To address the challenges of difficult colorectal endoscopic submucosal dissection (ESD), conversion to snare resection (rescue-snare ESD: rSnare), a variant of hybrid ESD, is commonly proposed. However, rSnare is associated with a lower en bloc resection rate compared with conventional ESD. Traction-assisted ESD has emerged as a technique to facilitate dissection, but its effectiveness as a rescue method remains unclear. This study was the first to compare the effectiveness of rSnare and rescue-traction-assisted ESD (rTraction).

This retrospective study involved 1464 consecutive lesions from 1372 patients with superficial colorectal neoplasms across eight institutions. Among these, 162 lesions required rescue methods of rSnare or rTraction. After propensity score matching, 88 lesions treated with either rSnare or rTraction were analyzed.

The rTraction group exhibited significantly higher en bloc resection and R0 resection rates (93.2% and 77.3%, respectively) compared with the rSnare group (45.5% and 38.6%, respectively). However, average procedure time was significantly longer in the rTraction group (122.3 ± 72.5 min) compared with the rSnare group (92.2 ± 54.2 min). In the rTraction group, univariable and multivariable analyses identified traction initiation time > 75 minutes as the only independent predictor of procedure durations exceeding 120 minutes.

Utilizing a traction device as a rescue technique in difficult colorectal ESD resulted in higher en bloc and R0 resection rates compared with conversion to snare resection. Initiating traction within 75 minutes may contribute to reducing overall procedure time for challenging colorectal ESD cases.

Gastric endoscopic submucosal dissection (ESD) for lesions located on the greater curvature of the upper and middle (U/M) third of the stomach remains challenging, even for experienced endoscopists. Accordingly, we have developed a novel traction technique, termed the outside-lesion clip-thread method (O-CTM). In this method, a clip thread is attached to the healthy mucosa outside the circumferential incision line, and traction is applied to bring the scope and lesion into proximity for ESD. Here, we assessed the efficacy of ESD using the O-CTM compared to ESD without the O-CTM.

We retrospectively reviewed data from 63 consecutive patients who underwent gastric ESD for 63 lesions located on the greater curvature of the U/M third of the stomach between September 2015 and April 2024. The primary outcome was the operation time, and secondary outcomes were resection speed, en bloc resection, R0 resection and complications in the O-CTM and without O-CTM ESD groups.

Of the 63 included lesions, 37 were resected without the O-CTM between September 2015 and June 2022 (without O-CTM group), and 26 lesions were resected using the O-CTM between July 2022 and April 2024 (O-CTM group). The O-CTM group had significantly shorter operation times (40 min vs. 77 min, p = 0.01) than the without O-CTM group. The resection speed was also significantly faster (20.1 mm2/min vs. 11.3 mm2/min, p = 0.02). No significant differences in en bloc resection rate, R0 resection rate, and complications were observed.

Gastric ESD using O-CTM is beneficial when compared with the ESD without O-CTM in reducing operation time and improving resection speeds for treating lesions located on the greater curvature of the U/M region.

We propose this variant of the clip technique as a method that assist traction during endoscopic submucosal dissection (ESD): traction on the mucosa plane using an hemoclip carrying a surgical silk and three rubber bands, before the incision, to allow easier access to the submucosa space. We propose this variant with the intention of facilitating access to ESD quickly and safely for beginners.

The endoscopic submucosal dissection (ESD) is a technically demanding and time-consuming procedure, with an increased risk of adverse events compared to standard endoscopic resection techniques. The main difficulties are related to the instability of the operating field and to the loss of traction. We aimed to evaluate in a pilot trial a new endoscopic platform [tissue retractor system (TRS); ORISE, Boston scientific Co., Marlborough, MA, USA], designed to stabilize the intraluminal space, and to provide tissue retraction and counter traction.

We prospectively enrolled all consecutive patients who underwent an ESD for sigmoid/rectal lesions. The primary outcome was the rate of technical feasibility. Further technical aspects such as en-bloc and R0 resection rate, number of graspers used, circumferential incision time, TRS assemblage time, submucosal dissection time, and submucosal dissection speed were provided. Clinical outcomes (recurrence rate and adverse events) were recorded as well.

In all, 10 patients (M/F 4/6, age: 70.4 ± 11.0 years old) were enrolled. Eight out of 10 lesions were located in the rectum. Average lesion size was 31.2 ± 2.7 mm, and mean lesion area was 1628.88 ± 205.3 mm². The two sigmoid lesions were removed through standard ESD, because the platform assemblage failed after several attempts. All rectal lesions were removed in an en-bloc fashion. R0 resection was achieved in 7/8 (87.5%) patients in an average procedure time of 60.5 ± 23.3 min. None of the patients developed neither intraprocedural nor postprocedural adverse events.

TRS-assisted ESD is a feasible option when used in the rectum, with promising result in terms of efficacy and safety outcomes. Nevertheless, our pilot study underlines few technical limitations of the present platform that need to be overcome before the system could be widely and routinely used.

The dissemination of endoscopic submucosal dissection (ESD) has been limited by its technical complexity and safety profile, particularly among non-experts. Various techniques and devices have facilitated the performance of ESD, but their yield and role in the path to learning ESD remain unclear.

We performed a systematic review by querying MEDLINE, EMBASE, Web of Science, and Japan Medical Abstracts Society specifically for comparative studies investigating the impact of assigned ESD techniques vs. conventional techniques among non-experts in ESD (< 50 ESD procedures). Procedural outcomes of efficacy, efficiency, and safety were assessed.

We identified 46 studies evaluating 54 cohorts in which a total 237 non-experts performed 2461 ESDs conventionally, and 1953 ESDs using an assigned ESD technique (knives, countertraction, miscellaneous techniques). The majority of studies were from East Asia (67%), single-center (96%), observational in design (61%), in an animal model (57%), and gastric location (63%). The most studied techniques were countertraction techniques (48% cohorts) and scissor knives (15% cohorts), both of which commonly enhanced efficiency of ESD, and less so efficacy or safety. Techniques found to be beneficial in experts were more likely to be beneficial in non-experts (70% concordance) than vice versa (47% concordance).

Based on the currently available literature, countertraction techniques and scissor knives should be considered for early incorporation into ESD training by non-experts. Several aspects of ESD training remain understudied, including techniques in Western non-experts, educational resources, and several commonly cited techniques. These areas should guide future investigation to enhance the pathway to learning ESD.

Endoscopic management is preferred to surgical management for large superficial colorectal lesions. However, the optimal endoscopic resection strategy (piecemeal endoscopic mucosal resection [pEMR] or endoscopic submucosal dissection [ESD]) is still debated from an economical point of view. To date, in France, there is no Health Insurance reimbursement rate for the hospital stays related to ESD. We searched to estimate the global cost of colorectal ESD and to define the most cost-effectiveness endoscopic strategy.

A model was created to compare the cost-effectiveness of ESD and pEMR according to optical diagnosis (Japan NBI Expert Team [JNET], laterally spreading tumour [LST], CONECCT). We distinguished three groups from the same multicentre ESD cohort and compared the medical and economic outcomes: real-life ESD data (Universal-ESD or U-ESD) compared to modelled selective ESD (S-ESD JNET; S-ESD LST; S-ESD CONECCT) and exclusive pEMR strategies (Universal-EMR or U-EMR).

The en-bloc, R0, and curative resection rates were 97.5%, 86.5%, and 82.6%, respectively in the real life French ESD cohort of 833 colorectal lesions. U-ESD was the least-expensive strategy, with a global cost of 2,858,048.17 €, i.e. 3,431.03 €/patient and was also the most effective strategy because it avoided 774 surgeries, which was more than any other strategy. It outperformed S-ESD CONNECT (global cost = 2,951,411.44 €, and 3,543.11 €/patient, 765 surgeries avoided, S-ESD LST (global cost = 3,055,951.53 €, and 3,668.61 €/patient, 749 surgeries avoided), and S-ESD JNET (global cost = 3,547,426.97 € and 4,258.62 €/patient, 704 surgeries avoided) and U-EMR (global cost = 4,060,547.62 € and 4,874.61 €/patient, 620 surgeries avoided). Even though a model which optimized pEMR results (0% technical failure, 0% primary surgery), U-EMR strategy remained the most expansive strategy and the one that avoided the least surgeries.

ESD for all LSTs upper than 20 mm is more cost-effective than pEMR, and S-ESD.

Endoscopic submucosal dissection (ESD) has been developed as a treatment for superficial gastrointestinal neoplasms, which can achieve en bloc resection regardless of the lesion size. However, ESD is technically difficult because endoscopists cannot bring their hand into the gastrointestinal tract, unlike surgeons in regular surgery. It is difficult to obtain sufficient tension in the dissection plane and a good field of vision. Therefore, ESD is associated with a long procedure time and a high risk of adverse events in comparison with endoscopic mucosal resection. Traction methods have been developed to provide sufficient tension for the dissection plane and a good field of vision during the ESD procedure. However, traction direction is limited in most traction methods, resulting in insufficient effect in some cases. Although traction direction is considered important, there have been few investigations of its effect. In the first half of this review, important traction methods are discussed, including traction direction. In second half, appropriate traction methods for each organ are considered. Other important considerations for traction method, such as ability to adjust traction strength, interference between traction device and endoscope, and the need for specialized devices are also discussed.

Endoscopic submucosal dissection (ESD) has been developed as a treatment for superficial gastrointestinal neoplasms, which can achieve en bloc resection regardless of the lesion size. However, ESD is technically difficult because endoscopists cannot bring their hand into the gastrointestinal tract, unlike surgeons in regular surgery. It is difficult to obtain sufficient tension in the dissection plane and a good field of vision. Therefore, ESD is associated with a long procedure time and a high risk of adverse events in comparison with endoscopic mucosal resection. Traction methods have been developed to provide sufficient tension for the dissection plane and a good field of vision during the ESD procedure. However, traction direction is limited in most traction methods, resulting in insufficient effect in some cases. Although traction direction is considered important, there have been few investigations of its effect. In the first half of this review, important traction methods are discussed, including traction direction. In second half, appropriate traction methods for each organ are considered. Other important considerations for traction method, such as ability to adjust traction strength, interference between traction device and endoscope, and the need for specialized devices are also discussed.

Endoscopic submucosal dissection (ESD) is technically difficult and requires considerable training. The authors have developed a multi-loop traction device (MLTD), a new traction device that offers easy attachment and detachment. We aimed to evaluate the utility of MLTD in ESD.

This ex vivo pilot study was a prospective, block-randomized, comparative study of a porcine stomach model. Twenty-four lesions were assigned to a group that undertook ESD using the MLTD (M-ESD group) and a group that undertook conventional ESD (C-ESD group) to compare the speed of submucosal dissection. In addition, the data of consecutive 10 patients with eleven gastric lesions was collected using electronic medical records to clarify the inaugural clinical outcomes of gastric ESD using MLTD.

The median (interquartile range) speed of submucosal dissection in the M-ESD and C-ESD groups were 141.5 (60.9-177.6) mm2/min and 35.5 (20.8-52.3) mm2/min, respectively; submucosal dissection was significantly faster in the M-ESD group (p < 0.05). The rate of en bloc resection and R0 resection was 100% in both groups, and there were no perforation in either group. The MLTD attachment time was 2.5 ± 0.9 min and the MLTD extraction time was 1.0 ± 1.1 min. Clinical outcomes of MLTD in gastric ESD were almost the same as those of ex vivo pilot study.

MLTD increased the speed of submucosal dissection in ESD and was similarly effective when used by expert and trainee endoscopists without perforation. MLTD can potentially ensure a safer and faster ESD.

Video 1Traction-assisted colorectal endoscopic submucosal dissection using the multiloop method for a previously tattooed laterally spreading tumor in the sigmoid colon.