Traction-assisted Endoscopic Submucosal Dissection Research Articles

Letter to the editor on ''Traction-assisted endoscopic submucosal dissection for resection of ileocecal valve neoplasia: a French retrospective multicenter case series''.

Letter to the editor on ''Traction-assisted endoscopic submucosal dissection for resection of ileocecal valve neoplasia: a French retrospective multicenter case series''.

Endoluminal single-clip traction-assisted endoscopic submucosal dissection: a green tip to reduce waste and cost.

Endoluminal single-clip traction-assisted endoscopic submucosal dissection: a green tip to reduce waste and cost.

Traction-Assisted Endoscopic Submucosal Dissection of Colonic Lesions: A North American Experience

Background and aimsTraction-assisted ESD (TA-ESD) is a proposed technique to improve the efficiency and efficacy of ESD. Multiple studies primarily from Asian centers yielded mixed results in terms of procedure time, en bloc resection rate and R0 resection rate in comparison to conventional ESD (C-ESD). We performed the first comparison of TA-ESD and C-ESD at a high-volume North American center. MethodsThis was a retrospective cohort matched study of all patients who underwent colonic ESD at a single center in the United States by a single operator. The study group were patients who underwent TA-ESD and were matched with a C-ESD case on a 1:1 basis based upon location within the colon, lesion size, and scope stabilization device usage. The baseline characteristics and procedure-related outcomes were compared between the groups. Results138 colonic ESD cases were included (69 TA-ESD, 69 C-ESD). There were no significant differences in the baseline characteristics between the groups. Mean procedure time was 91.0 min (SD 32.5) for TA-ESD and 85.4 min (SD 39.3) for C-ESD (p=0.36). En bloc resection was achieved in 69 (100%) of the TA-ESDs and 67 (97.1%) of the C-ESDs (p=0.15). R0 resection was achieved in 52 (75.4%) of the TA-ESDs and 48 (69.6%) of the C-ESDs (p=0.45). ConclusionWe did not show a significant difference in procedure time, en bloc resection, R0 resection, or adverse events. Further randomized prospective studies that are sufficiently powered and stratified by operator experience level are needed to further elucidate the utility of the technique.

Efficacy and Safety of Single Clip Traction Assisted Endoscopic Submucosal Dissection for Colonic Neoplasms: A Propensity Score Matching Analysis.

Endoscopic submucosal dissection (ESD) for colonic neoplasms is a technically intricate procedure. Internal traction using a single clip has emerged as a promising supportive technique for colonic ESD. Therefore, this study aimed to comprehensively evaluate and compare the efficacy and safety of ESD with and without the aid of single-clip traction. This retrospective study encompassed 36 patients who underwent single clip traction-assisted colonic ESD and 66 who underwent the traditional method of colonic ESD at Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University. We employed the propensity score-matching method to mitigate disparities in resected specimen size and tumor location. Post-matching, we comprehensively assessed treatment outcomes and incidence of adverse events between the two treatment groups (single clip traction-assisted ESD (scESD) and conventional ESD (cESD)). After propensity score matching, we observed 34 matched pairs. There were no significant differences between the two treatment groups regarding the en bloc resection rate, complete resection rate, and curative rate. However, the procedure duration was significantly shorter in the single clip traction-assisted ESD group compared to the conventional ESD group (20.00 [Interquatile Range (IQR)] (16.00-32.50) minutes vs 31.50 [IQR] (17.00-54.00) minutes, p = 0.0474). Furthermore, there was a significant increase in dissection speed in the single clip traction-assisted ESD group compared to the conventional ESD group (0.29 [IQR] (0.20-0.45) mm2/min vs 0.19 [IQR] (0.11-0.35) mm2/min, p = 0.0015). All lesions were resected in a single piece. Among the propensity-score-matched patients, only those treated with single clip traction-assisted ESD exhibited faster dissection speeds (p = 0.015). Furthermore, there were no substantial differences in adverse events such as intraoperative perforation, delayed perforation, or delayed bleeding. Our findings suggest that single clip traction-assisted colonic ESD is preferable to traditional colonic ESD, owing to its shorter procedure duration and faster dissection speed.

Conventional versus rubber band traction-assisted endoscopic submucosal dissection for rectal neuroendocrine tumors: a single-center retrospective study (with video)

BackgroundEndoscopic submucosal dissection (ESD) is a safe and effective technique for the treatment of gastrointestinal tumors, including rectal neuroendocrine tumors (r-NETs). However, the relative advantages of traction-assisted ESD for the treatment of small rectal lesions are still debated.AimsWe conducted a study to compare the efficacy and safety of rubber band traction-assisted ESD (RBT-ESD) to conventional ESD (C-ESD).MethodsThis study retrospectively analyzed consecutive patients with r-NET treated with ESD between October 2021 and October 2023. Our study assessed differences between the groups in the complete resection rate of lesions, muscular layer injury, surgical complications, operation time, resection speed, time to liquid diet, postoperative hospital stay, hospital cost, and recurrence rate.ResultsA total of 119 patients with r-NETs participated in this study (RBT-ESD group, n = 27; C-ESD group, n = 92). The operation time in RBT-ESD group was shorter than in C-ESD group, but the difference was not statistically significant (16.0 min [9.0–22.0 min] vs. 18.0 min [13.3–27.0 min], P = 0.056). However, the resection speed was significantly faster in the RBT-ESD group (6.7 vs. 4.1 mm2/min, P = 0.005). Furthermore, the RBT-ESD group showed significantly less muscular layer injury (P = 0.047) and faster diet recovery (P = 0.035). No significant differences were observed in the complete resection rate, surgical complications, postoperative hospital stay, hospital cost, or recurrence rate between the two groups.ConclusionFor r-NETs of < 2 cm in size, the RBT method did not significantly shorten the operation time but resulted in faster resection speed, less muscular layer injury, and earlier postoperative recovery to a liquid diet.Graphical

Clip-anchored floss traction-assisted endoscopic submucosal dissection combined with endoscopic tunneling in treatment of long circumferential early esophageal carcinoma.

Clip-anchored floss traction-assisted endoscopic submucosal dissection combined with endoscopic tunneling in treatment of long circumferential early esophageal carcinoma.

Traction-assisted endoscopic submucosal dissection for resection of ileocecal valve neoplasia: a French retrospective multicenter case series.

The ileocecal valve (ICV) is considered to be one of the most difficult locations for endoscopic submucosal dissection (ESD). The objective of this study was to evaluate the efficacy and safety of traction-assisted ESD in this situation. All patients who underwent traction-assisted ESD for an ICV lesion at three centers were identified from a prospective ESD database. En bloc and R0 rates were evaluated. Factors associated with non-R0 resection were explored. 106 patients with an ICV lesion were included. The median lesion size was 50 mm (interquartile range 38-60) and 58.5% (62/106) invaded the terminal ileum. The en bloc and R0 resection rates were 94.3% and 76.4%, respectively. Factors associated with non-R0 resection were lesions covering ≥75% of the ICV (odds ratio [OR] 0.21. 95%CI 0.06-0.76; P=0.02), and involving the anal lip (OR 0.36, 95%CI 0.13-0.99; P=0.04) or more than two sites on the ICV (OR 0.27, 95%CI 0.07-0.99; P=0.03). Traction-assisted ESD for treatment of ICV lesions was a safe and feasible option. Large lesions and anal lip involvement appeared to be factors predictive of difficulty.

The efficacy and safety of snare traction-assisted endoscopic submucosal dissection for circumferential superficial esophageal cancer.

This study aims to investigate the efficacy and safety of snare traction-assisted endoscopic submucosal dissection (ESD) for the management of circumferential superficial esophageal cancer. A total of 68 patients who underwent ESD for circumferential superficial esophageal cancer were included in this study. All the patients were divided into two groups based on whether the snare traction was used or not; the snare traction group (S-ESD, group n = 35) and the control group (C-ESD, group n = 33). There was no significant difference in the size of the resected area between the groups [21.98 (18.30, 27.00) cm2 vs 24.00 (15.28, 30.72) cm2, P = 0.976]. The snare traction group had a shorter dissection time [92.00 (74.00, 121.00) min vs 110.00 (92.50, 137.00) min, P = 0.017] and a faster resection speed [0.28 ± 0.13 cm2/min vs 0.22 ± 0.11cm2/min, P = 0.040] compared to the control group. There were no statistically significant differences between the two groups in terms of hospital stay, cost, en bloc resection rate, R0 resection rate, curative resection rate, bleeding rate, perforation rate, stricture rate, and recurrence rate (P > 0.05). Snare traction-assisted ESD is a safe and efficient approach for the treatment of circumferential superficial esophageal cancer. Its advantages includes shorter procedure so the anesthesia requirement, clear operative filed view, improved mucosal dissection efficiency, simple, and easily accessible equipment.

Role of Traction-Assisted Endoscopic Submucosal Dissection (ESD) in Large Esophageal Cancers

Role of Traction-Assisted Endoscopic Submucosal Dissection (ESD) in Large Esophageal Cancers

Conventional Versus Traction-Assisted Endoscopic Submucosal Dissection for Esophageal, Gastric, and Colorectal Neoplasms: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Endoscopic submucosal dissection (ESD) is increasingly being utilized for the resection of superficial gastrointestinal neoplasms. However, the long procedure time poses a technical challenge for conventional ESD (C-ESD). Traction-assisted ESD (T-ESD) was developed to facilitate the procedure by reducing its duration. This study compares the efficacy and safety of C-ESD versus T-ESD in the treatment of esophageal, gastric, and colorectal neoplasms. Nine randomized controlled trials (RCTs) were analyzed. Traction-assisted ESD exhibited shorter mean dissection times for the esophagus and colorectal regions and lower perforation rates in colorectal cases. No significant differences were observed in en bloc resection or bleeding rates. Traction-assisted ESD proves to be more efficient in mean procedure time for esophageal and colorectal cases and safer in perforation rates for colorectal cases, but similar rates are noted for en bloc resection or bleeding.

Efficacy of endoscopic submucosal dissection assisted by metal-clip pocket creation traction for colorectal tumors

To evaluate the clinical efficacy of endoscopic submucosal dissection (ESD) assisted by metal-clip pocketcreation traction for treatment of colorectal tumors. We retrospectively analyzed the clinical data of 244 patients with colorectal tumors undergoing colorectal ESD treatment between January, 2019 and December, 2022, including 169 patients receiving ESD without metal-clip pocket-creation traction (N-ESD group) and 75 with traction-assisted ESD (M-ESD group). Propensity score matching was used to screen the patients using general clinical data as the covariates for matching. Operative time, surgical resection outcome indicators, incidence of adverse events, and histopathological diagnosis indicators were compared between the two groups of patients after matching. The median operative time was significantly shorter in M-ESD group than in N-ESD group (20.0 [15.0, 30.0] vs 30 [20.0, 45.0] min, P=0.008). No significant difference was found in the en bloc resection rate (100% vs 98.6%), complete resection rate (97.3% vs 96%) and radical resection rate (97.3% vs 96%) between the two groups (P>0.05). The incidence of adverse events was low in both groups and showed no significant difference between them (P>0.05). In patients with colorectal tumors, the use of metal-clip pocket-creation traction can shorten the operative time of ESD although it does not significantly reduce the surgical resection rate or incidence of adverse events.

The Impact of Traction Methods on Endoscopic Submucosal Dissection Efficacy for Gastric Neoplasia: A Systematic Review and Meta-analysis.

Endoscopic submucosal dissection (ESD) for gastric neoplasms can be challenging due to limited traction and visualization. The efficacy of traction-assisted endoscopic submucosal dissection (TA-ESD) continues to require additional validation. This study aims to explore the safety and efficiency of TA-ESD for early gastric neoplasms located at varying sites, in comparison with conventional endoscopic submucosal dissection (C-ESD). We conducted a comprehensive literature search using databases up until August 2022. The outcome measures procedure time, en bloc resection rate, complete resection rate, procedure time, and procedure-related adverse event rate. We calculated pooled mean differences (MDs) and odds ratios (ORs) for these outcomes. The mean procedure time was significantly shorter in the TA-ESD group compared to the C-ESD group (MD - 14.9, 95% CI - 21.78 to - 8.03, I2 = 83%, p < 0.0001). Subgroup analysis revealed that mean procedure times for lesions on the greater curvature and upper/middle of the stomach were significantly shorter in the TA-ESD group - 19.2min (95% CI - 27.75 to - 10.65, I2 = 12%, p < 0.0001) and - 7.35min (95% CI - 35.4 to - 1.15, p = 0.04), respectively. The en bloc resection and complete resection rates were comparable between the two groups. The rate of perforation was significantly lower in the TA-ESD group than in the C-ESD group (OR 0.36, 95% CI 0.15-0.85, p = 0.02, I2 = 0%). This study demonstrates the potential benefits of TA-ESD over C-ESD in treating patients with early-stage gastric tumors, highlighting its safety and efficacy. The findings indicate a significant reduction in procedure times at challenging stomach sites with TA-ESD in comparison to C-ESD.

Two-step traction-assisted endoscopic submucosal dissection for a gastric neoplasm using a clip with a traction band and thread.

Two-step traction-assisted endoscopic submucosal dissection for a gastric neoplasm using a clip with a traction band and thread.

"Clip hooking rubber loop" technique for traction-assisted endoscopic submucosal dissection.

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Effects of traction methods in inexperienced endoscopists during colorectal endoscopic submucosal dissection

Background colorectal endoscopic submucosal dissection (ESD) remains a technical challenge, but traction devices show promise in making this procedure easier. However, the efficacy of traction techniques for colorectal ESD is still unknown for inexperienced endoscopists. Methods We selected 400 patients who underwent colorectal ESD performed by four inexperienced endoscopists. Each patient in the traction-assisted ESD (TA-ESD) group was matched to a patient in the conventional ESD (C-ESD) group according to propensity scores. Results One-to-one propensity score-matching analysis created 87 matched pairs. The self-completion rate in the TA-ESD group is significantly higher than that in the C-ESD group (100% [87/87] vs. 92% [80/87], p < 0.001). The median resection speed was significantly faster in the TA-ESD group than that in the C-ESD group (27 mm2/min [IQR, 19.5–47.3] vs.18 mm2/min [IQR, 13.5–33.8], p < 0.001) and the procedure time in the TA-ESD group was significantly shorter than that in the C-ESD group (33 min [IQR, 27–47] vs.53 min [IQR, 38–73], p < 0.001). However, the histologic complete resection rate was not significantly different between the TA-ESD and C-ESD groups (93.1% [6/87]) vs. 96.6% [3/87], p < 0.1888, respectively). The en bloc resection rate (96.6%) and perforation rate (4.6%) were equivalent between the TA-ESD group and the C-ESD group. Conclusion Traction techniques seem to improve resection speed and self-completion rate of colorectal ESD for inexperienced endoscopists.

Endoscopic submucosal dissection for large early squamous cell carcinoma—traction assisted methods

: Endoscopic resection is a minimally-invasive treatment for superficial esophageal tumors compared with surgery or chemoradiation therapy. Endoscopic submucosal dissection (ESD) is a well-established method with accurate histological evaluation and favorable procedural outcomes. However, ESD requires a high level of skill, and is therefore technically challenging and time-consuming. Traction-assisted ESD has been introduced to facilitate ESD and provides adequate submucosal visualization and satisfactory tissue traction. We reviewed the scientific literature in English to evaluate the efficacy of traction-assisted ESD for esophageal lesions, including the clip-with-thread (CT) method and the submucosal tunneling (ST) method. The CT method is a simple and affordable technique that uses commercially available hemoclips. Two randomized controlled trials and two retrospective studies showed that the CT method resulted in shorter procedure times and reduced local injection compared with conventional ESD, and no cases of perforation. The ST method does not require specific devices and facilitates the procedure by securing a stable submucosal visual field and maintaining a submucosal liquid cushion. Two retrospective studies reported shorter procedure times with similar en bloc resection rates and complete resection rates using the ST method compared with conventional ESD. Although a combination of the ST method with the CT method seems to be effective for large lesions, its efficacy and safety should be confirmed by a large-scale study. In the future, robotic traction has a great potential to be a breakthrough for esophageal ESD, providing appropriate and multi-directional traction to the lesions via an operator-controlled robotic arm. There is no doubt that traction assistance is key to facilitating esophageal ESD. Further studies are needed to elucidate the best method from the perspective of efficacy, safety, and cost.

Novel clip-traction band device-assisted endoscopic submucosal dissection for superficial pharyngeal carcinoma.

Extracorporeal traction-assisted endoscopic submucosal dissection (ESD) for superficial pharyngeal carcinoma has been useful [1] [2] [3]. However, owing to the anatomical features of the larynx and thyroid cartilage, working spaces within the pharynx are narrow. Furthermore, instruments such as intubation tubes, laryngoscopes, grasping forceps [1], and thin endoscopes [2] for traction of the lesion interfere with the endoscope, making endoscopic maneuverability difficult. Methods to overcome such difficulties have been reported in recent years [4] [5].

Underwater and traction-assisted endoscopic submucosal dissection in the gastric fundus using a multibending endoscope.

Underwater and traction-assisted endoscopic submucosal dissection in the gastric fundus using a multibending endoscope.

Novel single-operator through-the-scope traction device for endoscopic submucosal dissection: Outcomes of a multicenter randomized pilot ex-vivo study in trainees with limited endoscopic submucosal dissection experience (with video).

ObjectivesEndoscopic submucosal dissection is a technically demanding procedure. The pilot study aimed to prospectively evaluate the efficacy and safety of a novel single‐operator through‐the‐scope dynamic traction device among trainees with limited endoscopic submucosal dissection (ESD) experience.MethodsRandomized, controlled, pilot study comparing traction‐assisted ESD (T‐ESD) versus conventional ESD (C‐ESD) in an ex‐vivo porcine stomach model. Trainees were randomized to group 1 (T‐ESD followed by C‐ESD) and group 2 (C‐ESD followed by T‐ESD). Lesions were created on the gravity‐dependent area of the stomachs. The primary outcome was submucosal dissection speed. Secondary outcomes included differences in en‐bloc resection, adverse events, and workload, assessed by the National Aeronautical and Space Administration Task Load Index (NASA‐TLX).ResultsFive trainees performed two T‐ESD and two C‐ESD each, for a total of 20 procedures. Submucosal dissection speed was significantly faster in the T‐ESD group compared to the C‐ESD group (43.32 ± 22.61 vs. 24.19 ± 15.86 mm2/min; p = 0.042). En‐bloc resection was achieved in 60% with T‐ESD and 70% with C‐ESD (p = 1.00). The muscle injury rate was higher in the C‐ESD group (50% vs. 10%; p = 0.21) with 1 perforation reported with C‐ESD and none with T‐ESD. NASA‐TLX physical demand was lower with T‐ESD compared to C‐ESD (4.5 ± 2.17 vs. 6.9 ± 2.50; p = 0.03).ConclusionT‐ESD resulted in faster submucosal dissection and less physical demand when compared to C‐ESD, as performed by trainees in an ex‐vivo gravity‐dependent model. Future studies are needed to assess its role in human ESD cases.

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

BackgroundAmong 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.MethodA 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.ResultsAfter 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.ConclusionsCompared with traditional ESD, CRT-ESD with clip and rubber band is both safer and more effective in the treatment of colorectal lesions.Graphical abstract