Novel application of multi-loop traction device and threaded clip in gastric endoscopic submucosal dissection

Traction-assisted endoscopic submucosal dissection (ESD) employing a dental floss clip has demonstrated usefulness in gastric ESD [1]. However, it provides insufficient traction for large lesions when a single traction point is used. We developed a novel traction technique using a Multi-Loop Traction Device (MLTD; Boston Scientific Co. Ltd., Tokyo, Japan) that enables traction on three points with a single traction. We named this the “anchor traction method” [2]. Here we report application of this technique on a large lesion by combining MLTD and a threaded clip to achieve effective traction at three points.

A 68-year-old male presented with a 55-mm IIc lesion on the lesser curvature of the gastric body ([Fig. 1]). He then underwent ESD ([Video 1]).

Fig. 1 The lesion was a 55-mm 0-IIc lesion on the lesser curvature of the gastric body.

Novel application of MLTD and a threaded clip in gastric ESD.Video 1

A full circumferential incision was made and the middle loop of the MLTD was grasped with a reopenable clip (SureClip; MicroTech, Nanjing, China) and attached to the anal side of the lesion. Two additional loops of MLTD were then attached to the lesion, employing the “anchor traction method”. The scope was removed and a clip with thread was attached, then the scope was reinserted. The clip was then attached to the middle loop of the MLTD. The thread was pulled to obtain good traction ([Fig. 2]). Traction on multiple points enabled safe ESD using the IT knife 2. Histopathology result was 0-IIc, 55×30mm, tub2 > por1, pT1b (SM, 900 µm), INFa, LY0, V0, UL0, pHM0, pVM0 ([Fig. 3]), and the patient underwent additional surgery later.

Fig. 2 The combination of MLTD with a threaded clip can provide effective traction.

Fig. 3 The histopathology result was 0-IIc, 55 × 30 mm, tub2 > por1, pT1b (SM, 900 µm), INFa, LY0, V0, UL0, pHM0, pVM0.

Although there are already reports of traction devices allowing traction in multiple locations [3] [4], when treating lesions such as these in retroflex position, the traction device may interfere with the scope, causing traction to be removed. Therefore, the combination of MLTD with a threaded clip can provide effective traction in gastric ESD.

• References

• 1 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
• 2 Yamada K, Tajika M, Tanaka T. et al. A novel traction method using a multi-loop traction device in colorectal endoscopic submucosal dissection: Anchor traction method. Endoscopy 2024; 56: E780-E781
• 3 Grimaldi J, Masgnaux L-J, Lafeuille P. et al. Endoscopic submucosal dissection with adaptive traction strategy: first prospective multicenter study (with video). Gastrointest Endosc 2024; 100: 517-523
• 4 Okamura T, Honda T, Ikeda T. et al. Development of a novel multipoint traction device for gastric and colorectal endoscopic submucosal dissection and evaluation of its efficacy and safety. Surg Endosc 2024; 38: 4704-4711