Advanced endoscopic submucosal dissection with traction

Figure 1 Schema of clip-with-line method.

Figure 2 Clip-with-line method. A: Submucosal side of the target lesion in the esophagus was grasped using clip tied to long silk line; B: When the line was pulled very gently, submucosal layer was elevated; C: Lesion was dissected en bloc.

Figure 3 Schema of pulley method. The first clip with the line can be pulled to the anal side with the second clip, which is fixed at the opposite side.

Figure 4 Schema of Percutaneous-traction method. A small snare is introduced into the gastric lumen through a gastric port to grasp and pull the lesions.

Figure 5 Endoscopic submucosal dissection using external forceps. A: External grasping was anchored at distal margin of lesion in the lesser curvature of the antrum under control of endoscope and second grasping forceps; B: With gentle oral traction applied with external grasping forceps, submucosal layer was dissected in retroversion from aboral side.

Figure 6 Schema of Internal traction method. A: The second clip is attached at the opposite sides of the lesions; B: The second clip is attached at the opposite sides of the stomach.

Figure 7 Endoscopic submucosal dissection using double-channel R-scope. A: R-scope has two movable instrument channels: one moves grasping forceps vertically for lesion with traction and other swings cutting knife horizontally for dissection; B Cutting knife was horizontally swung.

Figure 8 Schema of outerroute method.

Figure 9 Endoscopic submucosal dissection using double-endoscopes. A: Lesion was grasped and lifted using grasping forceps through thin endoscope; B Submucosal dissection was done using needle knife through main scope.

Figure 10 Endoscopic submucosal dissection using external forceps. A: Bendable biopsy forceps; B: Bending forceps and traction applied using forceps elevated lesion and widened submucosal layer.