A new technique for gastric endoscopic submucosal dissection: peroral traction-assisted endoscopic submucosal dissection.

BACKGROUND: Compared with conventional EMR, endoscopic submucosal dissection (ESD) has a higher en bloc resection rate and complete resection rate, regardless of tumor size, in treating gastric neoplasms. However, ESD leads to more complications, such as bleeding or perforation, and, in particular, needs more procedure time than a conventional EMR.

OBJECTIVE: To report a new technique for ESD, peroral traction-assisted ESD with suture material, to perform easier and more rapid procedures in treating gastric neoplasms and to report the technique's early results.

DESIGN: A case series.

SETTING: A tertiary medical center.

PATIENTS AND METHODS: A total of 15 patients with gastric adenomas or early gastric cancers larger than 10 mm in diameter were consecutively enrolled. After marking around the periphery of the lesion, submucosal injection, followed by circumferential mucosal incision with a Flex-knife and an insulation-tipped knife, was conducted. After that, one hemostatic clip, tied by using a white silk suture, was applied at a site of the lesion suitable for oral traction. During submucosal dissection, the applied suture material was pulled to the oral side. Additional tractions were applied as needed.

MAIN OUTCOME MEASUREMENTS: En bloc resection rate, procedure time, complications.

RESULTS: All lesions were resected en bloc with free lateral and vertical margins by using this technique. The mean longest lesion size and specimen size were 18.1 mm (range 11-28 mm) and 43.7 mm in diameter (range 25-64 mm), respectively. The mean procedure time was 49.6 minutes (range 28-90 minutes). There was no significant bleeding that required blood transfusion or perforation related to the procedures.

LIMITATIONS: Single endoscopist, small patient number.

CONCLUSION: Peroral traction-assisted ESD with suture material is useful in treating gastric neoplasms located in various regions of the stomach. It may make ESD procedures easier, faster, and safer under better direct vision of the submucosal layer.