Endoscopic submucosal dissection: Challenges, innovations, and the road ahead

Table 2 Overview of innovative techniques in endoscopic submucosal dissection and their clinical advantages

Technique	Purpose/mechanism	Clinical benefit
Pocket creation method	Creation of a stable submucosal pocket before full incision	Maintains elevation, reduces perforation risk
Water pressure method	Saline infusion + water-jet pressure into submucosa	Enhances visibility, dissection precision
Clip-flap method	Endoclip replaces mucosal flap to open dissection plane	Improves access in fibrotic/complex lesions
Clip-with-line	Traction using string-connected endoclip	Enhances visualization, reduces procedure time
Pulley traction	Dual-directional clip system with external string redirection	Adjusts traction direction, useful in colorectal ESD
Loop clips/S-O clip	Loop with clip for traction without reinsertion	Simplifies complex ESD, effective for larger lesions
Line-assisted closure	Clip with nylon line to approximate tissue edges post-ESD	Enables complete defect closure in large ulcers
Loop clip closure	Loop structure aids in progressive closure with standard clips	Facilitates closure of wide defects
Clip-on-clip closure	Staggered clip placement to anchor and approximate tissue	Effective when standard clips slip
Mucosal incision around defect	Pre-incising around ulcer edges to improve clip grip	Improves clip fixation and wound approximation
Hand suturing (overstitch)	Endoscopic needle and suture system	Full-thickness closure, especially in difficult locations
Underwater clip closure	Closure performed under water immersion	Enhances tissue pliability and defect approximation

ESD: Endoscopic submucosal dissection.