Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video)

Background: The lack of countertraction in endoscopic submucosal dissection (ESD) results in increased technical demand and procedure time. Although the suture-pulley method for countertraction has been reported, its effectiveness compared with the traditional ESD technique remains unclear. Objective: To objectively analyze efficacy of countertraction using the suture-pulley method for ESD. Design: Prospective ex vivo animal study. Setting: Animal laboratory. Interventions: Twenty simulated gastric lesions were created in porcine stomachs by using a standard circular template 30 mm in diameter. In the control arm (n = 10) ESD was performed by using the standard technique. In the suture-pulley arm (N = 10) a circumferential incision was made and an endoscopic suturing device was used to place the suture pulley. Main Outcome Measurements: The primary outcome of this study was total procedure time. Results: The median total procedure time with the suture-pulley method was significantly shorter than the traditional ESD technique (median,25% to 75%, interquartile range [IQR]:531 seconds [474.3-549.3 seconds] vs 845 seconds [656.3-1547.5 seconds], P < .001). The median time (IQR) for suture-pulley placement was 160.5 seconds (150.0-168.8 seconds). Although there was a significantly longer procedure time for proximal versus middle/lower stomach lesions with traditional ESD (median 1601 seconds; IQR,1547.5-1708.8 seconds vs median, 663 seconds;IQR, 627.5-681.8 seconds P = .01), there was no significant difference in procedure time for lesions of various locations when using the suture-pulley method. Compared with traditional ESD, the suture-pulley method was less demanding in all categories evaluated by the NASA Task Load Index. Limitations: Ex vivo study. Conclusions: The suture-pulley method facilitates direct visualization of the submucosal layer during ESD and significantly reduces procedure time and technical difficulty. In addition, the benefit of the suture-pulley method was seen for both simple and more complicated ESDs.