Endoscopic submucosal dissection with the pulley method for early-stage gastric cancer

Background: Using EMR techniques, physicians frequently remove tumors >15 mm by piecemeal resection, which is associated with an increased rate of disease recurrence and difficulty in histologically evaluating the specimen. Endoscopic submucosal dissection (ESD) of early-stage gastric cancer improves the rate of successful en bloc resection, but it is associated with more complications, such as bleeding and perforation, than conventional EMR. Objective: To describe a simple technique that uses the pulley method to facilitate ESD procedures in the excision of large early-stage gastric cancers. Design: Case series. Setting: Tertiary medical center in Taiwan. Patients and Methods: Eleven patients with early-stage gastric cancers or adenomas >20 mm underwent ESD. Interventions: The pulley method with standard clips and dental floss was used to provide traction to improve visualization of the dissection plane during ESD. Main Outcome Measurement: Proportion with complete en bloc resection. Results: En bloc resection of the lesion was achieved in 11 patients. No perforation or emergent surgery was noted. Limitations: One endoscopist performed all procedures, and only 11 patients were studied in an uncontrolled manner. Conclusions: The pulley method seems to facilitate en bloc ESD of early-stage gastric cancers >20 mm.