Self-Made Internal Traction Method For Endoscopic Submucosal Dissection of Early Gastric Cancer

Summary

This protocol describes a self-made multiring thread method to provide controlled internal traction during gastric endoscopic submucosal dissection. The technique facilitates effective mucosal flap traction in desired directions and forces, enabling easy, safe, and cost-effective dissection.

Abstract

This protocol describes a self-made multiring thread method to provide controlled internal traction during endoscopic submucosal dissection (ESD) for early gastric cancer. ESD is a minimally invasive treatment that enables en bloc resection; however, the procedure can be technically challenging when adequate visualization and access to the submucosal layer are limited. Conventional traction methods, such as the dental floss clip technique, may be hindered by interference with the endoscope and instability of clip attachment. To address these limitations, a multiring thread device was developed to enable stable and adjustable traction. The device allows precise control of traction direction and force without interfering with endoscope maneuverability. This protocol outlines the preparation and deployment of the multiring thread during the procedure. The method facilitates improved exposure of the submucosal layer, enhances procedural efficiency, and supports safe dissection. This approach provides a simple, cost-effective, and reproducible technique for improving outcomes in gastric ESD.

Introduction

Gastric endoscopic submucosal dissection (ESD) has been widely used as a minimally invasive treatment for gastric neoplasms, including early gastric cancer and adenoma¹. Indications are determined based on endoscopic and pathological findings, such as lesion size, depth of invasion, ulceration (UL), and histological type². However, complete resection of some lesions remains technically challenging using conventional ESD techniques, resulting in prolonged procedure time, piecemeal resection, incomplete resection, and perforation³. Adequate visualization of the submucosal layer is essential for safe....

Protocol

This retrospective cohort study was approved by the Ethics Committee of Kitano Hospital (258005, August 19, 2025) and was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained through opt-out forms on our website (https://kitano.bvits.com/rinri/publish.aspx).

1. Prepare the multiring thread

1. Prepare a 2.5 mL plastic disposable syringe with an outer diameter of 10–12 mm.
2. Cut approximately 40 cm of 4-0 nylon thread. Adjust the length based on the number of rings required and lesion characteristics.
3. Tie three tight overhand knots around the syringe to form the fi....

Results

We retrospectively collected data on internal traction methods at a single institution. Patients who underwent gastric ESD using the internal traction method between January 2025 and September 2025 were consecutively enrolled. Use of the method was confirmed in recorded videos. Data were collected from medical records, endoscopic reports, and videos. Patients aged <20 years were excluded.

The study included patients taking antithrombotic agents. Management of these agents was conducted in .......

Discussion

We designed and applied this self-made device for traction of mucosal flaps during gastric ESD. The internal traction method is mainly used for colonic ESD^11,12. This self-made internal traction device, known as the multiloop method, was first reported in the field of colonic ESD¹³. Since its introduction, such traction methods have been used in the field of endoscopic retrograde cholangiopancreatography^14,

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
2.5 mL syringe	NIPRO CORPORATION (or equivalent)	4987458081262	Used as a cylindrical mold to construct the multiring thread (Step 1.1). Any manufacturer is permitted.
4-0 nylon	Natsume Seisakusho Co., Ltd. (or equivalent)	C-23S-N1	Used to create the multiring thread for internal traction (Steps 1.2–1.6). Any manufacturer is permitted.
Endoscope	Olympus (or equivalent)	GIF-H290T	Used to perform gastric ESD and deliver instruments through the working channel (Steps 2.1, 2.7–2.13).
ESD knife	Olympus (or equivalent)	KD-655L	Used for circumferential marking, mucosal incision, and submucosal dissection (Steps 2.2–2.4, 2.12–2.13).
Grasping forceps	Olympus (or equivalent)	FG-47L-1	Used to manipulate clips and remove the traction device after resection (Steps 2.8, 3.1).
Injection needle	Olympus (or equivalent)	NM-610L-0425	Used to inject solution into the submucosal layer (Step 2.5).
Injection solution	Boston Scientific (or equivalent)	1919 (MucoUp, Japan)	Used to create a submucosal fluid cushion during ESD (Steps 2.3, 2.5). A hyaluronic acid–based solution may be used; dilution with saline is acceptable. Equivalent solutions (e.g., saline, glycerol solution, or other submucosal lifting agents) may also be used.
Multiloop traction device (MLTD)	Boston Scientific	M00503140	Commercial multiloop traction device used for internal traction; included for comparison with the self-made device.
Reopenable clip	MC Medical, Inc. (or equivalent)	RO-CD26195	Used to grasp the multiring thread and apply traction to the mucosal flap and opposing mucosa (Steps 2.6–2.11). Any manufacturer is permitted.
Spring-assisted traction clip (S-O clip)	ZEON Medical Inc. (or equivalent)	TC1H05	Clip-based traction device with an elastic component used for internal traction; included for comparison purposes; not used in this protocol.
Sterile container	Hakuzo Medica (or equivalent)	1270001	Used to store prepared multiring threads prior to use (Step 1.7). Any manufacturer is permitted.