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World J Gastrointest Endosc. Apr 16, 2023; 15(4): 259-264
Published online Apr 16, 2023. doi: 10.4253/wjge.v15.i4.259
Two traction methods that can facilitate esophageal 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: December 19, 2022
Peer-review started: December 19, 2022
First decision: February 21, 2023
Revised: February 26, 2023
Accepted: March 30, 2023
Article in press: March 30, 2023
Published online: April 16, 2023
Processing time: 115 Days and 22.6 Hours
Abstract

Different traction devices that can provide a visual field and attain appropriate tension at the dissection plane during endoscopic submucosal dissection (ESD) have been developed. Clip-with-line (CWL) is a classic traction device that can offer per-oral traction toward the direction where the line is drawn. A multicenter randomized controlled trial (CONNECT-E trial) comparing the conventional ESD and CWL-assisted ESD (CWL-ESD) for large esophageal tumors was conducted in Japan. This study showed that CWL-ESD was associated with a shorter procedure time (defined as the time from initiating submucosal injection to completing tumor removal) without increasing the risk of adverse events. Multivariate analysis revealed that whole-circumferential lesion and abdominal esophageal lesion were independent risk factors for technical difficulties, which were defined as a procedure time of > 120 min, perforation, piecemeal resection, inadvertent incision (any accidental incision caused by the electrosurgical knife within the marked area), or handover to another operator. Therefore, techniques other than CWL should be considered for these lesions. Several studies have shown the usefulness of endoscopic submucosal tunnel dissection (ESTD) for such lesions. A randomized controlled trial conducted at five Chinese institutions showed that compared with the conventional ESD, ESTD had a significantly reduced median procedure time for lesions covering ≥ 1/2 of the esophageal circumference. In addition, a propensity score matching analysis conducted at a single Chinese institution showed that compared with the conventional ESD, ESTD had a shorter mean resection time for lesions at the esophagogastric junction. With the appropriate use of CWL-ESD and ESTD, esophageal ESD can be performed more efficiently and safely. Moreover, the combination of these two methods may be effective.

Keywords: Endoscopic submucosal dissection; Traction; Clip-with-line; Endoscopic submucosal tunnel dissection

Core Tip: Clip-with-line (CWL) was developed to overcome the challenges faced in endoscopic submucosal dissection (ESD). A multicenter randomized controlled trial comparing the conventional ESD and CWL-assisted ESD (CWL-ESD) for large esophageal tumors was conducted in Japan. Results showed that CWL-ESD had a shorter procedure time without increasing the risk of adverse events. However, this study revealed that there were issues with the use of CWL-ESD for whole-circumferential and abdominal esophageal lesions. Endoscopic submucosal tunnel dissection may be a promising option for treating these lesions.