Open Access, Peer-reviewed
pISSN 2093-582X
eISSN 2093-5641
    J Gastric Cancer. 2023 Oct;23(4):512-522. English.
    Published online Oct 24, 2023.
    https://doi.org/10.5230/jgc.2023.23.e37
    Copyright © 2023. Korean Gastric Cancer Association
    Original Article

    Indications for Dental Floss Clip Traction During Gastric Endoscopic Submucosal Dissection by Less-Experienced Endoscopists

    Hirosato Tamari,1 Shiro Oka,2 Takahiro Kotachi,2 Hajime Teshima,1 Junichi Mizuno,1 Motomitsu Fukuhara,1 Hidenori Tanaka,2 Akiyoshi Tsuboi,2 Ken Yamashita,2 Ryo Yuge,2 Yuji Urabe,3 Yasuhiko Kitadai,4 Koji Arihiro,5 and Shinji Tanaka1
      • 1Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan.
      • 2Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan.
      • 3Division of Regeneration and Medicine Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan.
      • 4Department of Health and Science, Prefectural University of Hiroshima, Hiroshima, Japan.
      • 5Department of Anatomical Pathology, Hiroshima University Hospital, Hiroshima, Japan.
    • Correspondence to Shiro Oka. Department of Gastroenterology, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan. Email: oka4683@hiroshima-u.ac.jp
    Received August 28, 2022; Revised October 12, 2022; Accepted December 28, 2022.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    Purpose

    Dental floss clip (DFC) traction-assisted endoscopic submucosal dissection (ESD) is widely performed owing to its simplicity. This study aimed to clarify the appropriate indications for the DFC traction method in early gastric cancer when ESD is performed by less-experienced endoscopists.

    Methods and Methods

    We retrospectively analyzed 1,014 consecutive patients who had undergone gastric ESD performed by less-experienced endoscopists between January 2015 and December 2020. Gastric ESD was performed without DFC in all cases before December 2017 [DFC (−) group, 376 cases], and ESD was performed with DFC in all cases after January 2018 [DFC (+) group, 436 cases]. The procedure time and rates of en bloc resection, complete resection, and adverse events of the groups were compared.

    Results

    The procedure time did not differ significantly between the 2 groups. However, when comparing lesions >20 mm, the procedure time in the DFC (+) group was significantly shorter than that in the DFC (−) group (95±46 vs. 75±31, P<0.01). The procedure time for lesions located in the greater curvature of the upper or middle stomach and lesions >20 mm located in the lesser curvature side of the stomach in the DFC (+) group was significantly shorter than that in the DFC (−) group.

    Conclusions

    The indications for DFC during gastric ESD by less-experienced endoscopists include lesions located in the greater curvature of the upper or middle stomach, and lesions >20 mm located in the lesser curvature of the stomach.

    Keywords
    Gastric cancer; Surgical clip; Endoscopic submucosal dissection

    INTRODUCTION

    Endoscopic submucosal dissection (ESD), the standard treatment for early gastric cancer in Japan and other countries, allows a high en bloc resection rate with fewer recurrences [1, 2, 3, 4, 5, 6]. However, ESD requires technical skills [1, 4, 7]. Especially for less-experienced endoscopists, proper training is necessary to master ESD techniques. Endoscopists must learn procedures for resection and hemostasis, and how to cope with problems that may arise [8]. Gaining experience with small and simple lesions in the lower stomach and gradually progressing to more difficult lesions is essential [9, 10]. Therefore, one must perform 30–40 ESDs to acquire the adequate skills to perform gastric ESD [11, 12]. However, even with the advanced skill levels of expert endoscopists, ESD is difficult to perform in some cases. Various traction methods have been developed to overcome these issues [13, 14, 15, 16, 17]. The dental floss clip (DFC) traction method is widely used among the clip-with-line methods because it is inexpensive and straightforward. Moreover, it reportedly reduces the procedure time without increasing complications [13, 18, 19, 20, 21]. However, these reports included ESD cases treated primarily by expert endoscopists. Expert endoscopists have found the DFC traction method to be very effective for ESD of early gastric cancer located in the greater curvature of the upper or middle region of the stomach [21]. However, the types of lesions for which less-experienced endoscopists find DFC useful have not yet been reported. In this study, we investigated the indications of DFC in ESD performed by less-experienced endoscopists for early gastric cancer.

    MATERIALS AND METHODS

    Enrolled patients

    Of the 1,014 consecutive patients (1,242 lesions) who underwent gastric ESD between January 2015 and December 2020 at the Hiroshima University Hospital, 294 (430 lesions) were excluded due to the following reasons: procedures performed by expert endoscopists, multiple simultaneous lesions, and change of operator to an expert endoscopist during ESD. Before December 2017, gastric ESD was performed without DFC in all cases [DFC (−) group], whereas ESD was performed with DFC in all cases after January 2018 [DFC (+) group]. The DFC (−) (350 patients, 376 lesions) and DFC (+) (376 patients, 436 lesions) groups were compared (Fig. 1). Resected lesions were histologically diagnosed as absolute or expanded indications according to the Japanese Gastric Cancer Treatment Guidelines [22, 23].

    Fig. 1
    Flowchart showing the data of patients enrolled in this study. The patients were divided into 2 groups: those who underwent DFC (−) group from January 2015 to December 2017, and those who underwent DFC (+) group from January 2018 to December 2020.
    ESD = endoscopic submucosal dissection; DFC (−) group = endoscopic submucosal dissection without dental floss clip; DFC (+) group = endoscopic submucosal dissection with dental floss clip.

    According to previous reports, less-experienced endoscopists were defined as those who have performed less than 40 gastric ESDs, while expert endoscopists were those who have performed more than 40 gastric ESDs [8, 11, 12, 24]. The location of the lesion was classified by dividing the stomach into 3 equal sections: upper, middle, and lower parts of the stomach. According to the Japanese Classification of Gastric Carcinoma, the stomach surface is further classified into lesser curvature, greater curvature, anterior wall, and posterior wall [25].

    Procedures for gastric ESD

    ESD was performed by less-experienced endoscopists. Intravenous sedation with midazolam and pentazocine was initiated with constant monitoring of cardiorespiratory function during the procedure. A single-channel endoscope (GIF-H260Z, or GIF-Q260J; Olympus, Tokyo, Japan) was used [26, 27, 28, 29]. In each case, a standard tip hood (Olympus) was attached to the tip of the endoscope. Marking dots were placed using a standard needle knife or argon plasma coagulation, approximately 5 mm outside the margin of the cancer lesion. A 50/50 mixture of 0.4% sodium hyaluronate (Muco Up; Boston Scientific, Tokyo, Japan) and 10% glycerin solution with a small amount of indigo carmine was prepared and injected into the submucosa. After an initial incision was made with a needle knife, a circumferential incision was made on the mucosa and the submucosa was dissected using an IT knife 2 (KD-611L; Olympus). Hemostasis was performed using a Coagrasper (FD-410LR; Olympus).

    In the DFC (+) group, after circumferential incision and submucosal trimming, the endoscope was removed and the DFC traction procedure was performed as follows. A hemoclip (HX-610-090; Olympus) was attached to a reusable delivery catheter (HX-110LR; Olympus). The catheter with an attached clip was inserted through the accessory channel of the endoscope. When the catheter was slightly outside the tip of the endoscope, the clip body was exposed to an extent that it could be retracted. Dental floss (reach, waxed type; Johnson & Johnson K.K., Tokyo, Japan) was secured to the base of the clip arm using a surgeon’s knot. After retracting the DFC into the accessory channel, the endoscope was reinserted into the stomach. Subsequently, the DFC was re-exposed and fixed to the lesion’s edge, and peroral traction was applied. The DFC was also attached to the edge of the mucosal flap on the anal side when the endoscope was used in the retroflex position or on the oral side when the endoscope was used in the straight position. During submucosal dissection, 20 mL of saline solution was attached to the end of the dental floss as a weight or the assistant would pull on the dental floss as needed to obtain the appropriate tension (Fig. 2).

    Fig. 2
    Endoscopic view of ESD with DFC. (A, B) After circumferential incision, the DFC is attached to the oral side of the resected mucosa. (C, D) DFC gives an appropriate tension, ensures a good submucosal view, and allows safe submucosal dissection.
    ESD = endoscopic submucosal dissection; DFC = dental floss clip.

    Pathological diagnosis

    All ESD specimens were stretched, fixed in 10% buffered formalin, and sectioned at 2-mm intervals. The histopathological type, tumor size, submucosal invasion depth, and resection margins were evaluated in each slice according to the Japanese Classification of Gastric Carcinoma [22]. En bloc resection was defined as the removal of the entire tumor as a single piece. Complete resection was defined as an en bloc resection without tumor cells on the lateral and vertical margins.

    Evaluation

    The procedure time, en bloc and complete resection rates, and adverse events (delayed bleeding and perforation) of the 2 groups were compared. Additionally, a subgroup analysis of the usefulness of DFC was performed based on the size, location, and position of the lesion, along with the ulcerative findings and macroscopic type. Procedure time was defined as the time from the start of the submucosal injection to the completion of tumor resection. Delayed bleeding was defined as clinical bleeding after ESD that required blood transfusion or endoscopic or surgical intervention [30]. Perforation was diagnosed when mesenteric fat or intra-abdominal space was observed during the procedure or when free air was identified on simple chest and abdominal radiographs after ESD.

    Statistical analysis

    Statistical analyses were performed using JMP version 15.0 software (SAS Institute Inc., Cary, NC, USA). Quantitative data were presented as means ± standard deviation or percentage, and compared using Pearson’s χ2 test or Fisher’s exact test. Continuous variables were analyzed using the Student’s t-test. Statistical significance was set at P<0.05.

    Ethical considerations

    The use of patient data in this study was approved by the Institutional Review Board of the Hiroshima University (No. E-1237-1). This study was carried out in accordance with the Declaration of Helsinki and its amendments.

    RESULTS

    The baseline patient characteristics are presented in Table 1. The treatment outcomes of ESD are shown in Table 2. There were no significant differences between the 2 groups regarding procedure time, en bloc resection, complete resection, specimen size, or complications. The mean number of total ESDs performed by endoscopists was 13.6±6.5 in the DFC (+) group, and 10.4±3.2 in the DFC (−) group. Difference of delayed bleeding and perforation according to the location are shown in Supplementary Tables 1 and 2.

    Table 1
    Baseline characteristics of patients undergoing gastric endoscopic submucosal dissection

    Table 2
    Treatment outcomes of patients undergoing gastric endoscopic submucosal dissection

    The results of the procedure time according to lesion size, location, presence of ulceration, and gross tumor type are shown in Table 3. The mean procedure time in the DFC (+) group was significantly shorter than that in the DFC (−) group for lesions >20 mm (75±31 vs. 95±46, P<0.01) and for lesions located in the greater curvature of the upper or middle stomach (63±20 vs. 91±53, P<0.01). The results of the procedure time for lesions ≤20 mm are shown in Table 4, and those for lesions >20 mm are shown in Table 5. For lesions located in the greater curvature of the upper or middle stomach, the DFC (+) group had a significantly shorter procedure time than that of the DFC (−) group, regardless of the lesion size. The DFC (+) group had a significantly shorter procedure time than that of the DFC (−) group for lesions >20 mm in the lesser curvature of the stomach.

    Table 3
    Average procedure time of gastric endoscopic submucosal dissection

    Table 4
    Average procedure time of gastric endoscopic submucosal dissection (≤20 mm)

    Table 5
    Average procedure time of gastric endoscopic submucosal dissection (>20 mm)

    DISCUSSION

    Our study revealed that DFC during gastric ESD performed by less-experienced endoscopists is useful for treating lesions of any size in the greater curvature of the upper or middle stomach and for lesions >20 mm in the lesser curvature of the stomach. The most prominent advantage of our study design was that we eliminated bias in treatment selection by clearly separating the periods with DFC from those without DFC.

    ESD is technically challenging for less-experienced endoscopists and requires appropriate training. Several studies have been conducted on the learning curve of gastric ESD [8, 9, 10, 11]. Yamamoto et al. [8] reported that before non-experts start ESD, they must first acquire the skills needed to troubleshoot by assisting experienced endoscopists for at least 1 year and acquire expertise in the hemostasis needed for ESD. Furthermore, they recommended that trainees should start with small lesions so that they have the opportunity to learn the entire ESD procedure before gradually moving on to larger lesions. Regarding the location of the lesion, non-experts should start with lesions in the lower stomach, which are less challenging to resect, and gradually move on to lesions in the upper or middle stomach [9, 10]. Choi et al. [11] reported a learning curve for ESD, with the en bloc rate increasing from 45%–85% after gaining experience in 40 cases. Gotoda et al. [12] commented that at least 30 cases are necessary for non-experts to gain early proficiency in ESD. Lesions in the upper, middle, or greater curvature of the stomach; large lesions (>20 mm); and ulceration are factors that prolong the procedure time and increase the technical difficulty, even for endoscopists proficient in ESD techniques [31]. Therefore, traction methods have been developed to overcome these technical challenges. Although various traction methods have been developed [14, 15, 32, 33, 34, 35], DFC is now the most widely used method because it is inexpensive, simple, and can be performed at any hospital [19, 20, 21].

    However, DFC is ineffective for certain gastric lesions. Indications for DFC in gastric ESD must be established because it takes several minutes to attach the DFC. Multicenter randomized trials [21] on gastric ESD with DFC mainly involved expert endoscopists and had a selection bias for lesions to be treated with DFC. For lesions located in the greater curvature of the upper or middle stomach, the mean procedure time in the DFC (+) group of expert endoscopists was significantly shorter. In contrast, the treatment outcomes of less-experienced endoscopists are reported as follows: en bloc resection rate, 93%−100%; perforation rate, 0%−2.6%; and delayed bleeding rate, 1.3%−6% [36, 37]. When ESD with DFC is performed by less-experienced endoscopists, the procedure time tended to be shorter, although the difference was not significant [19, 21].

    In this study, there was no trend of procedure time reduction using DFC; furthermore, we demonstrated a detailed comparison of the procedure time by location and size of the lesion. For lesions <20 mm, the procedure time for the DFC-ESD group was significantly shorter than that associated with lesions located on the greater curvature side of the upper or middle stomach. For lesions >20 mm, the procedure time for the DFC-ESD group was significantly shorter than that associated with lesions located on the lesser and greater curvature of the upper or middle stomach or the lesser curvature of the lower stomach. Less-experienced endoscopists have difficulty obtaining a good view of the submucosal dissection line when performing ESD for lesions on the greater curvature of the upper or middle stomach. We believe that DFC can overcome this problem; moreover, the procedure time differed significantly.

    Regarding complications, although this is mainly the outcome for expert endoscopists, the rates of delayed bleeding and perforation are reported as follows: 3.8%−4.4% and 0.3%−1.9% in the DFC (+) group, respectively, and 4.4%−9.0% and 2.2%−3% in the DFC (−) group, respectively [19, 20, 21]. Our study also did not show significant differences in complications between the 2 groups, indicating that less-experienced endoscopists can safely perform ESD with DFC.

    This study had some limitations. First, this was a retrospective single-center study. However, selection bias was eliminated by dividing the study period according to the use of DFC. Second, although the locations of the lesions treated by less-experienced endoscopists varied, they might have been determined preoperatively to allow easier resection. Third, cases in which the endoscopist changed during ESD were excluded, indicating a bias in case selection.

    In conclusion, the indications of DFC for less-experienced endoscopists during gastric ESD are lesions in the greater curvature of the upper or middle stomach, and lesions >20 mm located on the lesser curvature of the stomach.

    SUPPLEMENTARY MATERIALS

    Supplementary Table 1

    Difference of delayed bleeding according to the location

    Click here to view.(38K, xls)

    Supplementary Table 2

    Difference of perforation according to the location

    Click here to view.(37K, xls)

    Notes

    Conflict of Interest:No potential conflict of interest relevant to this article was reported.

    Author Contributions:

    • Conceptualization: T.H., O.S., T.S.

    • Data curation: T.H., M.J.

    • Formal analysis: F.M.

    • Investigation: T.H., A.K.

    • Methodology: T.A., U.Y.

    • Project administration: Y.K., K.Y.

    • Resources: Y.R.

    • Supervision: O.S.

    • Validation: T.H., K.T.

    • Visualization: T.H., K.T.

    • Writing - original draft: T.H.

    • Writing - review & editing: O.S., T.S.

    References

      1. Oka S, Tanaka S, Kaneko I, Mouri R, Hirata M, Kawamura T, et al. Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer. Gastrointest Endosc 2006;64:877–883.
      1. Oka S, Tanaka S, Kaneko I, Mouri R, Hirata M, Kanao H, et al. Endoscopic submucosal dissection for residual/local recurrence of early gastric cancer after endoscopic mucosal resection. Endoscopy 2006;38:996–1000.
      1. Higashimaya M, Oka S, Tanaka S, Sanomura Y, Yoshida S, Hiyama T, et al. Outcome of endoscopic submucosal dissection for gastric neoplasm in relationship to endoscopic classification of submucosal fibrosis. Gastric Cancer 2013;16:404–410.
      1. Ono H, Kondo H, Gotoda T, Shirao K, Yamaguchi H, Saito D, et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut 2001;48:225–229.
      1. Gotoda T, Yamamoto H, Soetikno RM. Endoscopic submucosal dissection of early gastric cancer. J Gastroenterol 2006;41:929–942.
      1. Oka S, Tanaka S, Higashiyama M, Numata N, Sanomura Y, Yoshida S, et al. Clinical validity of the expanded criteria for endoscopic resection of undifferentiated-type early gastric cancer based on long-term outcomes. Surg Endosc 2014;28:639–647.
      1. Rösch T, Sarbia M, Schumacher B, Deinert K, Frimberger E, Toermer T, et al. Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series. Endoscopy 2004;36:788–801.
      1. Yamamoto S, Uedo N, Ishihara R, Kajimoto N, Ogiyama H, Fukushima Y, et al. Endoscopic submucosal dissection for early gastric cancer performed by supervised residents: assessment of feasibility and learning curve. Endoscopy 2009;41:923–928.
      1. Imagawa A, Okada H, Kawahara Y, Takenaka R, Kato J, Kawamoto H, et al. Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success. Endoscopy 2006;38:987–990.
      1. Nagata S, Jin YF, Tomoeda M, Kitamura M, Yuki M, Yoshizawa H, et al. Influential factors in procedure time of endoscopic submucosal dissection for gastric cancer with fibrotic change. Dig Endosc 2011;23:296–301.
      1. Choi IJ, Kim CG, Chang HJ, Kim SG, Kook MC, Bae JM. The learning curve for EMR with circumferential mucosal incision in treating intramucosal gastric neoplasm. Gastrointest Endosc 2005;62:860–865.
      1. Gotoda T, Friedland S, Hamanaka H, Soetikno R. A learning curve for advanced endoscopic resection. Gastrointest Endosc 2005;62:866–867.
      1. Jeon WJ, You IY, Chae HB, Park SM, Youn SJ. A new technique for gastric endoscopic submucosal dissection: peroral traction-assisted endoscopic submucosal dissection. Gastrointest Endosc 2009;69:29–33.
      1. Kondo H, Gotoda T, Ono H, Oda I, Kozu T, Fujishiro M, et al. Percutaneous traction-assisted EMR by using an insulation-tipped electrosurgical knife for early stage gastric cancer. Gastrointest Endosc 2004;59:284–288.
      1. Gotoda T, Oda I, Tamakawa K, Ueda H, Kobayashi T, Kakizoe T. Prospective clinical trial of magnetic-anchor-guided endoscopic submucosal dissection for large early gastric cancer (with videos). Gastrointest Endosc 2009;69:10–15.
      1. Imaeda H, Iwao Y, Ogata H, Ichikawa H, Mori M, Hosoe N, et al. A new technique for endoscopic submucosal dissection for early gastric cancer using an external grasping forceps. Endoscopy 2006;38:1007–1010.
      1. Higuchi K, Tanabe S, Azuma M, Sasaki T, Katada C, Ishido K, et al. Double-endoscope endoscopic submucosal dissection for the treatment of early gastric cancer accompanied by an ulcer scar (with video). Gastrointest Endosc 2013;78:266–273.
      1. Li CH, Chen PJ, Chu HC, Huang TY, Shih YL, Chang WK, et al. Endoscopic submucosal dissection with the pulley method for early-stage gastric cancer (with video). Gastrointest Endosc 2011;73:163–167.
      1. Suzuki S, Gotoda T, Kobayashi Y, Kono S, Iwatsuka K, Yagi-Kuwata N, et al. Usefulness of a traction method using dental floss and a hemoclip for gastric endoscopic submucosal dissection: a propensity score matching analysis (with videos). Gastrointest Endosc 2016;83:337–346.
      1. Yoshida M, Takizawa K, Ono H, Igarashi K, Sugimoto S, Kawata N, et al. Efficacy of endoscopic submucosal dissection with dental floss clip traction for gastric epithelial neoplasia: a pilot study (with video). Surg Endosc 2016;30:3100–3106.
      1. Yoshida M, Takizawa K, Suzuki S, Koike Y, Nonaka S, Yamasaki Y, et al. Conventional versus traction-assisted endoscopic submucosal dissection for gastric neoplasms: a multicenter, randomized controlled trial (with video). Gastrointest Endosc 2018;87:1231–1240.
      1. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer 2017;20:1–19.
      1. Ono H, Yao K, Fujishiro M, Oda I, Nimura S, Yahagi N, et al. Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer. Dig Endosc 2016;28:3–15.
      1. Tsuji Y, Ohata K, Sekiguchi M, Ito T, Chiba H, Gunji T, et al. An effective training system for endoscopic submucosal dissection of gastric neoplasm. Endoscopy 2011;43:1033–1038.
      1. Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer 2011;14:101–112.
      1. Sanomura Y, Oka S, Tanaka S, Noda I, Higashiyama M, Imagawa H, et al. Clinical validity of endoscopic submucosal dissection for submucosal invasive gastric cancer: a single-center study. Gastric Cancer 2012;15:97–105.
      1. Sanomura Y, Oka S, Tanaka S, Higashiyama M, Yoshida S, Arihiro K, et al. Predicting the absence of lymph node metastasis of submucosal invasive gastric cancer: expansion of the criteria for curative endoscopic resection. Scand J Gastroenterol 2010;45:1480–1487.
      1. Higashiyama M, Oka S, Tanaka S, Sanomura Y, Imagawa H, Shishido T, et al. Risk factors for bleeding after endoscopic submucosal dissection of gastric epithelial neoplasm. Dig Endosc 2011;23:290–295.
      1. Higashimaya M, Oka S, Tanaka S, Numata N, Sanomura Y, Yoshida S, et al. Endoscopic submucosal dissection for residual early gastric cancer after endoscopic submucosal dissection. Gastrointest Endosc 2013;77:298–302.
      1. Tajiri H, Kitano S. Complications associated with endoscopic mucosal resection: definition of bleeding that can be viewed as accidental. Dig Endosc 2004;16:S134–S136.
      1. Ahn JY, Choi KD, Choi JY, Kim MY, Lee JH, Choi KS, et al. Procedure time of endoscopic submucosal dissection according to the size and location of early gastric cancers: analysis of 916 dissections performed by 4 experts. Gastrointest Endosc 2011;73:911–916.
      1. Imaeda H, Hosoe N, Ida Y, Kashiwagi K, Morohoshi Y, Suganuma K, et al. Novel technique of endoscopic submucosal dissection using an external grasping forceps for superficial gastric neoplasia. Dig Endosc 2009;21:122–127.
      1. Ueki M, Ikebuchi Y, Matsuoka H, Otani H, Yasugi A, Koda M, et al. Endoscopic submucosal dissection assisted by novel “clip fishing method” (with video). Endoscopy 2010;42 Suppl 2:E277–E278.
      1. Hijikata Y, Ogasawara N, Sasaki M, Mizuno M, Masui R, Tokudome K, et al. Endoscopic submucosal dissection with sheath-assisted counter traction for early gastric cancers. Dig Endosc 2010;22:124–128.
      1. Parra-Blanco A, Nicolas D, Arnau MR, Gimeno-Garcia AZ, Rodrigo L, Quintero E. Gastric endoscopic submucosal dissection assisted by a new traction method: the clip-band technique. A feasibility study in a porcine model (with video). Gastrointest Endosc 2011;74:1137–1141.
      1. Chung IK, Lee JH, Lee SH, Kim SJ, Cho JY, Cho WY, et al. Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study. Gastrointest Endosc 2009;69:1228–1235.
      1. Ono S, Kato M, Nakagawa M, Imai A, Yamamoto K, Shimizu Y. Outcomes and predictive factors of “not self-completion” in gastric endoscopic submucosal dissection for novice operators. Surg Endosc 2013;27:3577–3583.
    MeSH Terms
    Dental Devices, Home Care*
    Endoscopic Mucosal Resection*
    Humans
    Retrospective Studies
    Stomach
    Stomach Neoplasms
    Surgical Instruments
    Traction*
    Metrics
    Share
    Figures
    slide
    slide

    1 / 2

    Tables
    slide
    slide
    slide
    slide
    slide

    1 / 5

    ORCID IDs
    PERMALINK