Traction with dental floss and endoscopic clip improves trainee success in performing gastric endoscopic submucosal dissection (ESD): a live porcine study (with video)

Endoscopic submucosal dissection (ESD) is a prolonged procedure with serious adverse events. The clip with line traction method was reported to improve ESD. However, there was no comparison with conventional ESD especially for trainees. We report here on the feasibility and efficacy of traction using dental floss with endoscopic clip to facilitate ESD versus conventional method for ESD trainees. Twenty simulated gastric lesions, paired with location and size, were created in porcine stomachs using a standard template. After a circular incision was made, submucosal dissection (control, n = 10) was performed with standard ESD, while the study (clip, n = 10) was performed with traction using dental floss and endoclip. Primary outcome was speed of submucosal dissection. Secondary outcome included frequency of submucosal injection and adverse event. Compared with controls, median procedure time was significantly shorter in the clip group (5.6 +/- A 1.1 vs. 13.6 +/- A 2.5 min, P = 0.003), with a significantly faster submucosal dissection time (1.8 +/- A 0.3 vs. 0.6 +/- A 0.1 cm(2)/min, P = 0.001) and less frequent submucosal injection (5.7 +/- A 0.6 vs. 8.5 +/- A 1.0 times, P = 0.024). There were no perforations in either group, but less adverse events (bleeding and injury to muscularis propria) in the clip group (1 vs. 7, P = 0.068, alpha = 0.1). Traction provided by dental floss and endoclip improves visualization of the submucosal layer during ESD. It allows a faster and safer gastric ESD especially among trainees in the early learning phase.