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World J Gastrointest Endosc. Nov 16, 2022; 14(11): 667-671
Published online Nov 16, 2022. doi: 10.4253/wjge.v14.i11.667
Optimal traction direction in traction-assisted gastric endoscopic submucosal dissection
Mitsuru Nagata
Mitsuru Nagata, Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Fujisawa 251-0041, Kanagawa, Japan
Author contributions: Nagata M has been associated with the conception, drafting of the article, and final approval of the article.
Conflict-of-interest statement: No financial relationships with a commercial entity producing health-care related products and/or services relevant to this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Mitsuru Nagata, MD, Chief Doctor, Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, 1-5-1 Tsujidokandai, Fujisawa 251-0041, Kanagawa, Japan. mitsuru10jp@yahoo.co.jp
Received: September 7, 2022
Peer-review started: September 7, 2022
First decision: September 26, 2022
Revised: October 2, 2022
Accepted: October 14, 2022
Article in press: October 14, 2022
Published online: November 16, 2022
Abstract

Various traction devices have been developed to secure a visual field and sufficient tension at the dissection plane during endoscopic submucosal dissection (ESD). However, few large-scale studies have investigated the effectiveness of traction devices in gastric ESD. Clip-with-line (CWL) is one such traction device that is widely used in cases of gastric ESD. The CONNECT-G trial was the first multicenter randomized controlled trial to compare conventional ESD with CWL-assisted ESD (CWL-ESD) for superficial gastric neoplasms. Overall, no significant intergroup difference was observed in terms of the gastric ESD procedure time. However, subgroup analysis according to lesion location revealed a significant reduction in the procedure time of gastric ESD for the lesion located at the greater curvature of the middle and upper third of the stomach in the CWL-ESD group. In this subgroup analysis, lesion location was categorized as follows: anterior wall, posterior wall, lesser curvature, and greater curvature of the upper, middle, and lower thirds of the stomach. However, the gastric ESD procedure time showed no significant difference, except for lesions located at the greater curvature of the upper and middle thirds of the stomach. The traction direction of CWL in the stomach was limited to the cardia and changed depending on the lesion location. Therefore, outcomes of the CONNECT-G trail suggest that the effectiveness of CWL was influenced by lesion location, i.e., traction direction. Further studies are warranted to investigate the optimal traction direction in gastric ESD.

Keywords: Endoscopic submucosal dissection, ESD, Traction device, Clip-with-line, Traction direction, Vertical traction

Core Tip: Various traction devices have been developed for endoscopic submucosal dissection (ESD). However, few traction devices have been validated in large-scale studies thus far. The CONNECT-G trial was the first multicenter randomized controlled trial to compare conventional ESD with clip-with-line-assisted ESD for superficial gastric neoplasms. This study suggested that the effectiveness of traction devices in gastric ESD depends on the traction direction; in addition, the most optimal traction direction is vertical to the gastric wall.