Unidirectional versus direction-selectable traction device in gastric endoscopic submucosal dissection: a randomized controlled trial.

Background: The effects of traction direction in traction-assisted gastric endoscopic submucosal dissection (ESD) are underexplored. The clip-with-line (CWL) and spring-and-loop with clip (SLC) are unidirectional and direction-selectable traction devices, respectively. This study compared the procedure-related outcomes of CWL-assisted ESD (CWL-ESD) and SLC-assisted ESD (SLC-ESD) for superficial gastric neoplasms (SGNs).

Methods: This single-center randomized controlled trial included patients with SGNs who were randomly assigned to undergo CWL-ESD or SLC-ESD performed by an expert. The traction direction was classified as proximal, diagonally proximal, vertical, diagonally distal, or distal. Vertical traction (VT) was selected for SLC-ESD using the direction-selectable traction function. The primary endpoint was the median ESD time. The secondary endpoints included dissection speed. Multiple regression analysis was used to identify factors affecting ESD time.

Results: Overall, 105 patients who underwent SLC-ESD (n = 52) or CWL-ESD (n = 53) between August 2020 and April 2023 were included in the analysis. The median ESD time was significantly shorter in the SLC-ESD group than in the CWL-ESD group (26.0 vs. 40.5 min; P = 0.015). The median dissection speed was significantly faster in the SLC-ESD group than in the CWL-ESD group (24.9 vs. 18.2 mm/min; P = 0.001). The traction direction significantly differed between the groups (P < 0.001), as VT was selected in all cases in the SLC-ESD group, compared with that in 11.3% of cases in the CWL-ESD group. Multiple regression analysis revealed that VT was independently associated with a shorter ESD time (P < 0.001). The complete resection rate did not differ between the groups (98.1% vs. 96.2%; P = 1.000). Adverse event rates were not different between the groups.

Conclusions: A direction-selectable traction device may be more effective than a unidirectional traction device in gastric ESD.