Usefulness of the right lateral decubitus push method in endoscopic submucosal dissection for upper gastric lesions

Abstract

Endoscopic submucosal dissection (ESD) for lesions in the gastric fundus and greater curvature remains challenging owing to difficulties in achieving tangential access with conventional endoscopy, despite the widespread adoption of ESD. Recent reports highlight the need for improved techniques in managing lesions, such as “fundic gland-type gastric cancer” in these regions. Our institution previously introduced the “right lateral decubitus push method” (RPM), wherein the patient is positioned in the right lateral decubitus position, allowing tangential access to the lesion by advancing the endoscope (Fig. 1). This method facilitates a horizontal approach, stabilizes endoscopic operations by increasing the contact area between the endoscope and the gastric wall, and is simple to perform and cost-effective. RPM also permits the use of traction methods¹ and multibending endoscopes.² However, the method increases the risk of the gastric contents flooding the esophagogastric junction,³ necessitating frequent oral suction or the use of an overtube to prevent aspiration pneumonia.^{4, 5} The feasibility and maneuverability of RPM should be assessed preoperatively in each patient, as the method may not be suitable for all patients. We retrospectively compared the treatment outcomes of 16 cases in which ESD was performed using RPM for lesions from the gastric fundus to the upper greater curvature from January 2010 to December 2020, with 10 cases receiving conventional methods (cESD) (Table 1). Although there were no statistically significant differences in treatment outcomes between the groups, the RPM group showed lower rates of postoperative bleeding and intraoperative perforation, as well as shorter operative times versus the cESD group. Aspiration pneumonia was not observed, likely owing to preventive measures. RPM enabled safe and complete ESD for challenging lesions in the gastric fundus and greater curvature that were difficult to access with conventional left lateral decubitus ESD (Video S1). RPM offers a viable alternative for difficult gastric ESDs, improving accessibility and stability during the procedure.

Authors declare no conflict of interest for this article.

Approval of the research protocol by an Institutional Reviewer Board: This study was performed with the approval of the Saga Medical Centre Koseikan Ethics Committee (Approval number: 21-03-01-02).

Informed Consent: In this study, informed consent was obtained from patients using the opt-out method..

Registry and the Registration No. of the study/trial: N/A.

Animal Studies: N/A.