Endoscopic submucosal dissection with internal traction for early gastric cancer (with video)

Background: EMR techniques have high success rates for treating small lesions of the upper-GI tract; however, tumors larger than 15 mm are frequently removed by piecemeal resection, which is associated with an increased rate of disease recurrence and difficulty in histologically evaluating the specimen. Objective: To describe a simple technique of using internal traction to facilitate endoscopic submucosal dissection (ESD) procedures in the excision of large, early gastric cancers. Design: Case series. Setting: A tertiary medical center in Taiwan. Patients and Methods: Eight patients with early gastric cancers larger than 20 mm under-went ESD. Interventions: A standard hemoclip modified with surgical suture was used to provide traction to improve visualization of the dissection plane during ESD. Main Outcome Measurements: Proportion with complete en bloc resection. Results: En bloc resection of the lesion was achieved in 8 patients. One patient underwent additional surgery because an adequate safe margin was not obtained by ESD. Limitations: One endoscopist performed all procedures, and only 8 patients were studied in an uncontrolled manner. Conclusions: The internal traction method appears to facilitate en bloc ESD of early gastric cancers larger than 20 mm.