Endoscopic submucosal dissection with the pulley method for early-stage gastric cancer (with video)

Background Using EMR techniques, physicians frequently remove tumors >15 mm by piecemeal resection, which is associated with an increased rate of disease recurrence and difficulty in histologically evaluating the specimen. Endoscopic submucosal dissection (ESD) of early-stage gastric cancer improves the rate of successful en bloc resection, but it is associated with more complications, such as bleeding and perforation, than conventional EMR. Objective To describe a simple technique that uses the pulley method to facilitate ESD procedures in the excision of large early-stage gastric cancers. Design Case series. Setting Tertiary medical center in Taiwan. Patients and Methods Eleven patients with early-stage gastric cancers or adenomas >20 mm underwent ESD. Interventions The pulley method with standard clips and dental floss was used to provide traction to improve visualization of the dissection plane during ESD. Main Outcome Measurement Proportion with complete en bloc resection. Results En bloc resection of the lesion was achieved in 11 patients. No perforation or emergent surgery was noted. Limitations One endoscopist performed all procedures, and only 11 patients were studied in an uncontrolled manner. Conclusions The pulley method seems to facilitate en bloc ESD of early-stage gastric cancers >20 mm.