Debates on Colorectal Endoscopic Submucosal Dissection - Traction for Effective Dissection: Gravity Is Enough

Bo-In Lee

doi:10.5946/ce.2013.46.5.467

Articles

Page Path: HOME > Clin Endosc > Volume 46(5); 2013 > Article

Special Issue Article of IDEN 2013 Review Debates on Colorectal Endoscopic Submucosal Dissection - Traction for Effective Dissection: Gravity Is Enough: Bo-In Lee; Clinical Endoscopy 2013;46(5):467-471.
DOI: https://doi.org/10.5946/ce.2013.46.5.467
Published online: September 30, 2013

Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea.

Correspondence: Bo-In Lee. Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, 56 Dongsu-ro, Bupyeong-gu, Incheon 403-720, Korea. Tel: +82-32-280-5052, Fax: +82-32-280-5987, gidoc4u@gmail.com

• Received: June 8, 2013 • Revised: July 8, 2013 • Accepted: July 18, 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

6,913 Views
86 Download
22 Crossref
25 Scopus

prev next

Full Article

Download PDF

Abstract
INTRODUCTION
ROLE OF TRACTION DURING ESD
HOW TO ACHIEVE TRACTION FORCES DURING ESD?
GRAVITY VERSUS ADJUNCTIVE METHODS FOR TRACTION
CONCLUSIONS
NOTES
REFERENCES

Abstract

Colorectal endoscopic submucosal dissection (ESD) still remains a technically difficult procedure. The maintenance of tissue tension and good submucosal exposure during dissection is one of the most important factors for an effective and safe dissection. Although various traction methods have been developed, traction by gravity is one of the most useful method for colorectal ESD. Traction using adjunctive devices can thus be reserved for extremely difficult cases or for endoscopists in their learning periods for colorectal ESD.
Keywords: Colorectal neoplasms; Endoscopic submucosal dissection; Traction; Gravitation

INTRODUCTION

As a result of the development of endoscopic submucosal dissection (ESD), the en bloc resection of larger gastrointestinal neoplasms can be performed successfully. However, ESD still has many limitations, including its technical difficulty, long procedure times, and risks of perforation and bleeding. Because the colorectal wall is much thinner than the gastric wall, the risk of perforation is considerably greater in colorectal ESD than in gastric ESD. The perforation rates associated with colorectal ESD were approximately 10% in several reports1,2 although this rate has been decreasing as the skills, materials, and devices for ESD are improved.

Adequate tissue tension and good visibility of the tissue to be dissected are very important for effective and safe dissections, and they can be achieved by traction of the tissue to be dissected. In this article, we will discuss various techniques for achieving tractions during ESD and their advantages and disadvantages.

ROLE OF TRACTION DURING ESD

Traction decreases the contact area between the tissue and the electrosurgical knife by increasing the tissue tension (Fig. 1). The current density increases as the contact area decreases, which enables a more effective cut.

Secondly, traction can provide better submucosal exposure (Fig. 2). The precise dissection of the submucosal layer is the most important step for preventing perforation, and the electrosurgical knife should always aim for the submucosal layer during dissection. Therefore, improved submucosal exposure through traction is helpful for more effective and safer dissections.

HOW TO ACHIEVE TRACTION FORCES DURING ESD?

Surgeons are usually aided by the hands of assistants or by various instruments to maintain the tissue tension and visibility of the tissue to be dissected. In ESD, achieving good traction is not easy because only an electrosurgical knife can be passed through the single working channel. Therefore, ESD can be compared to one-handed surgery.

The transparent distal attachment is a simple device that provides tissue tension and submucosal exposure. By inserting the transparent hood in between the flap and its base, more submucosa can be exposed and better tissue tension can be achieved (Fig .3). This technique can also keep the tip of the endoscope at a suitable distance from the tissue such that the phenomenon of red-out can be avoided.

Traction force can be simply achieved through gravity.3 The direction of the traction force can be controlled by changing the position of the patient. While the patient's position during gastric ESD is limited to left lateral decubitus, various positions, even including the prone position are allowed during colorectal ESD. The optimal position is estimated by the location of fluid in the lumen. Locating fluid on the opposite side of the lesion, which can cause the flap to be strained to the side of the luminal center, is usually preferred. However, submucosal exposure may not be insufficient in the early stages of the dissection because the flap has not yet been sufficiently prepared. As the dissection progresses, the weight of the flap increases, and thus the traction force increases due to gravity (Fig. 4). Insufficient submucosal exposure at an early stage can be complemented by the submucosal injection of longlasting materials, such as glycerol or hyaluronic acid4 and the use of a transparent hood.

The traction force by gravity can be strengthened by applying a small weight.5 This sinker system consists of a 1-g weight, a clip, and a connecting nylon thread. By attaching the clip to the mucosal edge after a circumferential incision, the traction force due to weight allows a better submucosal exposure.

Various other adjunctive methods have been developed to control and strengthen the traction force. A thread and a clip can also be used for traction. The clip is attached to the tip of the flap and the end of the thread is pulled though a thin tube by an assistant during the colorectal ESD. Pushing the endoscope and pulling the thread can together lift the flap.6 Various methods using clips and a thread has also been attempted in esophageal or gastric ESD.7-12

The traction force can be prepared internally using elastic materials. A rubber band between a clip attached to the tip of the flap and another clip attached to normal mucosa can provide a continuous traction force during colorectal ESD.13 The method can also be applied to gastric lesions,13-15 and a thin spring can replace a rubber band.16,17

The use of an extracorporeal electromagnet was attempted in gastric ESD.18 In this trial, a large extracorporeal electromagnet was used to attract a small magnet that was attached to the mucosal edge for traction.

External forceps can be used for traction in rectal ESD.19 After a pair of bendable forceps is introduced with the help of other grasping forceps, and fixed to the mucosal edge, the bendable forceps are bent or pulled to elevate the lesion. Forceps to elevate the mucosa can be introduced through a channel within a specialized transparent hood.20 Similar methods have also been used for esophageal21 or gastric ESD.22,23

An additional thin endoscope can be introduced for traction during rectal ESD,24 and this method has also been attempted during gastric ESD.25-28

Percutaneous tractions,29,30 using a catheter and a double channel endoscope,31 and development of a new endoscope with two movable instrument channels32 have each been tested for gastric ESD. The various trials attempting to achieve a proper traction force during ESD are listed in Table 1.

GRAVITY VERSUS ADJUNCTIVE METHODS FOR TRACTION

One of the advantages of traction by gravity is that it does not require any additional devices. Moreover, the direction of traction force can be easily controlled by changing the patient's position. As mentioned above, traction force by gravity may not be sufficient at early stages of dissection, in which case the traction force can be complemented by a transparent hood and submucosal injection.

In contrast, traction by adjunctive devices can create a good traction force from the early stages. It may be more useful when submucosal exposure is insufficient because of fibrosis. However, traction by adjunctive devices requires additional materials and time. Specialized, expensive, or even huge devices may be required.18,32 Some methods are more invasive than conventional ESD,29,30 and the endoscope should occasionally be withdrawn and reinserted to provide traction.5-12,19,22 The movement of the primary endoscope may be hindered by the second endoscope to maintain traction.24-27 Moreover, majority of the methods has not been tested in colorectal ESD (Table 1).

The advantages and disadvantages of traction by gravity versus traction by adjunctive devices are listed in Table 2.

CONCLUSIONS

Colorectal ESD remains a technically difficult procedure. The maintenance of tissue tension and good submucosal exposure during dissection is one of the most important factors for an effective and safe dissection. Various traction methods using adjunctive devices have been developed and may be useful for difficult cases. However, they have many limitations and require additional effort.

Traction by gravity is not only a simple method, but also a useful method for most colorectal ESD cases and is preferred by majority of experts. Traction using adjunctive devices can thus be reserved for extremely difficult cases or for endoscopists in their learning periods of colorectal ESD.

The author has no financial conflicts of interest.

REFERENCES

1. Taku K, Sano Y, Fu KI, et al. Iatrogenic perforation associated with therapeutic colonoscopy: a multicenter study in Japan. J Gastroenterol Hepatol 2007;22:1409–1414.Article PubMed
2. Kim YJ, Kim ES, Cho KB, et al. Comparison of clinical outcomes among different endoscopic resection methods for treating colorectal neoplasia. Dig Dis Sci 2013;58:1727–1736.Article PubMed
3. Oyama T. Counter traction makes endoscopic submucosal dissection easier. Clin Endosc 2012;45:375–378.Article PubMed PMC
4. Fujishiro M, Yahagi N, Nakamura M, et al. Successful outcomes of a novel endoscopic treatment for GI tumors: endoscopic submucosal dissection with a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar. Gastrointest Endosc 2006;63:243–249.Article PubMed
5. Saito Y, Emura F, Matsuda T, et al. A new sinker-assisted endoscopic submucosal dissection for colorectal cancer. Gastrointest Endosc 2005;62:297–301.Article PubMed
6. Okamoto K, Muguruma N, Kitamura S, Kimura T, Takayama T. Endoscopic submucosal dissection for large colorectal tumors using a crosscounter technique and a novel large-diameter balloon overtube. Dig Endosc 2012;24(Suppl 1):96–99.Article PubMed
7. Oyama T, Y K, Shimaya S, et al. Endoscopic submucosal resection using a hook knife (hooking EMR). Stomach Intest 2002;37:1155–1161.
8. Chen PJ, Chu HC, Chang WK, Hsieh TY, Chao YC. Endoscopic submucosal dissection with internal traction for early gastric cancer (with video). Gastrointest Endosc 2008;67:128–132.Article PubMed
9. Ota M, Nakamura T, Hayashi K, et al. Usefulness of clip traction in the early phase of esophageal endoscopic submucosal dissection. Dig Endosc 2012;24:315–318.Article PubMed
10. Jeon WJ, You IY, Chae HB, Park SM, Youn SJ. A new technique for gastric endoscopic submucosal dissection: peroral traction-assisted endoscopic submucosal dissection. Gastrointest Endosc 2009;69:29–33.Article PubMed
11. Li CH, Chen PJ, Chu HC, et al. Endoscopic submucosal dissection with the pulley method for early-stage gastric cancer (with video). Gastrointest Endosc 2011;73:163–167.Article PubMed
12. Okamoto K, Okamura S, Muguruma N, et al. Endoscopic submucosal dissection for early gastric cancer using a cross-counter technique. Surg Endosc 2012;26:3676–3681.Article PubMed
13. Lee BI, Kim BW, Choi H, et al. Traction with using a rubber band and clips for effective endoscopic submucosal dissection. Korean J Gastrointest Endosc 2008;36:341–348.
14. Parra-Blanco A, Nicolas D, Arnau MR, Gimeno-Garcia AZ, Rodrigo L, Quintero E. Gastric endoscopic submucosal dissection assisted by a new traction method: the clip-band technique. A feasibility study in a porcine model (with video). Gastrointest Endosc 2011;74:1137–1141.Article PubMed
15. Matsumoto K, Nagahara A, Ueyama H, et al. Development and clinical usability of a new traction device "medical ring" for endoscopic submucosal dissection of early gastric cancer. Surg Endosc Epub 2013 Mar 23. DOI: http://dx.doi.org/10.1007/s00464-013-2887-6Article PubMed PMC
16. Sakamoto N, Osada T, Shibuya T, et al. Endoscopic submucosal dissection of large colorectal tumors by using a novel spring-action S-O clip for traction (with video). Gastrointest Endosc 2009;69:1370–1374.Article PubMed
17. Sakamoto N, Osada T, Shibuya T, et al. The facilitation of a new traction device (S-O clip) assisting endoscopic submucosal dissection for superficial colorectal neoplasms. Endoscopy 2008;40(Suppl 2):E94–E95.Article PubMed PDF
18. Gotoda T, Oda I, Tamakawa K, Ueda H, Kobayashi T, Kakizoe T. Prospective clinical trial of magnetic-anchor-guided endoscopic submucosal dissection for large early gastric cancer (with videos). Gastrointest Endosc 2009;69:10–15.Article PubMed PMC
19. Imaeda H, Hosoe N, Ida Y, et al. Novel technique of endoscopic submucosal dissection by using external forceps for early rectal cancer (with videos). Gastrointest Endosc 2012;75:1253–1257.Article PubMed
20. Motohashi O. Two-point fixed endoscopic submucosal dissection in rectal tumor (with video). Gastrointest Endosc 2011;74:1132–1136.Article PubMed
21. Motohashi O, Nishimura K, Nakayama N, Takagi S, Yanagida N. Endoscopic submucosal dissection (two-point fixed ESD) for early esophageal cancer. Dig Endosc 2009;21:176–179.Article PubMed
22. Imaeda H, Hosoe N, Ida Y, et al. Novel technique of endoscopic submucosal dissection using an external grasping forceps for superficial gastric neoplasia. Dig Endosc 2009;21:122–127.Article PubMed
23. Teoh AY, Chiu PW, Hon SF, Mak TW, Ng EK, Lau JY. Ex vivo comparative study using the Endolifter® as a traction device for enhancing submucosal visualization during endoscopic submucosal dissection. Surg Endosc 2013;27:1422–1427.Article PubMed
24. Uraoka T, Ishikawa S, Kato J, et al. Advantages of using thin endoscopeassisted endoscopic submucosal dissection technique for large colorectal tumors. Dig Endosc 2010;22:186–191.Article PubMed
25. Uraoka T, Kato J, Ishikawa S, et al. Thin endoscope-assisted endoscopic submucosal dissection for large colorectal tumors (with videos). Gastrointest Endosc 2007;66:836–839.Article PubMed
26. Higuchi K, Tanabe S, Azuma M, et al. Double-endoscope endoscopic submucosal dissection for the treatment of early gastric cancer accompanied by an ulcer scar (with video). Gastrointest Endosc 2013;78:266–273.Article PubMed
27. Ahn JY, Choi KD, Lee JH, et al. Is transnasal endoscope-assisted endoscopic submucosal dissection for gastric neoplasm useful in training beginners? A prospective randomized trial. Surg Endosc 2013;27:1158–1165.Article PubMed
28. Ahn JY, Choi KD, Choi JY, et al. Transnasal endoscope-assisted endoscopic submucosal dissection for gastric adenoma and early gastric cancer in the pyloric area: a case series. Endoscopy 2011;43:233–235.Article PubMed PDF
29. Kondo H, Gotoda T, Ono H, et al. Percutaneous traction-assisted EMR by using an insulation-tipped electrosurgical knife for early stage gastric cancer. Gastrointest Endosc 2004;59:284–288.Article PubMed
30. von Delius S, Karagianni A, von Weyhern CH, et al. Percutaneously assisted endoscopic surgery using a new PEG-minitrocar for advanced endoscopic submucosal dissection (with videos). Gastrointest Endosc 2008;68:365–369.Article PubMed
31. Hijikata Y, Ogasawara N, Sasaki M, et al. Endoscopic submucosal dissection with sheath-assisted counter traction for early gastric cancers. Dig Endosc 2010;22:124–128.Article PubMed
32. Yonezawa J, Kaise M, Sumiyama K, Goda K, Arakawa H, Tajiri H. A novel double-channel therapeutic endoscope ("R-scope") facilitates endoscopic submucosal dissection of superficial gastric neoplasms. Endoscopy 2006;38:1011–1015.Article PubMed

Fig. 1

Association between tissue tension and contact area. (A) Before applying tension. (B) After applying tension. Decreased contact area from increased tissue tension makes for an effective dissection.

Fig. 2

Improved submucosal exposure by traction. (A) Before traction. (B) After traction.

Fig. 3

Role of the distal transparent hood. (A) Insufficient submucosal exposure can be improved (B) by gently pushing the hood into the submucosal layer.

Fig. 4

The traction force by gravity during dissection. (A) Early stage of dissection. (B) After the dissection has progressed.

Table 1

Trials to Create the Traction Force during Endoscopic Submucosal Dissections

ESD, endoscopic submucosal dissection; EMR, endoscopic mucosal resection; PEG, percutaneous endoscopic gastrostomy.

Table 2

Traction by Gravity versus Traction by Adjunctive Devices for Colorectal Endoscopic Submucosal Dissection

Figure & Data

REFERENCES

Citations

Citations to this article as recorded by

Conventional Versus Traction Endoscopic Submucosal Dissection for Colorectal Tumors
Sahib Singh, Babu P. Mohan, Saurabh Chandan, Neil Sharma, Rakesh Vinayek, Sudhir Dutta, Sergey V. Kantsevoy, Michelle Le, Douglas G. Adler
Journal of Clinical Gastroenterology.2024; 58(10): 1016. CrossRef
Water pressure method for endoscopic submucosal dissection of a rectal tumor on the gravitational side close to the dentate line
Tao Dong, Hanying Wang, Lin Jing, Xuan Zhou, Yaohui Wang, Jun Xiao
Endoscopy International Open.2024; 12(04): E532. CrossRef
Transanal Minimally Invasive Surgery Versus Endoscopic Submucosal Dissection for Rectal Lesions: A Community Hospital Experience
Jau-Jie You, Ming-Yin Shen, William Tzu-Liang Chen, Jiun-Wei Fan, Yen-Chen Shao, Chun-Lung Feng, Chu-Cheng Chang, Yu-Hao Su, Abe Fingerhut
Journal of Laparoendoscopic & Advanced Surgical Techniques.2024; 34(10): 910. CrossRef
Experimental study of magnetic hydrogel assisted magnetic anchorguided endoscopic submucosal dissection in colonic tumors
Lin Cui, Xueyan Zhang, Yingying Wen, Cuihua Li, Jianyun Zhang, XiWei Cui, Hao Sun, Liu Chang
Technology and Health Care.2024; 32(6): 4505. CrossRef
A new traction device (S-O clip) facilitating the endoscopic submucosal dissection of tumors in the ileocecal valve region
Shangrui Yu, Pengfei Wang, Yanhu Feng
Zeitschrift für Gastroenterologie.2023; 61(04): 394. CrossRef
Magnetic anchor technique assisted endoscopic submucosal dissection for early esophageal cancer
Min Pan, Miao-Miao Zhang, Shu-Qin Xu, Yi Lyu, Xiao-Peng Yan
World Journal of Gastrointestinal Endoscopy.2023; 15(10): 584. CrossRef
ESD with elastic ring traction is more effective and safer than conventional ESD in large proximal colon neoplastic lesions: a retrospective cohort study (with video)
Sikong Yinhe, Jiao Yang, Zhang Aijun, Li Ruyuan
Surgical Endoscopy.2023; 37(12): 9658. CrossRef
Training program using a traction device improves trainees’ learning curve of colorectal endoscopic submucosal dissection
Yuki Mitsuyoshi, Daisuke Ide, Tomohiko Richard Ohya, Mitsuaki Ishihoka, Chihiro Yasue, Akiko Chino, Masahiro Igarashi, Akio Nakashima, Shoichi Saito, Junko Fujisaki, Masayuki Saruta
Surgical Endoscopy.2022; 36(6): 4462. CrossRef
A novel flexible auxiliary single-arm transluminal endoscopic robot facilitates endoscopic submucosal dissection of gastric lesions (with video)
Xiao-Xiao Yang, Shi-Chen Fu, Rui Ji, Li-Xiang Li, Yan-Qing Li, Xiu-Li Zuo
Surgical Endoscopy.2022; 36(7): 5510. CrossRef
Comparison Between Preincision Traction and On-Demand Traction in Assisting Colorectal Endoscopic Submucosal Dissection
Jun Li, Yunlei Wei, Di Zhang, Xiaojia Hou, Ming Shen, Kan Chen, Ruijin Wu, Kangsheng Peng, Feng Liu
Clinical and Translational Gastroenterology.2022; 13(12): e00539. CrossRef
Endoscopic resection of large (≥ 4 cm) upper gastrointestinal subepithelial tumors originating from the muscularis propria layer: a single-center study of 101 cases (with video)
Yu Zhang, Jin-Bang Peng, Xin-Li Mao, Hai-Hong Zheng, Shen-Kang Zhou, Lin-Hong Zhu, Li-Ping Ye
Surgical Endoscopy.2021; 35(3): 1442. CrossRef
Effectiveness of S-O Clip-Assisted Colorectal Endoscopic Submucosal Dissection
Haruka Fujinami, Akira Teramoto, Saeko Takahashi, Takayuki Ando, Shinya Kajiura, Ichiro Yasuda
Journal of Clinical Medicine.2021; 11(1): 141. CrossRef
Review on colorectal endoscopic submucosal dissection focusing on the technical aspect
Tak Lit Derek Fung, Chi Woo Samuel Chow, Pak Tat Chan, Kam Hung Kwok
Surgical Endoscopy.2020; 34(9): 3766. CrossRef
Novel approach to endoscopic submucosal dissection of a large gastroesophageal junction mass by use of the mucosal bridge technique
Salmaan Jawaid, Dennis Yang, Peter V. Draganov
VideoGIE.2019; 4(6): 249. CrossRef
Magnetic bead-assisted endoscopic submucosal dissection: a gravity-based traction method for treating large superficial colorectal tumors
Liansong Ye, Xianglei Yuan, Maoyin Pang, Johannes Bethge, Mark Ellrichmann, Jiang Du, Xianhui Zeng, Chengwei Tang, Stefan Schreiber, Bing Hu
Surgical Endoscopy.2019; 33(6): 2034. CrossRef
Advanced Endoscopic Treatment for Early Colorectal Cancers - Traction Assisted Endoscopic Submucosal Dissection for Colorectal Tumors -
NAOTO SAKAMOTO, TARO OSADA, AKIHITO NAGAHARA
Juntendo Medical Journal.2019; 65(5): 426. CrossRef
Efficacy of traction‐assisted colorectal endoscopic submucosal dissection using a clip‐and‐thread technique: A prospective randomized study
Yasushi Yamasaki, Yoji Takeuchi, Noriya Uedo, Takashi Kanesaka, Minoru Kato, Kenta Hamada, Yusuke Tonai, Noriko Matsuura, Tomofumi Akasaka, Noboru Hanaoka, Koji Higashino, Ryu Ishihara, Hiroyuki Okada, Hiroyasu Iishi
Digestive Endoscopy.2018; 30(4): 467. CrossRef
Magnetic anchor guidance for endoscopic submucosal dissection and other endoscopic procedures
Mohamed Mortagy, Neal Mehta, Mansour A Parsi, Seiichiro Abe, Tyler Stevens, John J Vargo, Yutaka Saito, Amit Bhatt
World Journal of Gastroenterology.2017; 23(16): 2883. CrossRef
Clinical outcomes of endoscopic submucosal dissection for large colorectal neoplasms: a comparison of protruding and laterally spreading tumors
Jung Ho Bae, Dong-Hoon Yang, Jae Yeon Lee, Jae Seung Soh, Seohyun Lee, Ho-Su Lee, Hyo Jeong Lee, Sang Hyoung Park, Kyung-Jo Kim, Byong Duk Ye, Seung-Jae Myung, Suk-Kyun Yang, Jin-Ho Kim, Jeong-Sik Byeon
Surgical Endoscopy.2016; 30(4): 1619. CrossRef
A Flexible Surgical Robotic System for Removal of Early-Stage Gastrointestinal Cancers by Endoscopic Submucosal Dissection
Ka Chun Lau, Esther Yun Yee Leung, Philip Wai Yan Chiu, Yeung Yam, James Yun Wong Lau, Carmen Chung Yan Poon
IEEE Transactions on Industrial Informatics.2016; 12(6): 2365. CrossRef
Advanced endoscopic submucosal dissection with traction
Hiroyuki Imaeda
World Journal of Gastrointestinal Endoscopy.2014; 6(7): 286. CrossRef
Endoscopic Submucosal Dissection (ESD) in Colorectal Tumors
Franz Ludwig Dumoulin, Bernd Sido, Reinhard Bollmann, Malte Sauer
Visceral Medicine.2014; 30(1): 39. CrossRef

PubReader
ePub Link

Cite

CITE: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format:

RIS — For EndNote, ProCite, RefWorks, and most other reference management software
BibTeX — For JabRef, BibDesk, and other BibTeX-specific software

Include:

Citation for the content below
Citation and abstract for the content below

Debates on Colorectal Endoscopic Submucosal Dissection - Traction for Effective Dissection: Gravity Is Enough

Clin Endosc. 2013;46(5):467-471. Published online September 30, 2013

DOI: https://doi.org/10.5946/ce.2013.46.5.467

XML Download

Figure

Debates on Colorectal Endoscopic Submucosal Dissection - Traction for Effective Dissection: Gravity Is Enough

Fig. 1 Association between tissue tension and contact area. (A) Before applying tension. (B) After applying tension. Decreased contact area from increased tissue tension makes for an effective dissection.

Fig. 2 Improved submucosal exposure by traction. (A) Before traction. (B) After traction.

Fig. 3 Role of the distal transparent hood. (A) Insufficient submucosal exposure can be improved (B) by gently pushing the hood into the submucosal layer.

Fig. 4 The traction force by gravity during dissection. (A) Early stage of dissection. (B) After the dissection has progressed.

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Debates on Colorectal Endoscopic Submucosal Dissection - Traction for Effective Dissection: Gravity Is Enough

Table 1

Trials to Create the Traction Force during Endoscopic Submucosal Dissections

ESD, endoscopic submucosal dissection; EMR, endoscopic mucosal resection; PEG, percutaneous endoscopic gastrostomy.

Table 2

Traction by Gravity versus Traction by Adjunctive Devices for Colorectal Endoscopic Submucosal Dissection

Table 1 Trials to Create the Traction Force during Endoscopic Submucosal Dissections

ESD, endoscopic submucosal dissection; EMR, endoscopic mucosal resection; PEG, percutaneous endoscopic gastrostomy.

Table 2 Traction by Gravity versus Traction by Adjunctive Devices for Colorectal Endoscopic Submucosal Dissection