Revisiting the novel traction technique: the monorail method with clip-line traction

We are deeply impressed by the innovative article authored by Masashi Ono et al. [1], which introduces a novel traction technique for endoscopic submucosal dissection (ESD). This advanced approach significantly enhanced operational ease and flexibility for patients in whom complete resection was challenging. Compared with other traction methods, such as pulley traction [2], magnet-assisted traction [3], and endoluminal combined fixation traction [4], this technique notably minimizes gastrointestinal mucosal damage and simplifies coordination between the operator and assistant. Consequently, it diminishes the risk of surgical complications, prioritizing the patient’s health.

However, we also have some concerns about the novel method. Firstly, the presented case involves a lesion located at the fundus dome of the stomach, an area that is notoriously difficult to access via gastroscopy. We wonder whether this method could also be applied to other challenging regions, such as the ileocecal junction. Secondly, we think the role of the monorail method in this case is more about encircling and resecting the lesion. It is our contention that for more complex or extensive lesions, this technique might exhibit certain limitations. It appears to be primarily effective in providing traction in a single direction, potentially lacking the versatility for multi-angle traction. Additionally, in cases involving fibrotic lesions, there might be concerns regarding insufficient traction force. Recent studies on gastric ESD traction for difficult cases highlighted the predominant use of combined traction methods for such lesions [5]. Therefore, it is advisable to conduct a comprehensive preoperative evaluation of the lesion’s location and carefully select the appropriate patient cohort before employing this technique.

Finally, I harbor a slight apprehension regarding how to adjust the clipping position if it needs to be changed for directional adjustments during the operation. Will forcibly removing the clip damage the tissue and affect the quality of the pathological diagnosis?

Publication History

Article published online:
27 September 2024

• References

• 1 Ono M, Fujimoto A, Yamaguchi K. et al. A new treatment method for patients with cancer that cannot be resected en bloc by endoscopic submucosal dissection: the monorail method with clip-line traction. Endoscopy 2023; 55: E1118-E1119
• 2 Nomura T, Kamei A, Sugimoto S. Gastric endoscopic submucosal dissection using the “pulley clip with elastic line” method. Endoscopy 2018; 50: E104-e106 DOI: 10.1055/s-0043-125358. (PMID: 29396974)
• 3 Gao Y, Liu W, Ye L. et al. Magnet-assisted traction method helps to reduce the difficulty of esophageal endoscopic submucosal dissection. Endoscopy 2023; 55: E1186-e1188 DOI: 10.1055/a-2186-5029. (PMID: 38029796)
• 4 Ota R, Doyama H, Tsuji K. et al. Deep colonic endoscopic submucosal dissection using a modified clip and snare method incorporating a pre-looping technique. BMJ Case Rep 2015; 2015 DOI: 10.1136/bcr-2014-207918. (PMID: 25616654)
• 5 Zhang Q, Yao X, Cai JQ. et al. Snare combined with endoclips in endoscopic submucosal dissection with mucosal traction for gastroesophageal neoplasia. J Gastroenterol Hepatol 2019; 34: 1049-1057