title: Facilitating retroflexed endoscopic full-thickness resection through loop-mediated or rope-mediated countertraction (with videos).
abstract: OBJECTIVE
  Endoscopic full-thickness resection (EFTR) is difficult to perform in a retroflexed fashion in the gastric fundus and lesser curvature. Here we describe two simple methods to provide countertraction and thereby facilitate dissection.
  
  
  METHODS
  In this retrospective cohort study, 62 patients diagnosed as having gastric submucosal tumors in the fundus or in the lesser curvature received EFTR with or without countertraction methods. For the clip-with-thread method, a clip tied with surgical suture was anchored on the distal edge of the tumor to provide countertraction; for the loop-assisted method, a snare placed on the transparent cap beforehand was adopted to grasp the tumor to provide countertraction.
  
  
  RESULTS
  Mean operative time was significantly reduced in the thread-with-clip group and loop-assisted group (45 minutes, 40 minutes, respectively) compared with the time needed in the traditional EFTR group (85 minutes). Intraoperative pneumoperitoneum occurred regularly among the 3 groups because of iatrogenic perforation, but fewer patients in the thread-with-clip group and loop-assisted group (23%, 18%, respectively) needed abdominal puncture to relieve free air and stabilize life signs compared with patients in the traditional EFTR group (63%). A reduced occurrence of high fever after surgery may contribute as another advantage from accelerated dissection. Both techniques did not jeopardize oncologic safety during short-term follow-up.
  
  
  CONCLUSIONS
  Both the thread-with-clip method and loop-assisted method provide effective countertraction and offer faster and safer gastric EFTR in difficult anatomic locations.
authors.affiliation: Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Gastroenterology, Qilu Hospital, Shandong University School of Medicine, Jinan, Shandong, China.
authors.forename: Jiaoyang
authors.initials: J
authors.lastname: Lu
authors.affiliation: Department of Statistics, Shandong Provincial Hospital, Jinan, Shandong, China.
authors.forename: Taotao
authors.initials: T
authors.lastname: Jiao
authors.affiliation: Department of Gastroenterology, Qilu Hospital, Shandong University School of Medicine, Jinan, Shandong, China; Department of Gastroenterology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Yanmei
authors.initials: Y
authors.lastname: Li
authors.affiliation: Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. Electronic address: zheng_minhua@yeah.net.
authors.forename: Minhua
authors.initials: M
authors.lastname: Zheng
authors.affiliation: Department of Gastroenterology, Qilu Hospital, Shandong University School of Medicine, Jinan, Shandong, China.
authors.forename: Xuefeng
authors.initials: X
authors.lastname: Lu
mesh_terms: D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D015331:Cohort Studies; D004210:Dissection; D005260:Female; D005748:Gastric Fundus / Q000601:surgery*; D005753:Gastric Mucosa / Q000601:surgery*; D046152:Gastrointestinal Stromal Tumors / Q000473:pathology / Q000601:surgery*; D005773:Gastroscopy / Q000379:methods*; D006801:Humans; D007889:Leiomyoma / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D012189:Retrospective Studies; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D013525:Surgical Instruments; D013536:Suture Techniques; D047368:Tumor Burden