Various methods of traction have been reported for gastric endoscopic submucosal dissection (ESD). We report a successful case in which a new traction method combining a tunnel and a ring-thread counter traction was effective. The patient was a 78-year-old man with early gastric cancer; an 85-mm tumor was located at the lesser curvature of the upper gastric body (Fig. 1). The macroscopic type was 0-IIa, and there were no obvious findings of suspected submucosal invasive carcinoma, such as irregular protrusion, surface depression, and nonextension sign. Multiple ulcer scars were found on the anterior and posterior sides of the lesion. The histological type from the biopsy was well-differentiated tubular adenocarcinoma. The ESD was performed using a single-channel endoscope (GIF-Q260J; Olympus Co, Tokyo, Japan). The tumor resection devices used were the DualKnife (KD-650L, Olympus Co) and the ITknife2 (KD-611L, Olympus Co), and the solution for local injection was a mixture of 0.4% sodium hyaluronate and indigo carmine with diluted epinephrine. First, we made a circumferential incision; next we created the submucosal tunnel from the oral side to the anal side (Figs. 2 and 3). By creating the tunnel, the dissection line was clear in the fibrosis part of the anterior side, but we could not approach the posterior side because the fibrosis area was extensive. Therefore, we attached a ring-shaped thread (made of floss) with 2 endoclips to connect the oral side of the lesion to the greater curvature side (Fig. 4). In this case, the diameter of the ring was about 10 mm, and it was used to pull the lesion at the lesser curvature side of the stomach to the greater curvature side. The thread provided good traction for the fibrosis area and thus allowed us to perform submucosal dissection of the side of the tunnel (Fig. 5). Finally, the lesion was completely resected en bloc without any adverse events. The lesion was 85 x 60 mm in size, and histological examination revealed it to be well-differentiated intramucosal carcinoma, with no lymphovascular invasion. All of the margins were tumor-free (Fig. 6).Figure 3The submucosal tunnel was created from the oral side to the anal side.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4The ring-shaped thread was attached to connect the oral side of the lesion to the greater curvature side of the stomach.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Severe fibrosis area in the side of the tunnel, in which the dissection line became clearer after attaching the ring-shaped thread.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6The opened specimen revealed intramucosal carcinoma and negative margins; the lesion was 85 × 60 mm in size.View Large Image Figure ViewerDownload Hi-res image Download (PPT) For difficult lesions, it has been a problem to provide the traction to secure a good view in ESD. The effectiveness of endoscopic submucosal tunnel dissection (ESTD) has been reported as a good method for providing traction.1Feng X. Linghu E. Chai N. et al.Endoscopic submucosal tunnel dissection for large gastric neoplastic lesions: a case-matched controlled study.Gastroenterol Res Pract. 2018; 2018: 1419369Crossref PubMed Scopus (12) Google Scholar,2Zhang X. Shi D. Yu Z. et al.A multicenter retrospective study of endoscopic submucosal tunnel dissection for large lesser gastric curvature superficial neoplasms.Surg Endosc. 2019; 33: 1910-1919Crossref PubMed Scopus (16) Google Scholar However, ESTD alone did not provide enough traction in this case because of the lesion size and extensive severe fibrosis. In such a situation, combined use of traction by using ring-thread counter traction was effective (Fig. 7). Several techniques, such as “clip and snare” and “internal traction method,” which have been reported previously, were effective traction methods using similar devices.3Matsumoto K. Nagahara A. Sakamoto N. et al.A new traction device for facilitating endoscopic submucosal dissection (ESD) for early gastric cancer: the “medical ring.Endoscopy. 2011; 43: E67-E68Crossref PubMed Scopus (38) Google Scholar,4Baldaque-Silva F. Vilas-Boas F. Velosa M. et al.Endoscopic submucosal dissection of gastric lesions using the “yo-yo technique.Endoscopy. 2013; 45: 218-221Crossref PubMed Google Scholar However, those methods may require the assistant’s habituation or reinsertion of the endoscope, may have limited traction direction, or may not be suitable for large lesions. This method is considered to be simple and inexpensive, it does not require another assistant, it is suitable for large lesions, and it allows the operator to decide the direction of traction depending on the clip position. Based on this case, ESTD with ring-thread counter traction may be effective for large gastric tumors with extensive severe fibrosis (Video 1, available online at www.VideoGIE.org). All authors disclosed no financial relationships relevant to this article. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlMmNjMGQ2NzQxODZmZjRkNzI3YjU3ZDFjMjg1ZDVhZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NDY0ODkzfQ.gjaAez8j4Wr7199z-8bz3AYl8ncfOCfLRgaEsH4OE7H9yCZAYPnM0006xSLBE4vncFqGsiVdbvauHJcXsP5a3vC-PIUtJNyKU7KEaWLsQh59uksWMYqxRjTJS6X37IfWhWF8CjiUUNa-Jsfewy7I6agXdcaWiHProO0Fvkni2RUlSPSl7riUHuQpxZTt-NvxUrO8hvbcSSucxmz4OiHij1oXIFMAsliqITH7sHPk2foVQ7FKA_avs_kgdTgn_3OYBOO8R39XmswaCFGWvgvpmIAd4dFL6LJnyQKKAaN25BzdysFcTD6l_moN-MScWPBTDI2wG1sO02VNkwJlFtwROw Download .mp4 (73.36 MB) Help with .mp4 files Video 1A large gastric tumor with severe fibrosis was successfully resected by endoscopic submucosal tunnel dissection with ring-thread counter traction.
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