Nagata Mitsuru
Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Fujisawa 251-0041, Kanagawa, Japan.
World J Gastrointest Endosc. 2023 Apr 16;15(4):259-264. doi: 10.4253/wjge.v15.i4.259.
Different traction devices that can provide a visual field and attain appropriate tension at the dissection plane during endoscopic submucosal dissection (ESD) have been developed. Clip-with-line (CWL) is a classic traction device that can offer per-oral traction toward the direction where the line is drawn. A multicenter randomized controlled trial (CONNECT-E trial) comparing the conventional ESD and CWL-assisted ESD (CWL-ESD) for large esophageal tumors was conducted in Japan. This study showed that CWL-ESD was associated with a shorter procedure time (defined as the time from initiating submucosal injection to completing tumor removal) without increasing the risk of adverse events. Multivariate analysis revealed that whole-circumferential lesion and abdominal esophageal lesion were independent risk factors for technical difficulties, which were defined as a procedure time of > 120 min, perforation, piecemeal resection, inadvertent incision (any accidental incision caused by the electrosurgical knife within the marked area), or handover to another operator. Therefore, techniques other than CWL should be considered for these lesions. Several studies have shown the usefulness of endoscopic submucosal tunnel dissection (ESTD) for such lesions. A randomized controlled trial conducted at five Chinese institutions showed that compared with the conventional ESD, ESTD had a significantly reduced median procedure time for lesions covering ≥ 1/2 of the esophageal circumference. In addition, a propensity score matching analysis conducted at a single Chinese institution showed that compared with the conventional ESD, ESTD had a shorter mean resection time for lesions at the esophagogastric junction. With the appropriate use of CWL-ESD and ESTD, esophageal ESD can be performed more efficiently and safely. Moreover, the combination of these two methods may be effective.
已经开发出了不同的牵引装置，这些装置能够在内镜黏膜下剥离术（ESD）期间提供视野并在剥离平面达到适当的张力。带线夹（CWL）是一种经典的牵引装置，它可以朝着拉线的方向提供经口牵引。在日本进行了一项多中心随机对照试验（CONNECT-E试验），比较传统ESD和CWL辅助ESD（CWL-ESD）治疗大型食管肿瘤的效果。这项研究表明，CWL-ESD与较短的手术时间（定义为从开始黏膜下注射到完成肿瘤切除的时间）相关，且不增加不良事件的风险。多变量分析显示，全周病变和腹段食管病变是技术困难的独立危险因素，技术困难定义为手术时间>120分钟、穿孔、分片切除、意外切开（电刀在标记区域内造成的任何意外切口）或需要交接给另一位操作者。因此，对于这些病变应考虑使用CWL以外的技术。几项研究表明内镜黏膜下隧道剥离术（ESTD）对这类病变有用。在中国五家机构进行的一项随机对照试验表明，与传统ESD相比，ESTD对于覆盖食管周长≥1/2的病变，其手术时间中位数显著缩短。此外，在中国一家机构进行倾向得分匹配分析显示，与传统ESD相比，ESTD对于食管胃交界部病变的平均切除时间更短。合理使用CWL-ESD和ESTD，可以更高效、安全地进行食管ESD。此外，这两种方法联合使用可能有效。
