Skip to main content

Advertisement

SpringerLink
Log in

Traction-assisted endoscopic submucosal dissection reduces procedure time and risk of serious adverse events: a systematic review and meta-analysis

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background and aims

Conventional endoscopic submucosal dissection (C-ESD) is a technically demanding procedure with prolonged procedure times and higher risk of adverse events. To overcome the procedural difficulty of ESD, several traction-assisted techniques (T-ESD) have been developed to improve visualization of the submucosa in hopes to facilitate safe and effective dissection. The aim of this study was to conduct a meta-analysis that compares short-term outcomes (30-day) of T-ESD to C-ESD.

Methods

Clinical studies published up to April 2020 comparing the efficacy and safety of T-ESD and C-ESD were identified using electronic bibliographic searches. Both randomized controlled trials and observational studies were included. Outcomes of interests were procedure time, rates of en bloc and R0 resection, and rates of adverse events. Fixed effect and random effect model were used to calculate pooled mean difference for continuous variables and risk differences (RDs) for categorical variables.

Results

Twenty-three studies with 2574 patients were included in this meta-analysis, with a total of 2582 lesions (1292 T-ESD and 1290 C-ESD). Pooled estimates of T-ESD showed shorter procedure times (weighted mean difference = −20.35 min, 95% CI −27.51 to −13.19, p < 0.001), higher R0 resection rates (RD 0.04, 95% CI 0.01–0.06, p = 0.004) and lower perforation rates (RD −0.03, 95% CI −0.04 to −0.01, p =  < 0.0001). No significant differences were seen in en bloc rates and bleeding risk between the two groups.

Conclusions

Traction-assisted ESD results in shorter procedure time, improved R0 resection rates and lower risk of perforation as compared to conventional ESD.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

Abbreviations

OR:

Odds ratio

ESD:

Endoscopic submucosal dissection

GI:

Gastrointestinal

EMR:

Endoscopic mucosal resection

T-ESD:

Traction-assisted endoscopic submucosal dissection

C-ESD:

Conventional endoscopic submucosal dissection

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

RCTs:

Randomized controlled trials

NOS:

Newcastle–Ottawa quality assessment scale

CIs:

Confidence intervals

References

  1. Choi K-S, Jung H-Y, Choi KD et al (2011) EMR versus gastrectomy for intramucosal gastric cancer: comparison of long-term outcomes. Gastrointest Endosc 73(5):942–948. https://doi.org/10.1016/j.gie.2010.12.032

    Article  PubMed  Google Scholar 

  2. Gotoda T, Yamamoto H, Soetikno RM (2006) Endoscopic submucosal dissection of early gastric cancer. J Gastroenterol 41(10):929–942. https://doi.org/10.1007/s00535-006-1954-3

    Article  PubMed  Google Scholar 

  3. Isomoto H, Shikuwa S, Yamaguchi N et al (2009) Endoscopic submucosal dissection for early gastric cancer: a large-scale feasibility study. Gut 58(3):331–336. https://doi.org/10.1136/gut.2008.165381

    Article  CAS  PubMed  Google Scholar 

  4. Pyo JH, Lee H, Min BH et al (2016) Long-term outcome of endoscopic resection vs. surgery for early gastric cancer: a non-inferiority-matched cohort study. Am J Gastroenterol 111(2):240–249. https://doi.org/10.1038/ajg.2015.427

    Article  PubMed  Google Scholar 

  5. Yokoi C, Gotoda T, Hamanaka H, Oda I (2006) Endoscopic submucosal dissection allows curative resection of locally recurrent early gastric cancer after prior endoscopic mucosal resection. Gastrointest Endosc 64(2):212–218. https://doi.org/10.1016/j.gie.2005.10.038

    Article  PubMed  Google Scholar 

  6. Imagawa A, Okada H, Kawahara Y et al (2006) Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success. Endoscopy 38(10):987–990. https://doi.org/10.1055/s-2006-944716

    Article  CAS  PubMed  Google Scholar 

  7. Saito Y, Fukuzawa M, Matsuda T, Fukunaga S, Sakamoto T, Uraoka T, Nakajima T, Ikehara H, Fu K, Itoi T, Fujii T (2010) Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc 24(2):343–352. https://doi.org/10.1007/s00464-009-0562-8

    Article  PubMed  Google Scholar 

  8. Bhatt A, Abe S, Kumaravel A, Vargo J, Saito J (2015) Indications and techniques for endoscopic submucosal dissection. Am J Gastroenterol 110(6):784–791. https://doi.org/10.1038/ajg.2014.425

    Article  PubMed  Google Scholar 

  9. De Ceglie A, Hassan C, Mangiavillano B et al (2016) Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: a systematic review. Crit Rev Oncol Hematol 104:138–155

    Article  Google Scholar 

  10. Schlachterman A, Yang D, Goddard A, Gotoda T, Draganov P (2018) Perspectives on endoscopic submucosal dissection training in the United States: a survey analysis. Endosc Int Open 6(4):E399–E409. https://doi.org/10.1055/s-0044-101452

    Article  PubMed  PubMed Central  Google Scholar 

  11. Ma MX, Bourke MJ (2018) Endoscopic submucosal dissection in the West: current status and future directions. Dig Endosc 30(3):310–320

    Article  Google Scholar 

  12. Hosokawa K, Yoshida S (1998) Recent advances in endoscopic mucosal resection for early gastric cancer. Gan To Kagaku Ryoho 25(4):476–483

    CAS  PubMed  Google Scholar 

  13. Maple JT, Dayyeh BKA, Chauhan SS et al (2015) Endoscopic submucosal dissection. Gastrointest Endosc 81(6):1311–1325

    Article  Google Scholar 

  14. Mizutani H, Ono S, Ohki D et al (2017) Recent development of techniques and devices in colorectal endoscopic submucosal dissection. Clin Endosc 50(6):562–568. https://doi.org/10.5946/ce.2017.108

    Article  PubMed  PubMed Central  Google Scholar 

  15. Tsuji K, Yoshida N, Nakanishi H, Takemura K, Yamada S, Doyama H (2016) Recent traction methods for endoscopic submucosal dissection. World J Gastroenterol 22(26):5917–5926. https://doi.org/10.3748/wjg.v22.i26.5917

    Article  PubMed  PubMed Central  Google Scholar 

  16. Wells G, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P (2015) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

  17. Reeves BC, Deeks JJ, Higgins JPT, Wells GA (2008) Including non-randomized studies. In: Higgins JPT, Green S (eds) Cochrane handbook for systematic reviews of interventions. Wiley, Chichester, pp 389–432. https://doi.org/10.1002/9780470712184.ch13

    Chapter  Google Scholar 

  18. Higgins JPT, Green S (eds) (2011) Cochrane handbook for systematic reviews of interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration. www.handbook.cochrane.org.

  19. R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/

  20. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5(1):13. https://doi.org/10.1186/1471-2288-5-13

    Article  PubMed  PubMed Central  Google Scholar 

  21. Ahn JY, Choi KD, Lee JH et al (2013) Is transnasal endoscope-assisted endoscopic submucosal dissection for gastric neoplasm useful in training beginners? Prospect randomized trial. Surg Endosc 27(4):1158–1165. https://doi.org/10.1007/s00464-012-2567-y

    Article  PubMed  Google Scholar 

  22. Hashimoto R, Hirasawa D, Iwaki T et al (2018) Usefulness of the S–O clip for gastric endoscopic submucosal dissection (with video). Surg Endosc 32(2):908–914. https://doi.org/10.1007/s00464-017-5765-9

    Article  PubMed  Google Scholar 

  23. Higuchi K, Tanabe S, Azuma M et al (2013) Double-endoscope endoscopic submucosal dissection for the treatment of early gastric cancer accompanied by an ulcer scar (with video). Gastrointest Endosc 78(2):266–273. https://doi.org/10.1016/j.gie.2013.01.010

    Article  PubMed  Google Scholar 

  24. Jacques J, Charissoux A, Bordillon P et al (2019) High proficiency of colonic endoscopic submucosal dissection in Europe thanks to countertraction strategy using a double clip and rubber band. Endosc Int Open 7(9):E1166–E1174. https://doi.org/10.1055/a-0965-8531

    Article  PubMed  PubMed Central  Google Scholar 

  25. Koike Y, Hirasawa D, Fujita N et al (2015) Usefulness of thread-traction-method in esophageal endoscopic submucosal dissection: randomised control trial. Gastroenterol Endosc 57(1):66–74

    Google Scholar 

  26. Mori H, Kobara H, Nishiyama N, Fujihara S, Matsunaga T, Masaki T (2017) Novel effective and repeatedly available ring-thread counter traction for safer colorectal endoscopic submucosal dissection. Surg Endosc 31(7):3040–3047. https://doi.org/10.1007/s00464-016-5326-7

    Article  PubMed  Google Scholar 

  27. Noda H, Ogasawara N, Koshino A et al (2016) Thread-traction with a sheath of polypectomy snare facilitates endoscopic submucosal dissection of early gastric cancers. Gastroenterol Res Pract 2016:9415497. https://doi.org/10.1155/2016/9415497

    Article  PubMed  Google Scholar 

  28. Okamoto K, Muguruma N, Kitamura S, Kimura T, Takayama T (2012) Endoscopic submucosal dissection for large colorectal tumors using a cross-counter technique and a novel large-diameter balloon overtube. Dig Endosc 24(Suppl 1):96–99. https://doi.org/10.1111/j.1443-1661.2012.01264.x

    Article  PubMed  Google Scholar 

  29. Okamoto K, Okamura S, Muguruma N et al (2012) Endoscopic submucosal dissection for early gastric cancer using a cross-counter technique. Surg Endosc 26(12):3676–3681. https://doi.org/10.1007/s00464-012-2364-7

    Article  PubMed  Google Scholar 

  30. Ota M, Nakamura T, Hayashi K et al (2012) Usefulness of clip traction in the early phase of esophageal endoscopic submucosal dissection. Dig Endosc 24(5):315–318. https://doi.org/10.1111/j.1443-1661.2012.01286.x

    Article  PubMed  Google Scholar 

  31. Ritsuno H, Sakamoto N, Osada T et al (2014) Prospective clinical trial of traction device-assisted endoscopic submucosal dissection of large superficial colorectal tumors using the S–O clip. Surg Endosc 28(11):3143–3149. https://doi.org/10.1007/s00464-014-3572-0

    Article  PubMed  Google Scholar 

  32. Sohda M, Kuriyama K, Yoshida T et al (2020) Comparable data between double endoscopic intraluminal operation and conventional endoscopic submucosal dissection for esophageal cancer. J Gastrointest Surg 24(2):307–312. https://doi.org/10.1007/s11605-019-04137-9

    Article  PubMed  Google Scholar 

  33. Suzuki S, Gotoda T, Kobayashi Y et al (2016) 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 83(2):337–346. https://doi.org/10.1016/j.gie.2015.07.014

    Article  PubMed  Google Scholar 

  34. Uraoka T, Ishikawa S, Kato J et al (2010) Advantages of using thin endoscope-assisted endoscopic submucosal dissection technique for large colorectal tumors. Dig Endosc 22(3):186–191. https://doi.org/10.1111/j.1443-1661.2010.00992.x

    Article  PubMed  Google Scholar 

  35. Wang F, Leng X, Gao Y et al (2019) Endoscopic submucosal dissection of distal intestinal tumors using grasping forceps for traction. Tech Coloproctol 23(11):1079–1083. https://doi.org/10.1007/s10151-019-02102-x

    Article  CAS  PubMed  Google Scholar 

  36. Xie X, Bai JY, Fan CQ et al (2017) Application of clip traction in endoscopic submucosal dissection to the treatment of early esophageal carcinoma and precancerous lesions. Surg Endosc 31(1):462–468. https://doi.org/10.1007/s00464-016-4939-1

    Article  PubMed  Google Scholar 

  37. Yamada S, Doyama H, Ota R et al (2016) Impact of the clip and snare method using the prelooping technique for colorectal endoscopic submucosal dissection. Endoscopy 48(3):281–285. https://doi.org/10.1055/s-0034-1393241

    Article  PubMed  Google Scholar 

  38. Yamasaki Y, Takeuchi Y, Uedo N et al (2018) Efficacy of traction-assisted colorectal endoscopic submucosal dissection using a clip-and-thread technique: a prospective randomized study. Dig Endosc 30(4):467–476. https://doi.org/10.1111/den.13036

    Article  PubMed  Google Scholar 

  39. Yoshida M, Takizawa K, Nonaka S et al (2020) Conventional versus traction-assisted endoscopic submucosal dissection for large esophageal cancers: a multicenter, randomized controlled trial (with video). Gastrointest Endosc 91(1):55-65.e2. https://doi.org/10.1016/j.gie.2019.08.014

    Article  PubMed  Google Scholar 

  40. Yoshida M, Takizawa K, Ono H et al (2016) Efficacy of endoscopic submucosal dissection with dental floss clip traction for gastric epithelial neoplasia: a pilot study (with video). Surg Endosc 30(7):3100–3106. https://doi.org/10.1007/s00464-015-4580-4

    Article  PubMed  Google Scholar 

  41. Yoshida M, Takizawa K, Suzuki S et al (2018) Conventional versus traction-assisted endoscopic submucosal dissection for gastric neoplasms: a multicenter, randomized controlled trial (with video). Gastrointest Endosc 87(5):1231–1240. https://doi.org/10.1016/j.gie.2017.11.031

    Article  PubMed  Google Scholar 

  42. Yoshida N, Doyama H, Ota R et al (2016) Effectiveness of clip-and-snare method using pre-looping technique for gastric endoscopic submucosal dissection. World J Gastrointest Endosc 8(12):451–457. https://doi.org/10.4253/wjge.v8.i12.451

    Article  PubMed  PubMed Central  Google Scholar 

  43. Ban H, Sugimoto M, Otsuka T et al (2018) Usefulness of the clip-flap method of endoscopic submucosal dissection: a randomized controlled trial. World J Gastroenterol 24(35):4077–4085. https://doi.org/10.3748/wjg.v24.i35.4077

    Article  PubMed  PubMed Central  Google Scholar 

  44. Ngamruengphong S, Ferri L, Aihara H et al (2020) Efficacy of endoscopic submucosal dissection for superficial gastric neoplasia in a large cohort in North America. Clin Gastroenterol Hepatol. https://doi.org/10.1016/j.cgh.2020.06.023

    Article  PubMed  Google Scholar 

  45. Farhat S, Chaussade S, Ponchon T et al (2011) Endoscopic submucosal dissection in a European setting. A multi-institutional report of a technique in development. Endoscopy 43(08):664–670. https://doi.org/10.1055/s-0030-1256413

    Article  CAS  PubMed  Google Scholar 

  46. Moss A, Williams SJ, Hourigan LF et al (2015) Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 64(1):57–65

    Article  Google Scholar 

  47. Fuccio L, Bhandari P, Maselli R et al (2018) Ten quality indicators for endoscopic submucosal dissection: what should be monitored and reported to improve quality. Ann Transl Med 6(13):5

    Article  Google Scholar 

  48. Raja S, Rice TW, Goldblum JR et al (2011) Esophageal submucosa: the watershed for esophageal cancer. J Thorac Cardiovasc Surg 142(6):1403-1411.e1

    Article  Google Scholar 

  49. Xia M, Zhou Y, Yu J, Chen W, Huang X, Liao J (2019) Short-term outcomes of traction-assisted versus conventional endoscopic submucosal dissection for superficial gastrointestinal neoplasms: a systematic review and meta-analysis of randomized controlled studies. World J Surg Oncol 17(1):1–10

    Article  Google Scholar 

Download references

Author information

Author notes

  1. Chawin Lopimpisuth and Malorie Simons have contributed equally to the study.

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Johns Hopkins University, 733 N Broadway, Baltimore, MD, USA

    Chawin Lopimpisuth, Malorie Simons, Venkata S. Akshintala & Saowanee Ngamruengphong

  2. Welch Medical Library, Johns Hopkins University, Baltimore, MD, USA

    Julie Nanavati

  3. Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand

    Chawin Lopimpisuth & Klaorat Prasongdee

Authors
  1. Chawin Lopimpisuth
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Malorie Simons
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Venkata S. Akshintala
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Klaorat Prasongdee
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Julie Nanavati
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Saowanee Ngamruengphong
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Malorie Simons.

Ethics declarations

Disclosures

Saowanee Ngamruengphong is a consultant for Boston Scientific. Chawin Lopimpisuth, Malorie Simons, Venkata S. Akshintala, Klaorat Prasongdee and Julie Nanavati have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lopimpisuth, C., Simons, M., Akshintala, V.S. et al. Traction-assisted endoscopic submucosal dissection reduces procedure time and risk of serious adverse events: a systematic review and meta-analysis. Surg Endosc 36, 1775–1788 (2022). https://doi.org/10.1007/s00464-021-08452-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-021-08452-8

Keywords

Search

Navigation