title: Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video).
abstract: BACKGROUND
  The lack of countertraction in endoscopic submucosal dissection (ESD) results in increased technical demand and procedure time. Although the suture-pulley method for countertraction has been reported, its effectiveness compared with the traditional ESD technique remains unclear.
  
  
  OBJECTIVE
  To objectively analyze efficacy of countertraction using the suture-pulley method for ESD.
  
  
  METHODS
  Prospective ex vivo animal study.
  
  
  METHODS
  Animal laboratory.
  
  
  METHODS
  Twenty simulated gastric lesions were created in porcine stomachs by using a standard circular template 30 mm in diameter. In the control arm (n = 10), ESD was performed by using the standard technique. In the suture-pulley arm (N = 10), a circumferential incision was made, and an endoscopic suturing device was used to place the suture pulley.
  
  
  METHODS
  The primary outcome of this study was total procedure time.
  
  
  RESULTS
  The median total procedure time with the suture-pulley method was significantly shorter than the traditional ESD technique (median, 25% to 75%, interquartile range [IQR]: 531 seconds [474.3-549.3 seconds] vs 845 seconds [656.3-1547.5 seconds], P < .001). The median time (IQR) for suture-pulley placement was 160.5 seconds (150.0-168.8 seconds). Although there was a significantly longer procedure time for proximal versus middle/lower stomach lesions with traditional ESD (median, 1601 seconds; IQR, 1547.5-1708.8 seconds vs median, 663 seconds; IQR, 627.5-681.8 seconds; P = .01), there was no significant difference in procedure time for lesions of various locations when using the suture-pulley method. Compared with traditional ESD, the suture-pulley method was less demanding in all categories evaluated by the NASA Task Load Index.
  
  
  CONCLUSIONS
  Ex vivo study.
  
  
  CONCLUSIONS
  The suture-pulley method facilitates direct visualization of the submucosal layer during ESD and significantly reduces procedure time and technical difficulty. In addition, the benefit of the suture-pulley method was seen for both simple and more complicated ESDs.
authors.affiliation: Developmental Endoscopy, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Aihara
authors.affiliation: Developmental Endoscopy, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Nitin
authors.initials: N
authors.lastname: Kumar
authors.affiliation: Developmental Endoscopy, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Marvin
authors.initials: M
authors.lastname: Ryou
authors.affiliation: Developmental Endoscopy, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Wasif
authors.initials: W
authors.lastname: Abidi
authors.affiliation: Developmental Endoscopy, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Michele B
authors.initials: MB
authors.lastname: Ryan
authors.affiliation: Developmental Endoscopy, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Thompson
mesh_terms: D000818:Animals; D004210:Dissection / Q000379:methods*; D005753:Gastric Mucosa / Q000601:surgery*; D005773:Gastroscopy / Q000379:methods*; D008953:Models, Anatomic; D023421:Models, Animal; D061646:Operative Time; D011446:Prospective Studies; D013270:Stomach / Q000601:surgery*; D013536:Suture Techniques; D013537:Sutures; D013552:Swine