Dental Floss Traction Assists in Treating Gastrointestinal Mucosal Tumors by Endoscopy

Giant gastric leiomyoma excision using endoscopic submucosal dissection with dental floss clip traction technique: a case report

For gastric leiomyomas measuring ≥5 cm, endoscopic resection is necessary. The larger size of these tumors significantly impairs the resection field of view, increasing the risk of intraoperative bleeding and perforation and potentially leading to incomplete tumor removal. The combination of dental floss and tissue clip traction techniques is commonly used for resecting mucosal lesions but is rarely reported for submucosal tumors. We recently completed a case of endoscopic resection of a giant gastric leiomyoma in the body of the stomach, approximately 7 cm in length, using endoscopic submucosal dissection with dental floss clip traction. The dissection was carefully controlled within the muscularis propria layer, avoiding damage to the serosa. No bleeding or perforation occurred. A special technique was employed to avoid damage to the muscle layer. By combining this technique with tissue forceps, better traction stability may have been achieved. During the traction process, slight tension was consistently maintained between the swelling and the muscle layer, preventing perforation due to traction. The resection field remained clear throughout the procedure, which lasted 50 minutes in total. The final outcome was satisfactory. This method may be worthy of clinical application.

New traction method (traction ring) for colorectal endoscopic submucosal dissection

OBJECTIVES

Colorectal endoscopic submucosal dissection (ESD) is challenging because of the difficulty in adequately visualizing the submucosal layer. Many traction methods have been developed to facilitate submucosal dissection; however, they are not widely applied. Therefore, we designed a new traction device, a traction ring, and conducted this pilot study to evaluate its feasibility and safety for colorectal ESD.

METHODS

Twenty patients with colorectal lesions who underwent traction ring-assisted ESD were retrospectively included. The main outcomes included en bloc resection rate, R0 resection rate, procedure time, resection time, and intraoperative and postoperative complications.

RESULTS

The median procedure time was 74.5 min (range 35-269 min). The median resection time was 55 min (range 25-209 min). Application of the traction system accounted for only 2.7% of the entire procedure time. The en bloc resection rate was 95.0% (19/20), whereas the R0 resection rate was 90.0% (18/20). All traction rings were successfully set and retrieved. Significant intraoperative bleeding was not observed. One patient experienced perforation after treatment, but no further intervention was required. No delayed complications were observed within 1 month post-ESD.

CONCLUSION

Traction ring is an effective and safe method for colorectal ESD and can be used at any location in the colorectum.

Methods that Assist Traction during Endoscopic Submucosal Dissection of Superficial Gastrointestinal Cancers: A Systematic Literature Review

Endoscopic submucosal dissection (ESD) is a well-established method for the treatment of early-stage gastrointestinal neoplasms. Adequate submucosal exposure is one of the most significant factors related to an effective and safe dissection. The aim of this systematic review was to evaluate the effcacy and safety of various methods that assist traction during ESD of precancerous and earlystage neoplastic lesions of the gastrointestinal tract. We performed an electronic search of the MEDLINE and the Cochrane Controlled Trials Register databases for relevant studies published up to May 2019. Trials exclusively recruiting patients undergoing ESD for superficial gastrointestinal cancer were considered eligible for inclusion. Thirty-three articles including 3,134 patients met the inclusion criteria. The studies evaluated different approaches for widening the endoscopic view, including magnetic anchor-guided ESD (3 studies), use of a second endoscope (5 studies), clip-involving technique (21 studies), and miscellaneous methods (4 studies). Among them, only 6 were randomized controlled trials evaluating different approaches. Overall, the implementation of methods that assist traction during ESD significantly improved the operating time and R0 resection rate and decreased the rate of complications (bleeding and perforation). Interventions that assist traction seem effcacious in improving tissue traction, thus facilitating ESD performance.

The efficacy of dental floss and a hemoclip as a traction method for the endoscopic full-thickness resection of submucosal tumors in the gastric fundus

BACKGROUND

Endoscopic full-thickness resection (EFTR) provides a significant advancement to the treatment of gastrointestinal submucosal tumors (SMTs). However, technological challenges, particularly in the gastric fundus, hinder its wider application. Here, we investigated the efficacy of a simple traction method that used dental floss and a hemoclip (DFC) to facilitate EFTR.

METHODS

Between July 2014 and December 2016, we retrospectively reviewed data from all patients with SMTs in the gastric fundus originating from the muscularis propria layer that were treated by EFTR at Zhongshan Hospital of Fudan University. Baseline characteristics and clinical outcomes, including procedure time and complications rate, were compared between groups of patients receiving DFC-EFTR and conventional EFTR.

RESULTS

A total of 192 patients were included in our analysis (64 in the DFC-EFTR group and 128 in the conventional EFTR group). Baseline characteristics for the two groups were similar. The mean time for DFC-EFTR and conventional EFTR was 44.2 ± 24.4 and 54.2 ± 33.2 min, respectively (P = 0.034). Although no serious adverse events presented in any of our cases, post-EFTR electrocoagulation syndrome (PEECS), as a minor complication, was less frequent in the DFC-EFTR group (3.1% vs. 12.5%, P = 0.036). Univariate and multivariate analysis identified that DFC, when used in EFTR, played a significant role in reducing procedure time and the rate of PEECS. The mean procedure time was significantly shorter in the DFC-EFTR group for lesions over 1.0 cm (P = 0.005), when the lesions were located in the greater curvature of the gastric fundus (P = 0.025) or when the lesions presented with intraluminal growth (P = 0.032). Moreover, when EFTR was carried out by experts, the mean procedure time was 20.4% shorter in the DFC-EFTR group (P = 0.038).

CONCLUSIONS

This study indicated that DFC-EFTR for SMTs in the gastric fundus resulted in a shorter procedure time and reduced the risk of PEECS, a minor complication.

Endoscopic Resection of Gastric Submucosal Masses by a Dental Floss Traction Method

BACKGROUND AND AIMS

ESE (endoscopic submucosal excavation) is widely used for the treatment of digestive diseases. The dental floss traction (DFT) method has been successfully used to facilitate ESE to resect mucosal lesions such as early gastric cancer. DFT has not been used in ESE to remove submucosal masses. This study aimed to examine the efficacy of DFT-assisted ESE (DFT- ESE) for the removal of submucous masses.

METHODS

From March 2017 to May 2017, a total of 12 patients with gastric submucosal masses at the First Affiliated Hospital of Nanchang University, Jiangxi, China, were enrolled. The tumor characteristics, en bloc resection rates, complications, and outcomes on follow-up were evaluated for all patients.

RESULTS

The 12 submucosal tumors were completely removed by DFT- ESE. Nine were gastrointestinal stromal tumors. Two were Schwannoma, located in the greater curvature of the gastric corpus. One was gastric ectopic pancreas. All the resected tumors were removed completely with intact tumor capsules. There was no more bleeding or perforation after the endoscopic closure of the perforation or the wound after the DFT-ESE, and no recurrences were identified at the time of follow-up.

CONCLUSIONS

The DFT method efficiently and safely facilitated the ESE procedure during the resection of gastric submucosal tumors. This study was registered with Chinese Clinical Trial Registry under Registration number ChiCTR-OOC-15005833).

Clinical Values of Dental Floss Traction Assistance in Endoscopic Full-Thickness Resection for Submucosal Tumors Originating from the Muscularis Propria Layer in the Gastric Fundus

BACKGROUND

Endoscopic full-thickness resection (EFTR) derived from endoscopic submucosal dissection has gradually been accepted and even promoted for the treatment of submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. However, there are some difficulties when EFTR is used to treat MP lesions in the gastric fundus. This study intends to explore whether EFTR can be made simpler, safer, and more effective with the traction assistance of dental floss.

METHODS

The clinical data of patients (trial group) with lesions in the MP layer in the gastric fundus undergoing EFTR with traction assistance of dental floss at Zhongshan Hospital, in 2016, were reviewed retrospectively. The control group was matched with the trial group according to tumor size. The differences in tumor resection time, patient hospitalization time, and complication rate were evaluated.

RESULTS

There was no significant difference in the average age of the two groups, each of which comprised 24 cases (58.7 ± 11.8 years versus 56.6 ± 7.9 years, t = 0.663, P = .511). However, there was a statistically significant difference in the operative time between the two groups (10.8 ± 2.8 minutes versus 19.0 ± 4.7 minutes, t = 7.298, P < .05). There was no statistically significant difference in the length of the postoperative hospital stay (3.2 ± 0.5 days versus 3.2 ± 0.5 days, t = 0.291, P = .772). In the trial group, there were 19 cases of gastrointestinal stromal tumors (group 1) and 5 cases of leiomyoma. The control group had similar results. Neither group experienced postoperative delayed bleeding, perforation, or other complications.

CONCLUSIONS

When EFTR is used to treat SMTs originating from the MP in the gastric fundus, dental floss traction assistance can relieve the tumor boundary to simplify the surgical procedure and save the operation time.