This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. The traction wire is a new retraction device for ESD. In this video, we present tips and techniques from four institutions. The traction wire is a curved wireframe with high shape memory that once attached to the lesion returns to its pre-curved state, lifting the mucosa and exposing the submucosa. The traction wire comes in two sizes, 20 and 35 millimeters. The kit includes both grasping devices and the traction wire. The first procedure is an ESD of a rectal polyp performed by Dr. Ahmed Batt at Cleveland Clinic. After completion of complete circumferential incision and submucosal trimming, the first clip with the traction wire is placed on the lesion with the clip in a 12 and 6 o'clock position and the traction wire at 12 o'clock. Next, the traction wire is grabbed with a second clip and attached to the opposite wall of the lesion a few centimeters proximal to the lesion. Once the device is deployed, it retracts and lifts the mucosa, exposing the submucosa beneath. With improved submucosal exposure, the submucosal dissection is performed close to the muscle layer, allowing us to avoid the rich vasculature in the superficial submucosa. Large penetrating vessels can be easily seen and avoided. Submucosal dissection is evenly performed along the width of the lesion. Large penetrating vessels can be easily identified, grabbed with coagulation graspers, and coagulated. The retraction continues throughout the ESD procedure and up to the final dissection. The final submucosal attachment is dissected with a needle-tipped knife. The anchoring clip on the normal mucosa is grabbed with grasping forceps and gently pulled off the mucosa, retrieving both the device and lesion in one piece. Teaching points. Complete a full circumferential incision and submucosal trimming before dissection. Complete a full circumferential incision and submucosal trimming before deployment of the device. The anchoring clip can be placed on the same, side, or opposite wall of the lesion. If the anchoring clip is placed higher than the lesion, it gives best traction. Next, we present a rectal ESD performed by Dr. Neil Sharma from Parkview Cancer Institute. After complete circumferential incision, the first clip and traction wire is placed at the distal aspect of the lesion. Next, a second clip is used to grab the traction wire, and here, rather than pulling it only a few centimeters beyond the lesion, the wire is overstretched and eventually pulls the device off the lesion. Round 2. This time, the second clip is placed only a few centimeters beyond the lesion. And this is enough to allow the traction wire to give good traction. Teaching Points. Don't overstretch the wire. You only need to place the anchoring clip a few centimeters beyond the lesion. For larger lesions, use the longer 3.5 centimeter traction wire, and poor placement can be simply salvaged by removing the anchoring clip and placing a new one. Next, we show an esophageal ESD by Dr. Ju-Ha Wang from Stanford University. Here is a squamous cell tumor after application of Lugol's solution. First, cautery markings are made around the lesion. Next, a complete circumferential incision is performed, making sure to dissect through the muscularis mucosa and have the lesion separate well. The first clip is placed on the proximal border of the lesion. Next, the clip in the three and nine o'clock position grabs the traction wire. Drags it a few centimeters beyond the lesion, the anchoring clip is deployed on the same wall as the lesion. The mucosa is lifted, exposing the submucosa for easier dissection with an insulated tip knife. With retraction, vessels are easier to identify and can be pre-coagulated. After dissection is completed, the traction wire is grabbed with the grasping forceps and removed with the device and lesion. Teaching points. Make sure your circumferential incision is through the muscularis mucosa to allow for full retraction from the device. Provide additional normal mucosal margin where the initial clip is placed so it does not interfere with pathologic analysis. Lastly, we present a gastric ESD by Dr. Waxman from University of Chicago. After complete circumferential incision, the first clip and traction wire are placed on the proximal border of the lesion in a 12 and six o'clock position. Next, the second clip grabs the traction wire and this anchoring clip is placed on a wall side to the lesion, but at a position higher than the lesion. As compared to prior, this greatly improves the exposure of the submucosa, allowing for easier submucosal dissection. During the procedure, the direction of traction is changed by placing a second clip on the traction wire at a new location to achieve the desired angle of retraction. Teaching points. During dissection, the angle of retraction can be changed During dissection, the angle of retraction can be changed by placing a second anchoring clip on the wire frame and attaching it to a different area of mucosa at the angle desired. The traction wire is easy to use and delivers effective retraction throughout the ESD procedure. We hope the tips and techniques presented in this video help you in using the device.

Braintree

traction wire

ESD procedures

rectal ESD

esophageal ESD