Clip-With-Line (CWL) Traction Assistance in Esophageal and Gastric Endoscopic Submucosal Dissection (ESD)
Annie Shergill* and Luis Nasiff
Larkin Community Hospital, Palm Springs Campus, Hialeah, FL, USA
*Corresponding author
Annie Shergill, Larkin Community Hospital, Palm Springs Campus, Hialeah, FL, USA.
Clip-with-line (CWL) is the main technique to use traction in esophageal and gastric Endoscopic Submucosal Dissection (ESD). In this short review, we will analyze difference between the two. Two major trials done to evaluate the efficacy of esophageal and gastric CWL-ESD are CONNECT-E and CONNECT-G trials respectively [1,2].
In CONNECT-G, gastric CWL-ESD was not associated with a reduced procedure time unlike CWL-ESD in the esophagus. Therefore, depending on the anatomic location of use, the procedure time may or may not be reduced with CWL-ESD. Traction direction used in CWL can be vertical, proximal, diagonally proximal, diagonally distal and distal. Given the large size of the stomach lumen, the direction of traction in the stomach can vary amongst the above-mentioned directions. Vertical traction was found to be the most effective in the CONNECT-G trial. The esophageal lumen is completely different and relatively narrow. As such, the traction is limited to the proximal direction. Proximal traction can make the mucosal flap to fall down towards the scope and inhibits the scope from getting under the flap easily. In the esophagus, CWL traction can be combined with traction by the hood attached to the scope tip therefore making CWL use effective in esophageal ESD.
Overall, CWL provides better procedure times and outcomes with ESD in both the esophagus and the stomach with essential differences that exist because of the anatomical difference of the dissection plane. Knowing these differences is important to continue to investigate this technique further and hopefully improve the application of CWL-ESD in removal of esophageal and gastric lesions.
References
- Masao Yoshida, Takizawa K, Nonaka S, Shichijo S, Suzuki S, Sato C, et al. Conventional versus traction-assisted endoscopic submucosal dissection for large esophageal cancers: a multicenter, randomized controlled trial. Gastrointestinal Endoscopy. 2020. 91: 91: 55-65.
- Yoshida M, Takizawa K, Suzuki S, Koike Y, Nonaka S, et al. CONNECT-G Study Group. Conventional versus traction-assisted endoscopic submucosal dissection for gastric neoplasms: a multicenter, randomized controlled trial (with video). Gastrointest Endosc. 2018. 87: 1231-1240
