Post written by Tomoaki Tashima, MD, PhD, from the Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan.

The indications for endoscopic submucosal dissection (ESD) in superficial nonampullary duodenal epithelial tumors (SNADETs) remain controversial because the procedure is technically challenging. The aim of this study was to compare the effectiveness of duodenal traction-assisted ESD (TA-ESD) and conventional ESD for SNADETs.

Recently, the efficacy of TA-ESD using a clip and thread for the treatment of esophagus, stomach, and colorectum lesions was reported, where TA-ESD apparently increased the rates of en-bloc resection and R0 resection, shortened the procedure time, and reduced the risk of intraoperative perforation. However, no published studies describe the effectiveness of clip-and-thread TA-ESD for SNADETs.

Our study demonstrated the effectiveness of TA-ESD in achieving a higher complete resection rate than conventional ESD for SNADETs.

The duodenum is a deep and markedly curved organ, and the effective application of direct traction to lesions in all its parts is challenging. We found that in the early stage, after the introduction of clip-and-thread duodenal TA-ESD, the thread was pulled along the anterior/medial wall of the duodenum, and traction force was applied.

Lesions of the anterior/medial wall do not receive a good traction effect and do not have an adequate traction force. However, lesions of the lateral/posterior wall receive a good traction effect and have an adequate traction force. In total, 26 of 32 (81.3%) TA-ESD cases in this study were lateral/posterior lesions. It implies that TA-ESD should be used routinely to selectively and aggressively treat lesions in the lateral/posterior duodenal wall and duodenal lesions with severe fibrosis impeding the submucosal insertion of the scope.

This study’s findings should be confirmed in larger prospective trials and with longer follow-up periods to allow their generalization.

An example of the clip-and-thread traction-assisted endoscopic submucosal dissection procedure for superficial nonampullary duodenal epithelial tumors. A, A 45-mm flat-elevated tumor in the posterior wall of the descending part of the duodenum. B, Mucosal incision and slight submucosal dissection are performed on the proximal side of the tumor. C, The thread is tied to the clip, and subsequently the clip-and-thread is inserted through the accessary channel. D, The clip-and-thread is deployed to the proximal specimen edge. E, The thread is pulled proximally outside the patient’s body. There is good submucosal layer visualization. F, A mucosal flap is created to insert the endoscope under the submucosal layer. G, Circumferential mucosal
incision is completed. H, A single traction enables a safe submucosal dissection with good visualization. I, Mucosal defect without perforation (measuring 50 43 mm). J, The mucosal defect was completely closed using the conventional clips, an endoloop, and an over-the-scope clip.

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