Endoscopic Submucosal Dissection Using the “Yo-Yo Technique”

Video Journal and Encyclopedia of GI Endoscopy (2014) 1, 603–606

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/vjgien

INNOVATION FORUM AND EXPERIMENTAL ENDOSCOPY

Endoscopic Submucosal Dissection Using the “Yo-Yo Technique”$, $$ Francisco Baldaque-Silvan, Margarida Marques, Filipe Vilas Boas, Guilherme Macedo Gastroenterology Department, Centro Hospitalar de São João, Alameda Prof Hernani Monteiro, Porto, Portugal Received 10 January 2013; accepted 24 April 2013

KEYWORDS Endoscopic submucosal dissection; Gastrointestinal; Neoplasia; Video

Abstract Background: Endoscopic submucosal dissection (ESD) has been increasingly used for en bloc resection of gastrointestinal lesions. One of the main difficulties during ESD is to mobilize the partially resected lesion, leading to increased procedure time and complication rates. We developed a new “yo-yo technique”, that allows a fast, cheap and easy way for, not only pulling, but also pushing the lesion during ongoing ESD. Aims: To describe the feasibility and safety of the “yo-yo technique” for ESD. Procedure: After marking and lifting the lesion, incision and partial dissection are performed. Then, a hemoclip is placed in the already dissected edge of the lesion. Afterwards, a conventional snare is introduced through the nose into the stomach. Using a forceps, the hemoclip is grabbed with the snare. Due to the moderate stiffness of the snare, the edge of the lesion can be pulled or pushed during ongoing ESD, independently from the endoscope's movements. This increases the visualization of the dissection plane, reducing complications rate and procedure time. Results: The pull and push movements of the snare allow easier ESD with better access to the submucosal space and to the lesions' distal margins. Lesions can be successfully and safely removed and en block resection achieved using the “yoyo technique”. The presence of the hemoclip in the resected specimen permits a precise anatomopathological orientation.

☆ This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. ☆☆ The terms of this license also apply to the corresponding video. n Corresponding author. Tel.: +351 936641601. E-mail addresses: [email protected] (F. Baldaque-Silva), [email protected] (M. Marques), fi[email protected] (F.V. Boas), [email protected] (G. Macedo).

2212-0971/$ - see front matter & 2014 The Authors. Published by Elsevier GmbH. All rights reserved. http://dx.doi.org/10.1016/j.vjgien.2013.04.002

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F. Baldaque-Silva et al. Conclusion: The “yo-yo technique” for ESD is feasible, cheap and safe allowing full mobilization of the lesion. & 2014 The Authors. Published by Elsevier GmbH. All rights reserved.

Video related to this article

 Hemoclip (resolution clip; Boston Scientific, Natick,

Video related to this article can be found online at http:// dx.doi.org/10.1016/j.vjgien.2013.04.002.

 Endoscopic snare (SD-210U-15, Olympus).  Soft transparent tape (Transpore, 3M Health Care, St. Paul,

Massachusetts, USA).

Minnesota, USA).

 Grasping forceps (FG-50L-1, Olympus). 1.

Background

 Endoscopic submucosal dissection (ESD) is being increas

ingly used due to its ability for en bloc resection of gastrointestinal lesions. Comparing to endoscopic mucosal resection, ESD is associated with an increased procedure time and increased perforation and bleeding rates due to poor visualization of the dissection plane during dissection.

5.

 After placing marking dots around the lesion and inject  

2. Strengths and limitations of standard procedure/device

 

 Different techniques were developed to increase visua

lization of the submucosal space during dissection, aiming to increase safety and reduce procedure time. Most of these ESD auxiliary techniques are laborious, time consuming, expensive and allow only traction of the partially resected lesion.



6. 3. Potential benefit of the proposed procedure/device

 Using conventional endoscopic devices, the “yo-yo tech

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nique” allows full mobilization of the partially resected specimen. This technique improves access to the submucosal space, dissection plane and luminal side of the lesions, allowing a safe and accurate ESD.

Materials

 Gastroscope GIF-H180 and GIF-HQ190 (Olympus Corp., Hamburg, Germany)

 Transparent cap (D-201-11804; Olympus).  Saline solution with diluted epinephrine (1:200 000),  

methylene blue and hydroxypropyl methylcellulose (0.4%). Dual-knife (KD-650L, Olympus). Insulation tipped IT-knife2 (KD-611L, Olympus).

Endoscopic procedure the solution for lifting, incision and partial dissection is done using Dual Knife and IT Knife 2. Then, a hemoclip is placed in the proximal and already dissected edge of the lesion. Afterwards, a conventional snare is introduced through the nose into the stomach. The hemoclip is grabbed using a crocodile forceps inserted through the working channel of the endoscope. Due to the moderate stiffness of the snare, the hemoclip and the corresponding edge of the lesion may be pulled or pushed during ongoing ESD, independently from the endoscope's movements. The submucosal space, submucosal vessels and dissection plane can be easily accessed, increasing the safety and accuracy of the ESD and reducing the procedure time.

Discussion

Endoscopic submucosal dissection is replacing endoscopic mucosal resection in the removal of gastrointestinal lesions, due to its capability for en bloc resection and proper pathological assessment [1]. However, ESD is associated with increased bleeding and perforation rates and prolonged procedure time, being only performed in referral centers by skillful endoscopists [2]. The poor visualization of the submucosal space and difficult access to the lesions’ margins during dissection, may result in unintentional cut of submucosal vessels and poor estimation of dissection depth, causing bleeding and perforation [3]. Different ESD auxiliary techniques, such as external grasping forceps, magnetic anchor, medical ring, internal traction, the pulley method, peroral traction and the clipband technique, were developed [4–10]. All aim to mobilize the partially resected lesion, increasing the visualization of the dissection plane. However, most of them are complex, laborious, allow only traction of the lesion, are timeconsuming, and some are invasive, expensive, and dependent on the endoscope maneuvers. We developed a new “yo-yo technique”, that uses conventional and non-expensive endoscopic devices [11]. The moderate stiffness of the snare allows the lesion to be pulled or pushed, increasing the visualization and access to

Endoscopic submucosal dissection the dissection plane and to the proximal and distal margins of the lesion, enabling its full mobilization. These pulling and pushing characteristics are not present in most of the previously described techniques, and are of most importance in the distal antrum where there is a tendency for the fragment to move inside the duodenum and in the posterior wall of the antrum where the access to the submucosal layer is more difficult. The fact that in the “yo-yo technique” the lesion mobilization is independent of the endoscope's movements enables also a more accurate and faster ESD that is less prone to complications. The flexibility of this technique is highlighted by the fact that in large lesions, more than one clip may be placed along the lesion edges, enabling mobilization of the lesion in different directions and locations. Contrary to most Japanese centers, ESD in Europe is usually performed without using an overtube. The fact that in the “yo-yo technique” the snare is inserted through the nose, reduces the friction with the endoscope and allows wide access to the oropharynx, enabling aspiration of patient secretions when needed, increasing procedure safety. During snare insertion, there is a risk for inducing trauma not only to the nose mucosa, but also along the gastrointestinal tract. That is the reason why we place a tape in the tip of the snare. Using it, the risk of complications is low. The same tape is used to lock the snare handle. In this way, there is no need for another operator to lock and control the snare movements. After lesion retrieval, the hemoclip is easily observed in the specimen. That allows an accurate anatomo-pathological orientation. This important characteristic is also not present in most of previously described auxiliary techniques. In conclusion, using conventional endoscopic devices, the “yo-yo technique” allows wide access to the dissection plane and lesions edges, enabling easy, safe and accurate ESD.

7.

Take-home messages

 The “yo-yo technique” uses conventional endoscopic devices and is easy to set up.

 Contrary to most of previously described auxiliary tech-



8.

niques, the “yo-yo technique” enables the lesions to be pulled and pushed, increasing the access to the submucosal space, dissection plane and lesion's edges. This improves ESD accuracy and safety. The “yo-yo technique” may be used in different regions of the gastrointestinal tract.

Scripted voiceover

Voiceover Text Endoscopic submucosal dissection (ESD) is being increasingly used due to its ability for en bloc resection of gastrointestinal lesions. The “yo-yo technique” is a new and simple ESD auxiliary technique.

605 Voiceover Text For demonstration of the technique, a case of a patient with a type II-a dysplastic gastric lesion, referred for ESD, is presented. For lifting, a solution of saline with adrenalin, hydroxypropyl methylcellulose and methylene blue, is used. As the lifting sign is good, subepitelial injection is continued. A circumferential incision, is made outside the dots, using Dual knife on endocut mode effect 2. In this case, an IT knife 2 is also used, due the difficult access to the lesion margins and need for retroflection. A cap is placed in the tip of the endoscope to increase access to the submucosal space. Subepitelial injection is done as needed to increase the submucosal space. We can see that, even using a cap and subepitelial injection, the visualization of the dissection plane is difficult, turning the ESD procedure more prone to bleeding and perforation In the yo-yo technique a clip is placed in the appropriate margin of the lesion Tape is placed in the tip of a snare to avoid mucosal injury. After applying gel, the snare is carefully inserted through the nose using endoscopic guidance. In order to orientate the snare, a foreign body forceps is inserted through the endoscope working channel. With the orientation of the forceps, the clip is grabbed by the snare. Due to the moderate stiffness of the snare, the partially resected lesion can be pulled or pushed, exposing the luminal side and the submucosal space. A tape is used to block the snare handle. In this way, there is no need for an additional operator to control the snare movements. By pulling the snare, the lesion is pulled, uncovering the submucosal space and the dissection plane, turning ESD faster and safer. In case of bleeding, the bleeding vessel can be easily exposed and hemostasis performed. A coagrasper is used with soft coagulation, effect 5, 80 watts. The usefulness of a water jet is also highlighted in this case. With the yo-yo technique, submucosal injection is needed less frequently, turning ESD in a faster procedure. The advantages of this technique are highlighted in this case, where a retroflexion position is needed and access to the submucosal space and luminal side is hampered. With the yo-yo, the full mobilization of the lesion enables fewer and more precise maneuvers of the endoscope and knife. The presence of the clip in the specimen permits a precise anatomapathological orientation. Now, some cases using the yo-yo technique in different contexts, are presented. This is a case of a patient with a dysplastic lesion in the pylorus. In this region there a tendency for the partially resected specimen, to curl hiding the submucosal space, or to move inside the duodenum, hampering access to the distal luminal side. The pulling and pushing movements of the snare enable easy access not only to the submucosa but also to the distal luminal side.

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Voiceover Text

References

In this case, a patient with a type IIa-IIc gastric lesion with high grade dysplasia was referred for ESD resection. The localization enabled good submucosal visualization, but using the yo-yo technique and pulling the snare, the access to the submucosal space improved. Pushing the snare, the luminal side is displayed, turning ESD a safer and faster procedure. In this last case, the access to the submucosal space was difficult due to localization of the dysplastic lesion in the antrum posterior wall. Pushing the snare, the submucosa becomes evident, exposing the dissection plane and enabling precise dissection.  The “yo-yo technique” uses conventional endoscopic devices and is easy to set up.

[1] Park YM, et al. The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis. Surg Endosc 2011;25(8):2666–77. [2] Farhat S, et al. Endoscopic submucosal dissection in a European setting. A multi-institutional report of a technique in development. Endoscopy 2011;43(8):664–70. [3] Othman MO, Wallace MB. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in 2011, a Western perspective. Clin Res Hepatol Gastroenterol 2011;35(4): 288–94. [4] Imaeda H, et al. A new technique for endoscopic submucosal dissection for early gastric cancer using an external grasping forceps. Endoscopy 2006;38(10):1007–10. [5] Gotoda T, et al. Prospective clinical trial of magnetic-anchorguided endoscopic submucosal dissection for large early gastric cancer (with videos). Gastrointest Endosc 2009;69(1):10–5. [6] Matsumoto K, et al. A new traction device for facilitating endoscopic submucosal dissection (ESD) for early gastric cancer: the medical ring. Endoscopy 2011;43(Suppl 2):E67–8. (UCTN). [7] Chen PJ, et al. Endoscopic submucosal dissection with internal traction for early gastric cancer (with video). Gastrointest Endosc 2008;67(1):128–32. [8] Li CH, et al. Endoscopic submucosal dissection with the pulley method for early-stage gastric cancer (with video). Gastrointest Endosc 2011;73(1):163–7. [9] Jeon WJ, et al. A new technique for gastric endoscopic submucosal dissection: peroral traction-assisted endoscopic submucosal dissection. Gastrointest Endosc 2009;69(1):29–33. [10] Parra-Blanco A, et al. Gastric endoscopic submucosal dissection assisted by a new traction method: the clip-band technique. A feasibility study in a porcine model (with video). Gastrointest Endosc 2011;74(5):1137–41. [11] Baldaque-Silva, F., et al., Endoscopic submucosal dissection of gastric lesions using the “yo-yo technique”. Endoscopy, 2012 4. [Epub ahead of print].

 Contrary to most of previously described techniques, the “yo-yo technique” enables the lesions to be pulled and pushed, increasing the access to the submucosal space, dissection plane and lesion’s edges.

 The “yo-yo technique” improves ESD accuracy and safety.

 This technique may be used in different regions of the gastrointestinal tract.

Acknowledgments Authors would like to thank João Diogo Maia, Inês Cunha, Jorge Lima and Ana Freire for their assistance during video caption.