Is a traction device an almighty tool for overcoming the difficulties of endoscopic submucosal dissection?

Endoscopic submucosal dissection (ESD) is the most powerful endoscopic resection technique allowing reliable en bloc resection, regardless of the size and location of a tumor. This technique is however much more difficult and time-consuming than any other endoscopic resection technique, which has resulted in a delay in its widespread use in Western countries. The difficulty comes from the fact that ESD is a single-handed multistep procedure that requires very precise control of the endoscope. In particular, submucosal dissection is something that was not previously done in endoscopic procedures, and it is extremely difficult for beginners to open the submucosa while using a hood on the endoscope and keeping it in a stable position.

One way of overcoming the difficulties of ESD is to use a long-lasting submucosal injection solution; however, this sometimes flows into unintended areas owing to gravity, particularly for large cumbersome lesions requiring multiple injections. Another way of overcoming the difficulties is to use some kind of traction. A wide variety of traction devices have been proposed as allowing safer and faster dissection by opening the submucosa; however, an ideal traction device with simple and universal application has not yet been developed.

This device seems more effective than previously reported techniques, especially for larger lesions, because appropriate multipolar traction can be maintained by tightening the loop.

In this issue, Masgnaux et al. present their experience with a new ESD traction device, the ATRACT (Adaptive TRACTion), to facilitate submucosal dissection [11]. The device is unique in that it can pull the lesion from multiple directions and adapt the level of traction force according to the situation. The authors conducted a retrospective study of this device, analyzing more than 50 consecutive cases, and showed excellent clinical results: 96% R0 and 90% curative resection rates, with reasonable rates of adverse events (1.9% perforation and 3.8% delayed bleeding). This device seems more effective than previously reported techniques, especially for larger lesions, because appropriate multipolar traction can be maintained by tightening the loop, allowing the dissection plane, as well as the end point, to be easily recognized. The clinical results were excellent, and the extremely fast resection speed compared with the pocket creation method (PCM) was also very impressive. Despite the time needed to set up the ATRACT device, once submucosal dissection began, the fast overall resection speed meant the submucosa could be dissected very efficiently. It is also remarkable that the risk of specimen damage and complications was very low, despite the continuous application of traction.

It is however assumed that there are limitations on lesion size for this technique, as there is no room to adjust the traction loop when the lesion covers more than two-thirds of the circumference. Unfortunately, there are no data on circumferential spread in this study, although the resected specimen size is fairly large. Furthermore, the enrolled cases are relatively small in number and inhomogeneous, including small numbers of gastric and duodenal cases, with the majority being colorectal cases, which of course, does not allow us to evaluate the efficacy of this device in the stomach and duodenum. In addition, its use seems to be difficult in flexures; unfortunately, there is no information or evaluation of lesion location in this paper, so it is unclear whether the device can be used in any location. Also, as the majority of the procedures were performed by two experienced experts, it is not clear whether these highly effective results can be reproduced by regular endoscopists. Therefore, a larger study would be needed to further assess the true value of this device, although the overall impression at this stage is very positive.

Traction techniques can be roughly divided into two categories: natural force and mechanical force. The simplest natural force traction technique is the use of gravity and a transparent hood. The submucosal tunneling method [22] and the PCM [33] are also very effective techniques, which can secure the working space and stabilize the tip of the endoscope to facilitate submucosal dissection. The water pressure method (WPM) [44] is another technique, which gently opens the submucosa by active pressure of saline irrigation, facilitating submucosal dissection, and can be used in any location and for any sized lesion.

In contrast, mechanical force traction techniques actually pull the target tissue to open the submucosa to facilitate submucosal dissection. This makes them safer because the dissection plane can be clearly visualized, yet the tissue can be more easily cut because of the traction force. The simplest technique is the clip-with-line method [55]; however, it is difficult to use, particularly in the deep colon, owing to uncertainty in directional control. Other mechanical force traction techniques include the S-O clip [66] and the multiloop traction device [77], among others, which grip the incision margin and clip it to the contralateral wall in order to open the submucosa. These can be used in any location, except for the flexures, and the extent of traction can be controlled by changing the volume of CO₂ gas or additional clipping. Because of the nature of their mechanism, they do however provide only one directional traction and the traction force decreases as dissection proceeds.

So how should we select a traction technique? When the lesion size is relatively small, any kind of traction technique is acceptable. When the lesion is up to two-thirds of the circumference, the ATRACT may be a very good option. For larger lesions, the WPM or a combination of the PCM with the tunneling method may be good options. However, no matter how advanced the traction device, we must remember to assess the lesion properly beforehand, because a curative resection cannot be achieved if the depth or extent of the lesion is misjudged. In addition, poor maneuverability makes resection extremely difficult and even dangerous, regardless of the use of traction devices. Therefore, we should carefully check the lesion and the maneuverability of the endoscope preoperatively, in order to adopt the right treatment strategy to achieve successful results.

Publication History

Article published online:
22 January 2024

• References

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