Usefulness of bilateral traction method for endoscopic submucosal dissection of superficial pharyngeal cancer

Pharyngeal endoscopic submucosal dissection (ESD) has been increasingly performed as a minimally invasive treatment, similar to gastrointestinal ESD [1] [2]. However, the hypopharynx presents a challenging treatment area due to its complex anatomical structure and interference from the intubation tube, which limits the available working space. Various traction methods have been proposed to address these challenges [3] [4]. Previously, we reported the efficacy of the bilateral traction (BLT) method for colorectal ESD [5]. Herein, we report a case in which BLT facilitated hypopharyngeal ESD ([Video 1]).

Bilateral traction method in pharyngeal endoscopic submucosal dissection.Video 1

A 62-year-old man with reflux esophagitis underwent esophagogastroduodenoscopy, which revealed a reddish, protruding lesion in the right arytenoid ([Fig. 1]). Biopsy results confirmed squamous cell carcinoma. The patient was referred to our hospital for pharyngeal ESD. Under general anesthesia, an otolaryngologist inserted a curved rigid laryngoscope (Nagashima Medical Instruments, Tokyo, Japan), and a mucosal incision was initiated using a dual knife (Olympus Medical Systems Co., Tokyo, Japan). However, the limited working space around the larynx made this procedure challenging ([Fig. 2]). After completing the circumferential incision, subepithelial dissection was initiated; however, dissection around the larynx remained difficult. Therefore, we attached an EZ clip (HX-610-090; Olympus Medical Systems Co., Tokyo, Japan) with a double thread to the specimen for traction ([Fig. 3]). Each segment of the doubled thread was pulled in the left and right directions to improve the field of view for dissection. Initially, we dissected the pyriform sinus side by pulling the left thread ([Fig. 4]), which reduced interference from the intubation tube and allowed for sufficient dissection. The right thread was subsequently pulled to facilitate dissection of the central side of the arytenoid ([Fig. 5]). Subsequently, en bloc resection was achieved with negative margins.

Fig. 1 White-light imaging reveals a reddish protruded lesion in the right arytenoid.

Fig. 2 The narrow working space and interference with the intubation tube around the larynx make treatment difficult.

Fig. 3 Traction is performed using a clip with a thread. Each thread can be pulled in the left and right directions.

Fig. 4 a Dissection of the pyriform sinus side. Countertraction to the left makes it easier to maintain the resection view and reduces interference with the intubation tube. b Schema of (a). The working space for dissection around the larynx is maintained by pulling the left thread.

Fig. 5 a Dissection of the central side of the arytenoid. Countertraction to the right makes it easier to maintain the resection view and keep a distance from the intubation tube. b Schema of (a). The working space for dissection around the larynx is maintained by pulling the right thread.

The BLT method provided adjustable visualization for the endoscopist, which was useful in the hypopharynx, where the working space is narrow.

Endoscopy_UCTN_Code_TTT_1AO_2AG_3AD

Publication History

Article published online:
17 July 2025

• References

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