title: Endoscopic submucosal dissection with sheath-assisted counter traction for early gastric cancers.
abstract: 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.
authors.affiliation: Department of Gastroenterology, Aichi Medical University School of Medicine, Yazako, Nagakute-cho, Japan.
authors.forename: Yasutaka
authors.initials: Y
authors.lastname: Hijikata
authors.forename: Naotaka
authors.initials: N
authors.lastname: Ogasawara
authors.forename: Makoto
authors.initials: M
authors.lastname: Sasaki
authors.forename: Mari
authors.initials: M
authors.lastname: Mizuno
authors.forename: Ryuta
authors.initials: R
authors.lastname: Masui
authors.forename: Kentaro
authors.initials: K
authors.lastname: Tokudome
authors.forename: Akihito
authors.initials: A
authors.lastname: Iida
authors.forename: Masayuki
authors.initials: M
authors.lastname: Miyashita
authors.forename: Yasushi
authors.initials: Y
authors.lastname: Funaki
authors.forename: Kunio
authors.initials: K
authors.lastname: Kasugai
mesh_terms: 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