Endoscopic submucosal dissection with sheath-assisted counter traction for early gastric cancers.
OBJECTIVE
Endoscopic submucosal dissection (ESD) is associated with frequent complications, such as bleeding and perforation. The procedure is technically difficult, requires considerable skill and is longer than conventional endoscopic mucosal resection (EMR). Thus, non-invasive tools and methods are needed to facilitate direct visualization of the submucosal layer during ESD.


METHODS
An insulation-tipped (IT) knife was inserted into one channel, and a conventional injection sheath was inserted to the other channel of a double-channel fiberscope. The submucosal layer was lifted via a circumferential incision using the conventional injection sheath for visualizing cutting lines, and the submucosal layer under the lesion was directly dissected from the underlying muscularis propria.


RESULTS
Sheath-assisted traction resulted in successful ESD with en bloc resection in all 25 patients. Hemostasis and manipulation of blood vessels were uncomplicated and dissection was completed safely, without either bleeding or perforation. The movement of the sheath was not suppressed while lifting the submucosal layer and the IT knife could be moved freely, which allowed submucosal dissection independently of the sheath movement.


CONCLUSIONS
Sheath-assisted traction ESD, using simple materials and methods, has several advantages over other standard traction methods. Our procedure is straightforward, safe, non-invasive, cost-effective and uses readily available instruments to enhance visualization of cutting lines.
Hijikata
Yasutaka
Y
Department of Gastroenterology, Aichi Medical University School of Medicine, Yazako, Nagakute-cho, Japan.
Ogasawara
Naotaka
N
Sasaki
Makoto
M
Mizuno
Mari
M
Masui
Ryuta
R
Tokudome
Kentaro
K
Iida
Akihito
A
Miyashita
Masayuki
M
Funaki
Yasushi
Y
Kasugai
Kunio
K
D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery*; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D004210:Dissection / Q000295:instrumentation*; D005260:Female; D005753:Gastric Mucosa / Q000601:surgery*; D020699:Gastroscopes; D005773:Gastroscopy; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D014143:Traction; D016896:Treatment Outcome