Pre-incision traction method using clip-and-thread for gastric endoscopic submucosal dissection

Gastric endoscopic submucosal dissection (G-ESD) has become a widely accepted and well-established treatment modality [1]. However, G-ESD can be technically challenging depending on the lesion’s location owing to the difficulty in creating a mucosal flap. This can increase procedure time and lead to unintentional bleeding during mucosal incision and submucosal dissection. To address these challenges, we present a new method called the “pre-incision traction method” for G-ESD.

A 67-year-old man presented with early gastric cancer located on the greater curvature of the middle gastric body ([Fig. 1]). A semi-circumferential mucosal incision on the oral side was performed using the ITknife 2 (Olympus, Tokyo, Japan) ([Fig. 2] a). Subsequently, a threaded clip (EZ clip; Olympus) was applied to the anal side where the mucosal incision had not yet been completed ([Fig. 2] b). When mucosal incision on the anal side of the clip was performed with FlushKnife BT-S (Fujifilm, Tokyo, Japan), a mucosal flap was immediately created, providing an excellent field of view and facilitating submucosal dissection ([Fig. 2] c). The dissection speed was also improved due to the adequate tension provided by the clip. The threaded clip did not interfere with subsequent procedures, and a constant tension was kept by pulling the thread. En bloc resection was achieved without any complications ([Fig. 2] d, [Video 1]).

Fig. 1 An early gastric cancer located on the greater curvature of the middle gastric body.

Fig. 2 Pre-incision traction method for gastric endoscopic submucosal dissection. a A semi-circumferential mucosal incision was performed on the oral side. b A threaded clip was applied to the anal side. c When mucosal incision on the anal side of the clip was performed, a mucosal flap was immediately created. d En bloc resection was achieved without any complications.

Pre-incision traction method using clip-and-thread for gastric endoscopic submucosal dissection.Video 1

The traction methods reported to date typically involve a full circumferential incision to facilitate submucosal dissection [2]. Our novel “pre-incision traction method” aims to simplify the creation of the mucosal flap and maintain a clear field of view, thereby making G-ESD safer and more time efficient. While similar traction methods have been reported for colorectal ESD [3], there have been no such reports for G-ESD. We are currently planning a feasibility study to investigate the efficacy and safety of this new method.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Ono H, Yao K, Fujishiro M. et al. Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition). Dig Endosc 2021; 33: 4-20
• 2 Yoshida M, Takizawa K, Suzuki S. et al. Conventional versus traction-assisted endoscopic submucosal dissection for gastric neoplasms: a multicenter, randomized controlled trial (with video). Gastrointest Endosc 2018; 87: 1231-1240
• 3 Ide D, Ohya TR, Saito S. et al. Clinical utility of the pocket-creation method with a traction device for colorectal endoscopic submucosal dissection. Surg Endosc 2021; 35: 2110-2118

Publication History

Article published online:
28 January 2025