A modified method of endoclip-and-snare to assist in endoscopic submucosal dissection with mucosal traction in the upper GI tract

Abstract

There are several methods of assisting gastric endoscopic submucosal dissection (ESD) through mucosal traction, but they have some limitations.1Suzuki S. Gotoda T. Kobayashi Y. et al.Usefulness of a traction method using dental floss and a hemoclip for gastric endoscopic submucosal dissection: a propensity score matching analysis (with videos).Gastrointest Endosc. 2016; 83: 337-346Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 2Imaeda H. Hosoe N. Ida Y. et al.Novel technique of endoscopic submucosal dissection using an external grasping forceps for superficial gastric neoplasia.Dig Endosc. 2009; 21: 122-127Crossref PubMed Scopus (36) Google Scholar, 3Gotoda T. Oda I. Tamakawa K. et al.Prospective clinical trial of magnetic-anchor-guided endoscopic submucosal dissection for large early gastric cancer (with videos).Gastrointest Endosc. 2009; 69: 10-15Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar, 4Wang Z. Phee S.J. Lomanto D. et al.Endoscopic submucosal dissection of gastric lesions by using a master and slave transluminal endoscopic robot: an animal survival study.Endoscopy. 2012; 44: 690-694Crossref PubMed Scopus (50) Google Scholar, 5von Delius S. Karagianni A. von Weyhern C.H. et al.Percutaneously assisted endoscopic surgery using a new PEG-minitrocar for advanced endoscopic submucosal dissection (with videos).Gastrointest Endosc. 2008; 68: 365-369Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The clip-with-line method can achieve only unidirectional traction, and the firmness and strength of traction seem to be limited.1Suzuki S. Gotoda T. Kobayashi Y. et al.Usefulness of a traction method using dental floss and a hemoclip for gastric endoscopic submucosal dissection: a propensity score matching analysis (with videos).Gastrointest Endosc. 2016; 83: 337-346Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Using the external forceps method, it is difficult to deal with lesions at the cardia, lesser curvature, and posterior wall of the upper gastric body.2Imaeda H. Hosoe N. Ida Y. et al.Novel technique of endoscopic submucosal dissection using an external grasping forceps for superficial gastric neoplasia.Dig Endosc. 2009; 21: 122-127Crossref PubMed Scopus (36) Google Scholar Methods like the magnetic anchor and robot-assisted methods need special adjuvant devices.3Gotoda T. Oda I. Tamakawa K. et al.Prospective clinical trial of magnetic-anchor-guided endoscopic submucosal dissection for large early gastric cancer (with videos).Gastrointest Endosc. 2009; 69: 10-15Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar, 4Wang Z. Phee S.J. Lomanto D. et al.Endoscopic submucosal dissection of gastric lesions by using a master and slave transluminal endoscopic robot: an animal survival study.Endoscopy. 2012; 44: 690-694Crossref PubMed Scopus (50) Google Scholar The percutaneous-traction method is invasive.5von Delius S. Karagianni A. von Weyhern C.H. et al.Percutaneously assisted endoscopic surgery using a new PEG-minitrocar for advanced endoscopic submucosal dissection (with videos).Gastrointest Endosc. 2008; 68: 365-369Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Considering these limitations, our team explored a modified method of assisting gastric ESD with the application of endoscopic snare and endoclips (SC-ESD) (Video 1, available online at www.VideoGIE.org). After the gastric mucosa is circumferentially incised along the premarked dots, a snare is fixed to 1 or more sides of the incised mucosa with endoclips, and the mucosa fixed on the snare is pulled or pushed by pulling or pushing the snare to expose the submucosa for dissection (Figs. 1A-C). Any side of the incised mucosa can be fixed on the snare with endoclips, which contributes to adjusting the traction position in real time. With some lesions for which the submucosa cannot be effectively exposed in this way, a method of internal traction has been devise