In this video, we will show methods of countertraction in ESD.
This is a 67-year-old female who presented for iron deficiency anemia. Upper endoscopy revealed a 30mm 0-IIa lesion per Paris criteria at the posterior wall of the lower stomach. Biopsy at the outside hospital revealed well differentiated adenocarcinoma. EUS showed intramucosal carcinoma with no submucosal invasion.
To treat the lesion, EMR was attempted at the outside hospital but was unsuccessful. Tattooing was then performed directly into the lesion to mark its location.
Here, you can see a 30mm 0-IIa lesion at the posterior wall of the lower gastric body.
Circumferential incision was started with an ESD knife with an insulated tip. As submucosal dissection was continued, significant submucosal fibrosis was observed, likely from the tattooing and attempted EMR.
In this case, suture pulley method was chosen for countertraction.
The suture pulley method was first reported in 2011 and has been shown to decrease the time of the procedure. Using an endoscopic suturing device, a suture is strategically placed to provide countertraction to allow optimal visualization of the dissection plane.
Currently, several other traction methods are available, including “suture and clip method,” “overtube traction method”, and “magnetic anchor method.”
The advantage of the suture-pulley method includes a wider dissection plane and robustness of the system. These are facilitated by the fulcrum point, which is made by a full-thickness suture at the opposite wall. Also when deployed, this traction system works independently from the endoscope. This is critical for ESD to allow enough working space for ESD knives.
First, the endoscope was switched to a double channel endoscope with an attached suturing device and a 2-0 monofilament suture.
The 1st stitch was placed at the opposite wall to the lesion. A helical grasper was used to ensure full thickness suture is placed.
Then the 2nd stitch was placed at the proximal edge of the lesion.
The anchor was dropped. The double channel scope was then withdrawn and the suture was grasped at the mouth of the patient. Dissection was then continued.
As can be seen here, the suture pulley method provided a direct view of the submucosal dissection plane. A suitably strong traction force can be obtained by pulling the monofilament suture from the mouth.
Even though there was fibrosis in the submucosal layer due to the tattooing and previous EMR attempt, ESD was completed without any adverse events.
Finally, the lesion was removed in en-bloc fashion. Pulling on the lesion with the attached anchor allowed the removal of suture without any adverse events.
Pathologically, this lesion was diagnosed as well differentiated adenocarcinoma with negative vertical and horizontal margins, with no submucosal invasion.
The next case is a 65-year-old female. Her screening colonoscopy revealed a 40mm laterally spreading non granular type lesion in the ascending colon. Tattooing was performed at the outside hospital.
Here you can see a 40 mm lesion in the ascending colon. First, the lesion was lifted with hydroxypropylmethylcellurose solution, commonly used as artificial tears. Then circumferential incision was performed using a needle-type ESD knife.
Submucosal dissection was performed starting from the left side of the lesion. In the middle, the angle of the knife became perpendicular to the muscle layer. To avoid perforation, rubber band traction method was chosen for countertraction.
This method uses a rubber band and a suture loop that are fixed at the proximal edge of the lesion and the opposite wall using two hemoclips. In this system, the fulcrum point at the opposite wall allows a wider dissection plane. Also, the advantage of this system is that the endoscope does not need to be withdrawn to deploy the traction system because the rubber band and the suture loop can be delivered through the scope channel. This aspect is the biggest advantage in this method, especially because it is particularly important for the lesions in the proximal colon.
First, the rubber band was fixed at the edge of the lesion with a clip.
Then the suture loop was fixed at the wall, opposite to the lesion.
The rubber band traction method effectively applied a traction force to the lesion and provided the wider and clearer dissection plane. ESD was completed without perforation.
Since the lesion was attached to the rubber band, Endoscopic scissors were used to cut the suture loop and the specimen was retrieved.
Pathologically, this lesion was diagnosed as adenoma with no dysplasia. There was no adenomatous tissue at the resection edge.
In conclusion, countertraction methods can be critical for successful ESD in challenging
situations.