24 consecutively treated, bayoneted distal radius fractures to be reduced from average translational and shortening deformities of 11.4 and 6.5 mm to 2.1 and 0.4 mm, respectively (P<0.0001). Two (8%) of the 24 patients had failure to eliminate bayonet displacement, whereas only 3 patients (12.5%) ultimately required operative intervention. No cases of growth arrest were noted. A biomechanical assessment of the maneuver showed the ability to generate an average of 597.8 Newtons (N) of axial traction which is statistically significant in comparison to other accepted methods of reduction. The LEAFR is a clinically effective and biomechanically sound technique for reduction of bayoneted distal radius fractures in children. It is a simple, reproducible technique not reliant on equipment or additional skilled providers. In addition, it results in decreased rates of operative management and represents advancement in the treatment of pediatric distal radius fractures. Level IV (Retrospective Case Series), Level I (Biomechanical Comparison Study).

How to shorten the resecting time of gastric tumor by the counter-traction methods of ESD

How to shorten the resecting time of gastric tumor by the counter-traction methods of ESD

Pacemaker and ICD lead extraction with electrosurgical dissection sheaths and standard transvenous extraction systems: results of a randomized trial

The purpose of this prospective randomized study was to evaluate the safety and efficacy of transvenous pacemaker and implantable cardioverter-defibrillator (ICD) lead extraction with an electrosurgical dissection sheath (EDS) system in a single-centre experience. Methods Over 10 years, 462 patients have undergone transvenous lead extraction in our institution. From these, 120 consecutive patients (with 161 leads) were randomized to either radiofrequency (RF) current supported extraction or standard countertraction lead removal (60 patients in each arm, 96 men and 24 women). The mean age of randomized patients was 62.7 +/- 9.6 years. In 16 patients, we explanted 17 ICD leads. The average time from the date of implantation to the extraction procedure was 73.4 +/- 15.7 months. The most common reason for lead extraction was infection (95.6%). Results The complete extraction of 78 leads (93%) was achieved in the RF group and 56 leads (73%) with the standard transvenous lead extraction system by counter-traction (P < 0.01). Among these leads, we successfully removed nine of 10 ICD leads (90%) in the RF group and only four of seven ICD leads (57%) in the standard group. We also observed a significant reduction in the time taken for the successful removal of pacemaker and ICD leads using the RF system (9.6 +/- 6.2 min versus 21 +/- 9 min, P < 0.01). Partial success was achieved in six patients with the RF system and in 11 with standard sheaths. In those cases where we failed to remove the lead from the body we sent all but one patient to cardiac surgery. Serious complications were associated with the standard system in two patients, both of whom developed septic pulmonary embolization. Serious bleeding occurred in three patients, one with standard and two with the EDS lead extraction system. The EDS extraction system is significantly more effective and quicker. However, the standard counter-traction method is still an effective alternative when used in a highly experienced centre.

Feasibility, safety, and determinants of extraction time of percutaneous extraction of endocardial implantable cardioverter defibrillator leads by intravascular countertraction method

Previous studies of the removal of implantable cardioverter defibrillator (ICD) leads have been restricted to case reports or small series. In this report, we describe our experience in ICD lead extraction by intravascular countertraction method using Cook’s extraction kit. A total of 47 high-voltage (HV) leads, 3 rate sensing (S) leads, and 2 subcutaneous arrays were removed from 42 patients (33 men, 9 women; mean age 59 years [range 14 to 81]). One HV superior vena cava (SVC) lead and 11 HV right ventricular (RV) leads were explanted by manual traction only and defined in the “lead removal” category. One S lead was removed using a femoral venous approach. The remaining 37 leads were explanted by SVC approach using extraction sheaths and defined in the “lead extraction” category. Twenty leads were extracted for “infectious” (group A) and 17 leads for “noninfectious” (group B) etiologies for which extraction times of 27.0 ± 18.0 and 27.0 ± 15.0 minutes (mean ± SD), respectively, were not different. Although extraction time, 34.0 ± 11.0 minutes, for leads implanted for >48 months was longer than 23.0 ± 16.0, 28.0 ± 18.0, and 24.0 ± 14.0 minutes, for leads with implant durations of 12, 24, and 48 months, respectively, such differences were not statistically significant. The extraction time, however, was directly related to the degree of fibrosis around the lead, 39.0 ± 15.0 minutes for leads with severe fibrosis compared with 13.0 ± 6.0 minutes for the leads with mild fibrosis (p <0.001). Patient’s age, sex, or history of coronary artery bypass graft surgery did not significantly affect extraction time. All except the initial 2 lead extractions were performed in the electrophysiology laboratory. No mortality or serious complications associated with the procedure using these methods were observed.

Extraction of pacemaker and implantable cardioverter defibrillator leads.

The common reasons for removal of pacing and defibrillator leads are infection, malfunction, or design defects such as fracture of J wires in Teletronics Accufix leads (Telectronics Pacing, Englewood, CO), which impose considerable risk for cardiac morbidity and mortality. Chronically implanted leads are fixed to the myocardium by fibrous tissue. Fibrous scar tissue may also encase the lead along its course. Furthermore, fragility of the lead and its tendency to break when extraction force is applied to overcome resistance imparted by the scar tissue add to the challenge of lead extraction. Thus, the extraction of chronically implanted leads is an important issue. Until a few years ago, the only methods available for the removal of chronically implanted leads were traction on the proximal segment of the lead and cardiac surgery. New techniques were developed to extract the leads by a transvenous approach using locking stylets, sheaths, snares, and retrieval baskets. Lead extraction using intravascular countertraction methods has since evolved as a specialty of its own. Progress has also been made in developing other system, such as Excimer laser energy for lead extraction. In this article, we discuss principles, techniques, and experience with these methods of extraction of chronic pacemaker and defibrillator leads.

New traction devices to aid reduction of shoulder dislocations

A set of traction devices that aid in the reduction of shoulder dislocations is described and their use and efficiency are discussed. A series of 47 consecutive patients seen over a six-month period and diagnosed as having shoulder dislocations with no other major trauma composed the study population. After radiographic confirmation and premedication with analgesics and muscle relaxants, the devices were used. The traction- countertraction method was used initially. When this method was unsuccessful, the Stimson method was performed using an alternate traction strap. These devices were successful in 96% of the relocations attempted. No complications were encountered. The traction devices were found to be effective and easy to use.

The well-leg countertraction method details of technique

The well-leg countertraction method details of technique