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

Table 3 Summary of major endoscopic submucosal dissection innovations, evidence level, and clinical use

Category	Example/technique	Main advantages	Limitations	Supporting evidence	Best clinical use
Endo-knives	Dual knife, flush knife, hook knife, SB knife Jr., IT-nano	Precise cutting, hemostasis control	Risk of tissue injury, longer learning curve	RCTs and meta-analyses[11-16]	Standard ESD for upper and lower GI lesions
Traction methods	Clip-flap, clip-with-line, pulley, S-O clip	Shorter procedure time, improved visualization	May need device reinsertion, limited control direction	Multiple RCTs[18-28]	Complexor fibrotic colorectal lesions
Pocket creation method	Submucosal pocket dissection	Maintains lift, prevents fluid leakage	Technically demanding	RCT[16]	Large or fibrotic gastric/colorectal lesions
Water pressure- underwater ESD	Saline immersion with dynamic jet	Enhanced submucosal visibility	Requires water-jet function	Prospective trials[17]	Lesions with poor submucosal lift
Closure techniques	Line-assisted, loop clip, clip-on-clip, hand-suturing	Reduces perforation and PECS	Added time, cost	Observational and case series[35-42]	Large post-ESD defects, right colon

PECS: Post-endoscopic submucosal dissection coagulation syndrome; ESD: Endoscopic submucosal dissection; RCT: Randomized controlled trial; GI: Gastrointestinal.