Endoscopic submucosal dissection (ESD) is a proven and safe
technique in the en bloc removal of early gastrointestinal tract cancers
[1]. With the array of available ESD devices and
improvement in ESD techniques, it is now safe to resect lesions even in
difficult locations, such as the esophagus [2]. However,
technical challenges remain when attempting to resect large lesions in
locations within a confined space. When the tumor occupies greater than
three-quarters of the esophageal circumference, the endoscopic view is
diminished when the resection reaches the central portion of the tumor, making
further resection difficult and unsafe. To counteract this problem, we have
devised a modified version of a traction system previously described in the
resection of intragastric lesions [3].
We advocate the use of an esophageal overtube to facilitate the
withdrawal and reinsertion of the endoscope in such cases. Before introduction
into the patient, an endoclip device is loaded into the endoscope and a length
of 0.285-mm fishing line is tied to one jaw of the endoclip ([Fig. 1 a] and [b]).
Fig. 1 a Fishing line tied to
the endoclip. b A plastic sheath is inserted along the
fishing line after placement of the endoclip.
The endoscope is reinserted into the patient through the overtube
with the fishing line running alongside the shaft of the endoscope. The
endoclip is placed over the central portion of the proximal margin of the
partially resected tumor and a low resistance plastic sheath (100 cm) is
inserted over the fishing line ([Fig. 2 a]
and [b]).
Fig. 2 a The endoclip with the
fishing line attached is placed on the resected portion of the esophageal
tumor. b The plastic sheath is inserted over the fishing
line, as traction starts to be applied. c Full traction
is applied, which leads to an improvement in endoscopic view and allows
continuation of ESD.
The plastic sheath allows the endoscope to be easily maneuvered
without interrupting the traction placed on the tumor. When traction is applied
the tumor is lifted with a subsequent improvement in the endoscopic view, and
this allows safe continuation of the ESD ([Fig. 2 c]). This method is simple, easily
applied, and cost-effective, and counteracts the problem created by the
resection of large esophageal tumors by ESD.
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