A new traction device for facilitating endoscopic submucosal dissection (ESD) for early gastric cancer: the “medical ring”

Abstract

The main factor that make endoscopic submucosal dissection (ESD) a difficult procedure is the risk associated with cutting along the line of the submucosal layer blind: the cut edge of the lesion curls inwards and obscures the endoscopist's view. Several methods have been devised to facilitate visibility [1] [2] [3], however, no devices have yet been developed that meet the demands of convenience, cost, sterility, and safety. Furthermore, most devices lift up only one part of a lesion, which means that resection can only be carried out from one side; their use is also limited depending on the tumor's location [4]. We have designed a new traction device which employs a bilateral approach ("medical ring"; Okamoto Co. Ltd, Tokyo, Japan) ([Fig. 1]). The device comprises an inert elastic band, which is made of the same material as used in several medical devices including the endoscopic variceal ligation O-ring. The device is mounted by connecting it with 3-0 silk to a hemoclip (HX 610-090; Olympus Optical Co. Ltd, Tokyo, Japan) ([Fig. 2]). It is stored in a sheath, which opens and elongates when wet. The device can be passed through the instrument channel of a standard endoscope. The ESD procedure using the device is illustrated in [Fig. 3] and [Video 1]. The lesion is pulled up, opening the resection margin, and dissection can then be carried out quickly as the tension in the elastic material helps maintain visibility of the margin throughout the procedure ([Fig. 4]). In the illustrated case, the size of the resected lesion was 40 mm and the dissection time was 12 min. The device is recoverable with the resected lesion, and can be easily removed with forceps. With this medical ring, the ESD method can be safely and easily carried out while maintaining direct vision of the resected site. This method is also potentially applicable in the resection of esophageal and colorectal lesions.