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Endoscopic submucosal dissection (ESD) for gastric cancer located in the pyloric ring is technically challenging due to the narrow working space and the difficulty in approaching the duodenal side. It is often arduous to observe the lesion entirely, resulting in decreased complete resection rates [1] [2]. Therefore, several ESD methods have been reported for the approach to gastric cancer near the pyloric ring [3] [4] [5].
Herein, we described a case of successful gastric ESD using a novel traction method that employs a clip-band traction device ([Fig. 1 a]): the triangle traction method ([Video 1]). Mucosal incision and submucosal dissection were performed using a new electrosurgical knife capable of local injection without a separate injection needle (GoldKnife T-type 2.0 mm; Micro-Tech Co. Ltd, Nanjing, China) ([Fig. 1 b]).
Fig. 1 The device used in the procedure. a Clip-band traction device. The clip used is reopenable. Because it is reopenable, it can be re-gripped when a point is grasped The band is made of silicone and can be removed from the clip using grasping forceps. b Mucosal incision and submucosal dissection are performed using a knife capable of local injection. Local injection is administered from the tip of the knife.Video 1 Novel triangle traction method using a clip-band traction device for endoscopic submucosal dissection of early gastric cancer involving the pyloric ring.
A 74-year-old woman presented with gastric adenocarcinoma (15 mm, type 0-IIc) located on the pyloric ring. After circumferential mucosal incision ([Fig. 2 a]), a clip-band traction device (elastic traction device; Micro-Tech) was attached to the proximal and distal sides of the specimen using a reopenable clip (SureClip; Micro-Tech) to position the bridge ([Fig. 2 b, c]). The clip grasped the second band, and the band was fixed to the normal mucosa of the anterior wall of the antrum for the most effective traction ([Fig. 2 d, e]). Hence, the entire lesion was pulled out into the gastric lumen, and good visualization of the duodenal side was obtained. Complete en bloc resection was performed without adverse events.
Fig. 2 Scheme of the triangle traction method using a clip-band traction device. a A circumferential incision is made. b The clip-band traction device is attached to the submucosal layer on the proximal side of the lesion. c The third band is clipped to the opposite duodenal edge, forming a bridge position. d After the second band has been grasped using the reopenable clip, the band is pulled in the direction of most effective traction and fixed. e The whole lesion is pulled out into the gastric lumen, and good visualization, including of the duodenal side, is obtained. f The whole dissection plane is lifted.In conclusion, the triangle traction method is a technique that forms a triangle with the bridge as the base and the second band fixed at the apex. This method can ensure a more extensive lift of the dissection plane than the simple traction method ([Fig. 2 f]). This easy-to-use method involves clips and a clip-band traction device, and it can allow the direction of traction to be adjusted at will without the need to reinsert the endoscope. Our method thus enabled safe ESD for resection of gastric cancer located near the pyloric ring.
Endoscopy_UCTN_Code_TTT_1AO_2AG
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Publication HistoryArticle published online:
18 November 2022
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